Hemorrhoid stapler: Less pain but less effective. (Alternative to Standard Excision).

SAN DIEGO -- Surgeons have embraced a vast array of alternatives to excisional hemorrhoidectomy. The explanation is simple: The operation hurts like the dickens.

Hemorrhoids have been frozen, heated, strangled with rubber bands, cut with a harmonic scalpel, and--most recently--stapled into submission. But there is a price to be paid for less procedural pain in treating hemorrhoids, and that price is reduced efficacy, Dr. Peter Cataldo said at the annual meeting of the American Society of Colon and Rectal Surgeons.

In summarizing a recent metaanalysis in which other investigators looked at 18 prospective randomized studies comparing various methods of treating hemorrhoids, Dr. Cataldo said that the message was clear: "No pain, no gain."

"Hemorrhoidectomy costs the most and hurts the most, but has the least recurrence. Sclerotherapy with phenol injections and infrared coagulation have the least pain but highest recurrence. And rubber band ligation is somewhere in the middle," said Dr. Cataldo, a surgeon at the University of Vermont, Burlington.

The novel therapy that everyone at the meeting was buzzing about was stapled hemorrhoidectomy. In several small, randomized European trials, it has resulted in less pain--indeed, less than half the pain in some studies--and faster return to normal activity, compared with conventional hemorrhoidectomy.

Invented in Italy during the mid-1990s, stapled hemorrhoidectomy has taken continental Europe by storm but has been available in the United States on a limited basis. The procedure can be done on an outpatient basis.

In stapled hemorrhoidectomy, following four-finger anal dilation, the surgeon places a purse-string suture in the rectal mucosa and submucosa about 2 cm above the hemorrhoids.