Stapled Hemorrhoidopexy is non-inferior to excisional hemorrhoidectomy in long-term follow-up: A comparative study

doi:10.21203/rs.3.rs-2244915/v1

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Stapled Hemorrhoidopexy is non-inferior to excisional hemorrhoidectomy in long-term follow-up: A comparative study

https://doi.org/10.21203/rs.3.rs-2244915/v1

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Purpose: Symptomatic hemorrhoids are one of the most common perianal problems with various treatment options. Up to 20% of patients suffering from symptomatic hemorrhoids will require surgery. Excisional Hemorrhoidectomy (EH) and stapled hemorrhoidopexy (SH) are both standard and safe procedures. While SH has a short-term advantage of faster recovery and lower postoperative pain, its long-term efficacy is debatable. The purpose of this study was to compare the long-term outcomes of EH and SH.

Methods: This retrospective study compares outcomes of patients who underwent surgical treatment for symptomatic hemorrhoids in our institution during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and quality of life improvement.

Results: Three hundred sixty-two patients were included, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure. Twenty-three patients (6.3%) suffered postoperative complications or were readmitted. There were no statistically significant differences between the groups regarding rate of complications, symptoms' recurrence, or fecal incontinence. A higher proportion of patients who underwent SH stated they would undergo the surgery again if they had to (p=0.011). There was no difference in quality of life improvement between the groups (p=0.904).

Conclusion: Stapled hemorrhoidopexy is non-inferior to hemorrhoidectomy in long-term follow-up regarding patient satisfaction, quality of life improvement, and symptoms' recurrence.

Excisional hemorrhoidectomy

Stapled hemorrhoidopexy

patients’ satisfaction

Quality-of-life

Hemorrhoids are normal arteriovenous structures that become symptomatic when engorged and prolapsed. The most common symptoms include bleeding, itching, pain, and tissue protrusion. Symptomatic hemorrhoids are a widespread problem affecting many people, and the true incidence is probably unknown due to inaccurate diagnosis and underreporting. [1]. The step-up treatment approach for hemorrhoids starts with conservative treatment followed by office-based procedures and surgery when those are failed [2].

About 10-20% of patients suffering from symptomatic hemorrhoids will eventually undergo a surgical procedure. [3,4] Excisional hemorrhoidectomy (EH) can be done with the incision left open (“Milligan Morgan”) or with its closure (“Ferguson”). Stapled hemorrhoidopexy (SH) is another common procedure in which a circular stapler is utilized to excise a ring of mucosal and submucosal tissue above the dentate line and to fashion a mucosa-to-mucosa anastomosis, and hence to decrease hemorrhoidal tissue blood supply and to pull the prolapsed tissue back into the anal canal.
Compared to EH, the main advantage of SH is faster recovery and significantly lower post-operative pain. [1,2,5,6] However, there are reports of higher recurrence rates and the need for repeated procedures following SH. [1,2,5,6]. Never the less, both procedures are considered safe and appropriate for treating high-grade hemorrhoids [2,7]

This study aimed to evaluate the long-term outcomes of surgical procedures for the treatment of symptomatic hemorrhoids and to compare the efficacy of SH versus EH. We hypothesized that there are no significant differences between the surgical procedures when comparing the change in patients’ quality of life, overall satisfaction, complication, and recurrence rate.

Study design and patient inclusion:

The study was conducted under the supervision of the Hadassah Medical Center institutional review board (approval number 0098-21- HMO). We conducted this study according to the principles of the declaration of Helsinki.

Consecutive patients aged ≥ 18 years who underwent surgical treatment for hemorrhoids at our institution between January 1^st 2015, and June 30^th 2020 were evaluated for inclusion in this study. Exclusion criteria included; patients with impaired cognitive function or language difficulty, who could not complete the questionnaire; and patients who were unable or unwilling to participate. Informed consent was provided by all patients who agreed to participate in the study.

Perioperative management and surgical technique:

All Surgeries were performed by, or under the direct supervision, of a fellowship trained colon and rectal surgeon. The type of procedure for each patient (EH, SH, or a combination) was selected by the surgeon and the patient according to patient's complaints and findings at physical examination, and after explaining the pros and cons of each procedure.

We perform SH using the Ethicon Procedure for Prolapse and Hemorrhoids (PPH ™) circular stapler. Following anoscopy, a purse-string suture is created in the distal rectal submucosa about 2 centimeters above the dentate line. The stapler is then inserted and the purse string tied around it. The stapler is tightened and fired (after ensuring by vaginal exam in females that the stapler does not inadvertently include the posterior vaginal wall). The stapler line is then inspected for any bleeding and hemostatic sutures are placed as necessary.

For EH, we perform the Ferguson technique with either Bovie cautery or LigaSure™; after anoscopy, we make an incision that surrounds the hemorrhoidal tissue starting from the perianal skin to the hemorrhoid base. We then dissect the hemorrhoid away from the sphincter muscle, suture the hemorrhoidal pedicle, and excise the hemorrhoidal tissue. The wound is then closed with absorbable suture in a running locking fashion while taking small bites of the underlying internal sphincter muscle.

We utilize a combined procedure of SH and simultaneous resection of residual hemorrhoidal tissue in patients with significant internal as well as external hemorrhoids, in which SH alone is not expected to resolve the symptoms, and EH alone is expected to result in a wide excision with increased risk for development of anal stenosis following recovery and scarring.

Outcome measures:

All eligible patients were contacted over the phone by a member of the research team. Following informed consent, the patient was asked to answer a questionnaire regarding recurrent symptoms (anal pain, tissue prolapse or swelling, bright red blood per rectum or perianal itching), fecal incontinence (Wexner fecal incontinence score [FIS]) and overall satisfaction from surgery (each patient was asked to state if he/she would repeat the surgery if needed and how would they evaluate their improvement in quality of life after surgery on a scale of 1-10) [Supplement 1].

Data collected from the patients' medical records included demographics, comorbidities, type of surgery, type of anesthesia and simultaneous procedures, perioperative complications and post-operative follow-up.

The Included patients were divided into three groups according to the type of surgery: EH, SH, and combined procedures, and outcomes were compared.

Statistical analysis:

Statistical analysis was performed using EZR (version 1.55) and R software (version 4.1.2) [8]. Categorical data were expressed as numbers and percentages and were analyzed with Fisher’s exact or χ2 test. To explore association of factors affecting satisfaction, we used a multivariate logistic regression. Continuous variable presented by interquartile range (IQR). A student t-test or Mann-Whitney test was employed on continuous variables. We utilized ANOVA test to compare groups for continuous variables. A p-value ≤0.05 was considered significant for all comparisons.

Six hundred fifty-five patients underwent surgical treatment for hemorrhoids at our institution during the study period.

Three hundred sixty-two patients (55.2%) agreed to participate and were included in the study, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure.

One hundred forty-two (39.2%) patients were female, patients ages ranged from 22 to 88 years; the median overall follow-up time was 45.8 months (ranged between 19.5 to 86.4 months). There were no differences between the three groups regarding sex, age, type of anesthesia, American Society of Anesthesiology (ASA) score, comorbidities, and previous interventions for hemorrhoids (Table 1). Twenty-seven patients (7.5%) underwent previous interventions for hemorrhoids, either clinic-based procedures or surgery; there was no difference between the groups regarding previous intervention for symptomatic hemorrhoids (p = 0.229) (Table 2).

Follow-up time from surgery to questionnaire was longer for patient who underwent SH as compared to that of patients who had EH or combined procedures (49 months, 41 months and 43 months respectively, p = 0.02).

Table 1

Comparing patients’ demographic and clinical characteristics between the three groups.
		SH	EH	combined surgery	p.value
No. of patients		215	99	48
Age (SD)		52.30 (15.40)	49.42 (13.27)	51.46 (15.50)	0.282
Sex N(%)	male	126 (58.6)	69 ( 69.7)	25 ( 52.1)	0.072
Sex N(%)	female	89 (41.4)	30 ( 30.3)	23 ( 47.9)	0.072
Types of anesthesia N(%)	General	127 (59.9)	70 ( 70.7)	33 ( 68.8)	0.139
Types of anesthesia N(%)	Spinal	85 (40.1)	29 ( 29.3)	15 ( 31.2)	0.139
ASA score N(%)	1	87 (50.3)	27 ( 33.3)	16 ( 39.0)	0.248
	2	74 (42.8)	47 ( 58.0)	23 ( 56.1)
	3	10 ( 5.8)	6 ( 7.4)	2 ( 4.9)
	4	2 ( 1.2)	1 ( 1.2)	0 ( 0.0)
Received anticoagulants N(%)	No	191 (88.8)	90 ( 90.9)	44 ( 91.7)	0.766
Received anticoagulants N(%)	Yes	24 (11.2)	9 ( 9.1)	4 ( 8.3)	0.766
CHF N(%)	No	213 (99.1)	97 ( 98.0)	46 ( 95.8)	0.268
CHF N(%)	Yes	2 ( 0.9)	2 ( 2.0)	2 ( 4.2)	0.268
Chronic lung disease N(%)	No	209 (97.2)	94 ( 94.9)	46 ( 95.8)	0.591
Chronic lung disease N(%)	Yes	6 ( 2.8)	5 ( 5.1)	2 ( 4.2)	0.591
CRF N(%)	No	214 (99.5)	98 ( 99.0)	47 ( 97.9)	0.521
CRF N(%)	Yes	1 ( 0.5)	1 ( 1.0)	1 ( 2.1)	0.521
CVA N(%)	No	210 (97.7)	94 ( 95.9)	48 (100.0)	0.322
CVA N(%)	Yes	5 ( 2.3)	4 ( 4.1)	0 ( 0.0)	0.322
Other neurological conditions N(%)	No	207 (96.3)	96 ( 98.0)	47 ( 97.9)	0.665
Other neurological conditions N(%)	Yes	8 ( 3.7)	2 ( 2.0)	1 ( 2.1)	0.665
DM N(%)	No	197 (91.6)	90 ( 90.9)	46 ( 95.8)	0.561
DM N(%)	Yes	18 ( 8.4)	9 ( 9.1)	2 ( 4.2)	0.561
HTN N(%)	No	173 (80.5)	83 ( 83.8)	39 ( 81.2)	0.774
HTN N(%)	Yes	42 (19.5)	16 ( 16.2)	9 ( 18.8)	0.774
IHD N(%)	No	204 (94.9)	96 ( 97.0)	46 ( 95.8)	0.702
IHD N(%)	Yes	11 ( 5.1)	3 ( 3.0)	2 ( 4.2)	0.702
Immunosuppression status N(%)	No	212 (98.6)	99 (100.0)	48 (100.0)	0.356
Immunosuppression status N(%)	Yes	3 ( 1.4)	0 ( 0.0)	0 ( 0.0)	0.356
Follow up (months) IQR		49.07 [36.37, 68.20]	41.43 [30.85, 59.77]	43.17 [31.09, 61.69]	0.02

SH- stapled hemorrhoidectomy, EH- excisional hemorrhoidectomy,

ASA- American Society of Anesthesiology) score, CHF- congestive heart failure, CRF- chronic renal failure, CVA-cerebrovascular accident, DM-diabetic Mellitus, HTN-hypertension, IHD-ischemic heart disease., IQR-inter-quartile range

Table 2

Previous interventions for symptomatic hemorrhoids.
	SH (n = 215)	EH (n = 99)	Combined procedures (n = 48)	P. value
Any intervention N(%)	14 (6.5)	11 (11.1)	2 (4.2)	0.229
Rubber band ligation N(%)	5 (0.023)	2 (0.02)	0 (0)
HAL N(%)	1 (0.0046)	0 (0)	0 (0)
SH N(%)	2 (0.009)	4 (0.04)	1 (0.02)
EH N(%)	2 (0.009)	4 (0.04)	1 (0.02)
Unknown procedure N(%)	4 (0.018)	0 (0)	0 (0)

SH-stapled hemorrhoidopexy, EH -excisional hemorroidectomy, CS combined surgery, HAL- Hemorrhoidal artery ligation.

Operative and postoperative complications

Twenty-three patients (6.3%) experienced postoperative complications or readmissions. Five patients required a blood transfusion, five had urinary retention, and seven were readmitted for pain control. One patient had retroperitoneal bleeding caused by a pudendal block performed at the time of surgery. Two patients underwent emergency re-intervention: one due to bleeding and one due to an abscess. One patient was admitted to the neurology department for post–spinal anesthesia headache, one had a long admission for postoperative diabetic control, and one suffered a stapler line perforation after using an enema. There was no difference between the groups in complication rate (p = 0.074, Table 3).

Table 3

post-operative complications
	SH (n = 215)	EH (n = 99)	CS (n = 48)	P. value
Any complications	10 (4.7)	11 (11.1)	2(4.2)	0.074
Bleeding requiring blood transfusion N(%)	3 (0.01)	1 (0.01)	1 (0.02)
Reoperation N(%)	2 (0.009)	0 (0)	0 (0)
Urinary retention N(%)	1 (0.004)	4 (0.04)	0 (0)
Other major complication ^# N(%)	2 (0.009)	0 (0)	0 (0)
Readmission for pain N(%)	1(0.004)	5 (0.05)	1 (0.02)
Non-perianal related admission^* N (%)	1 (0.004)	1 (0.01)	0 (0)

SH- stapled hemorrhoidopexy, EH- excisional hemorrhoidectomy, CS-combined surgery.

# Retroperitoneal bleeding, stapler line perforation due to enema

*Diabetes mellitus control, post spinal-anesthesia headache.

Recurrent symptoms and fecal incontinence

One hundred ninety-six patients (54.1%) reported symptoms that might be attributed to recurrent disease; eighty patients reported itching, 117 (32.3%) reported bleeding, 130 (35.9%) reported pain, and 142 (39.2%) reported perianal swelling. However, only 90 patients (24.8%) required symptomatic treatment of some sort and only 19 (5.2%) were definitely diagnosed with recurrent symptomatic hemorrhoids and required repeated interventions for recurrent symptoms.

Two hundred and seventy-seven patients (76.5%) reported perfect continence (FIS = 0). Only 22 patients (6.1%) had a FIS ≥ 10. Only one patient reported deterioration in his incontinence status following the surgery. No statistically significant differences between the groups were found regarding FIS or symptoms' recurrence (Table 4).

Table 4

Comparing outcomes between the three groups.
Factor	Group	SH	EH	combined	p.value
No.		215	99	48
Symptoms that might be attributed to recurrent disease:
Reported any symptoms that might be attributed to recurrent disease N(%)		118 (54.9)	56 (56.6)	22 (45.8)	0.446
Pain, N(%)	No	138 (64.2)	61 (61.6)	33 (68.8)	0.699
Pain, N(%)	Yes	77 (35.8)	38 (38.4)	15 (31.2)	0.699
Itching, N(%)	No	168 (78.1)	74 (74.7)	40 (83.3)	0.496
Itching, N(%)	Yes	47 (21.9)	25 (25.3)	8 (16.7)	0.496
Swelling, N(%)	No	126 (58.6)	61 (61.6)	33 (68.8)	0.42
Swelling, N(%)	Yes	89 (41.4)	38 (38.4)	15 (31.2)	0.42
Bleeding, N(%)	No	143 (66.5)	68 (68.7)	34 (70.8)	0.819
Bleeding, N(%)	Yes	72 (33.5)	31 (31.3)	14 (29.2)	0.819
Needed any treatment for anorectal symptoms?, N(%)	No	143 (66.8)	71 (71.7)	38 (79.2)	0.244
	Symptomatic conservative treatment	56 (26.2)	24 (24.2)	10 (20.8)
	Interventional treatment	15 ( 7.0)	4 ( 4.0)	0 ( 0.0)
Fecal incontinence score:
Gas incontinence, N(%)	0	165 (77.5)	84 (86.6)	42 (87.5)	0.104
	1	1 ( 0.5)	2 ( 2.1)	2 ( 4.2)
	2	5 ( 2.3)	1 ( 1.0)	1 ( 2.1)
	3	13 ( 6.1)	3 ( 3.1)	0 ( 0.0)
	4	29 (13.6)	7 ( 7.2)	3 ( 6.2)
Liquid incontinence, N(%)	0	190 (88.8)	84 (86.6)	45 (93.8)	0.876
	1	6 ( 2.8)	3 ( 3.1)	0 ( 0.0)
	2	6 ( 2.8)	3 ( 3.1)	1 ( 2.1)
	3	3 ( 1.4)	3 ( 3.1)	0 ( 0.0)
	4	9 ( 4.2)	4 ( 4.1)	2 ( 4.2)
Solid incontinence, N(%)	0	192 (89.7)	90 (92.8)	45 (93.8)	0.551
	1	8 ( 3.7)	2 ( 2.1)	0 ( 0.0)
	2	3 ( 1.4)	0 ( 0.0)	0 ( 0.0)
	3	3 ( 1.4)	1 ( 1.0)	2 ( 4.2)
	4	8 ( 3.7)	4 ( 4.1)	1 ( 2.1)
Wearing pads, N(%)	0	202 (94.4)	94 (96.9)	47 (97.9)	0.825
	1	2 ( 0.9)	0 ( 0.0)	0 ( 0.0)
	2	1 ( 0.5)	1 ( 1.0)	0 ( 0.0)
	3	3 ( 1.4)	0 ( 0.0)	0 ( 0.0)
	4	6 ( 2.8)	2 ( 2.1)	1 ( 2.1)
Lifestyle alternation, N(%)	0	191 (89.3)	91 (93.8)	45 (93.8)	0.8
	1	7 ( 3.3)	1 ( 1.0)	0 ( 0.0)
	2	1 ( 0.5)	1 ( 1.0)	0 ( 0.0)
	3	4 ( 1.9)	1 ( 1.0)	1 ( 2.1)
	4	11 ( 5.1)	3 ( 3.1)	2 ( 4.2)
FIS, median (IQR)		0.00 [0.00, 1.00]	0.00 [0.00, 0.00]	0.00 [0.00, .00]	0.096
SH-Stapled hemorrhoidopexy, EH- excisional hemorrhoidectomy. IQR-inter-quartile range

Patient satisfaction

One hundred fifty-eight of the patients who underwent SH (79%), 57 of the patients who underwent EH (67.9%) and 36 of the patients who underwent combined procedures (80%) stated they would undergo surgery again if needed (p = 0.108).

A multivariate logistic regression model was utilized to assess factors affecting satisfaction. Symptoms that might be attributed to recurrent disease and female gender both had a significantly negative effect on patient satisfaction (p < 0.001, p = 0.002, respectively). The surgical technique did not affect patient satisfaction (p = 0.966).

There was no significant difference between the three groups while comparing the improvement in quality of life (p = 0.111).

While comparing only EH to SH, the difference in patient satisfaction rate between the groups became statistically significant (p = 0.011, Table 5). More patients in the SH group stated they would undergo the surgery again if needed (Fig. 1). However, no difference in the self-assessed quality of life improvement was found (Table 5, p = 0.904)

Table 5

comparing patient satisfaction between EH and SH groups.
		SH N = 215	EH N = 99	P value.
Would you undergo the surgery again if needed	No	42 (19.5)	27 (27.3)	0.011
	Yes	158 (73.5)	57 (57.6)
	Maybe	15 (7.0)	15 (15.2)
Improvement in QOL, median (IQR)		8.00 [5.00, 10.00]	8.00 [6.00, 10.00]	0.903
Fecal incontinence score, median (IQR)		0.00 [0.00, 1.00]	0.00 [0.00, 0.00]	0.106

SH-Stapled hemorrhoidopexy, EH-Excisional hemorrhoidectomy, IQR-inter-quartile range.

Hemorrhoidal disease is one of the most common anal pathologies, and about 10-20% of the patients will require surgery [3]. SH is a safe procedure with short-term advantages, including less pain and faster recovery [5,6]. This study supports the hypothesis that the efficacy of SH and the long-term patients’ satisfaction rate are not inferior to those of EH.

Recurrent symptoms

In a randomized prospective study, Kim et al. showed that patients report easier recovery following SH compared to EH, with no significant difference in recurrence rate (18% for SH and 23% in the EH group) between the groups, in a median follow-up of 5.93 years. [9]. Aytac et al. found equal reintervention rates (3% for additional surgery), and equal symptoms resolution when comparing SH to EH. [3]. On the other hand, Waston et al., in a multicenter randomized controlled trial of 777 patients and two years of follow-up, found that there were fewer residual symptoms in the EH group compared to the SH group; they showed a recurrence rate of 42% in the SH group compare to only 25% in the EH group. Nine percent of patients in the SH group underwent reintervention compared to 6% in the EH group. [5]. Sturiale retrospectively followed SH patients for 12 years and found a high recurrence rate; 40.3% of the patients requiring medical therapy and 9.3% requiring reintervention. [4]

Our study demonstrates a high rate of 54% of patients reporting symptoms that might be attributed to recurrent hemorrhoidal disease, but only 24.8% of the patients required medical treatment to alleviate their symptoms, and only 5.2% required reintervention. There were no differences between the groups regarding symptoms, medical therapy, or reintervention. We found a high rate of such symptoms for the entire cohort, although Porrett et al. report a recurrence rate of 58.9% with staple hemorrhoidopexy in their meta-analysis[10]. However, our reintervention rate was low, as previously reported [4,5,9]. Evaluating the specific connection between reported symptoms and symptomatic hemorrhoidal disease recurrence is difficult. Some patients with recurrent symptoms also had an alternative explanation, as they reported other perianal conditions such as fissure, abscess, or fistula. Moreover, many reported that they did not seek medical evaluation and advice.

Satisfaction and quality of life

This study found a high satisfaction rate in all three groups. Moreover, while comparing the satisfaction rate of patients following SH to that of patients following EH, we found that patients who underwent SH were more satisfied than patients who underwent EH. Unsurprisingly, symptoms that might be attributed to recurrent hemorrhoidal disease were related to lower satisfaction; we also found that males were significantly more satisfied than women. Festen has previously shown that female gender is an independent predictor of persistent prolapse following SH[11]. High satisfaction rates after SH as reflected in patients’ interviews at different post-operative time frames, had already been shown in several previous publications [3,4,12]

In this series, 79 % of patients who underwent SH stated they would undergo surgery again if needed. This finding is similar to previous studies; Aytac et al. found similar satisfaction rates following SH and EH; in their study, 83% of patients following SH stated they would undergo surgery again[3]. The same rate was described by Sturiale as well [4]. Waston found a similar quality of life score at 12 months post-surgery in patients who underwent SH or EH, but found a higher satisfaction rate after traditional EH 24 months postoperatively [5]. In our study, the median follow-up time was longer, and we found similar self-reported improvements in quality of life regardless of the type of surgery.

Data regarding the long-term outcomes of a combined procedure of stapled hemorrhoidopexy and simultaneous resection of residual hemorrhoidal tissue is scarce. The results of our series of patients who underwent a combined procedure were found to be similar to those of the patients who had either one of the procedures. As mentioned above, a combined procedure was used in select cases to maximize efficiency and minimize the chance of complications. We found that selectively utilizing the combined procedure results in similar outcomes regarding postoperative complications, patient satisfaction, and quality of life improvement.

Our study has several limitations: First, its retrospective nature which might have created a selection bias. Secondly, a participation rate of 55% of eligible patients might under- or overestimates the true satisfaction and recurrence rates. Lastly, as anorectal symptoms are often mistakenly attributed to hemorrhoids[1], relying only on patients self-reported recurrent symptoms may have over-estimated the true recurrence rate.

This study supports the hypothesis that stapled hemorrhoidopexy is not inferior to excisional hemorrhoidectomy in long-term follow-up regarding patient satisfaction, quality of life improvement, and symptoms recurrence. We suggest that using a combination of both techniques, when appropriate, allows for a less aggressive EH without compromising the surgical outcomes. The utilization of a tailored approach with each of the techniques results in high long-term satisfaction rates.

All authors declare that they have no relevant conflict of interest.

No funding was received for this research.

Author contributions:

All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by Rachel Gefen, Adham Handal, Carmel Ben-Ezra, Shani Parnasa, and Noam Shussman. Rachel Gefen and Noam Shussman wrote the first draft of the manuscript.
All authors- Rachel Gefen, Adham Handal, Carmel Ben-Ezra, Shani Parnasa, Ido Mizrahi, Mahmud Abu-Gazala, Alon Pikarsky, and Noam Shussman commented on previous versions of the manuscript, read and approved the final manuscript.

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No competing interests reported.

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Stapled Hemorrhoidopexy is non-inferior to excisional hemorrhoidectomy in long-term follow-up: A comparative study

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Abstract

Figures

Introduction

Methods

Results

Operative and postoperative complications

Recurrent symptoms and fecal incontinence

Patient satisfaction

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1