Background:
The generally accepted theory of why hemorrhoidal disease (HD) occurs is that the hemorrhoidal cushions slid down in the anal canal (muco-anal prolapse), which allows them to swell up. This creates problems with bleeding, leakage (soiling), itching and pain.
Traditionally, severe HD is treated by surgical removal of the hemorrhoids, but the procedure is associated with long recovery time, pain and complications like stenosis and incontinence. Minimal invasive and hemorrhoid preserving surgery has gained popularity during the last two decades with new methods like Procedure for Prolapse and Hemorrhoids (PPH)/Stapled Anopexy and Transanal Hemorrhoidal Dearterialisation (THD)/Hemorrhoidal Artery Ligation and Recto Anal Repair (HAL/RAR). Several studies have shown, thought that mucopexy alone result in equally good result as THD/HAL-RAR. There are several ways to perform a mucopexy with different ways in how the sutures are applied and how many rows of sutures that are done.
Other available methods focus on tissue destruction, for example sclerosing injections, laser, radio ablation, or methods with applied electricity that induce heat. These methods make the hemorrhoids to swell down but does not treat the muco-anal prolapse that are present in grade II and III hemorrhoids.
PexyEazy® perform a mucopexy in a new, semi-automatic way with the benefit of reducing the cost and time of surgery and is estimated to be able to be conducted without the need of general anesthesia.
Method:
PexyEazy® is a single-use device for surgical treatment of internal HD grade II and III (according to the Goligher classification). It is based on the mucopexy method, but instead of applying the sutures by hand, the mucosa is folded by the device and then a loop of suture is introduced into the folded mucosa. When knots are applied, the hemorrhoids are lifted inwards, as the folded mucosa above the hemorrhoids is pulled together. Due to that the most proximal suture is longer and deeper and acts as an anchoring stich, the lifting motion is inwards, towards the deeper stitch. When the position of the hemorrhoids is normalized, the venous drainage is improved, and the hemorrhoids swell down, and symptoms disappears.
PexyEazy® consists of five major parts: PexyEazy® examination proctoscope, handle with depth setting piston, light shuttle with a led lamp, PexyEazy® Mucopexy Device (MD) and the battery-pack. All parts are sterile, except the re-usable battery-pack.
With the examination proctoscope, a correct position of the operation area is set by pushing a depth setting piston, that is part of the handle, towards the skin when the proctoscope is aligned with the dentate line. The handle is then transferred to the MD, which is inserted into the rectum until the depth- setting piston touches the skin, ensuring a correct position of the operation area.
The MD have three operation areas that are positioned alongside the device at 3, 7, and 11 o'clock, which corresponds with the position of the three major internal hemorrhoids. Each operation area consists of 5 indentations, 4 smaller and one larger furthest in. The floor of the indentations has small holes, so when vacuum suction is applied within the device, the mucosa is sucked down into the indentations and thereby folding the mucosa above the hemorrhoids. A double needle is then pushed through the folded mucosa and docks with the ends of a loop of a suture that is stored in the suture cassette at the tip the tip of the device. When the needles are retracted, a loop of suture is introduced through the folded mucosa. The position of the sutures starts 10mm above the dentate line thanks to the settings done through the examination proctoscope and the depth setting piston. The sensation of pain is not present 10mm above the dentate line, which enables surgery without anesthesia. The stitches are 4mm wide, 3mm deep and 10mm long in the first four stitches and 6mm deep and 12mm long in the final stitch furthest in. The unit forming the walls of the indentations is divided into three longitudinal parts. When a supportive tray is removed the unit falls apart into three pieces and is removed, leaving the suture in the mucosa. Knots are then applied with a knot pusher, which pulls the folded mucosa together and the hemorrhoids are lifted inwards. The compressed mucosa is estimated to create multiple adhesion points/scar tissues that fixate the hemorrhoid in the new elevated position, ensuring a long-lasting result after the suture is absorbed (60-90 days). A special mucosa spatula is used to push out any protruding mucosa to make extraction of the device easier without damaging the tissue.
Number of subjects: 31-35 patients
The SCI-Pex study will evaluate the safety and performance of PexyEazy on patients with hemorrhoids grade II and III. For safety reasons will the first 6-10 patients undergo the procedure under general anesthesia and then the procedure will be done on awake patients (25) with 1 week, 3 months and 1 years follow up with questionnaires and a clinical examination after 3 months and 1 year to document result.
