Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up

Superselective superior rectal artery embolization in the treatment of hemorrhoidal disease

Hemorrhoids are a prevalent and benign anal disorder for which minimally invasive treatments are increasingly preferred. The UK National Institute for Health and Care Excellence clinical guideline (2010) recommends hemorrhoidal artery ligation as a treatment option for hemorrhoidal disease. Superior rectal artery embolization (SRAE) leverages this principle by using digital subtraction angiography to precisely identify and superselectively embolize the arteries supplying the hemorrhoidal region. This procedure has demonstrated favorable clinical outcomes. SRAE is minimally invasive, painless, preserves the anal sphincter and normal anal anatomy, and offers a quick recovery, establishing it as an effective minimally invasive surgical option. As a result, this technique has gained increasing clinical recognition and adoption. This article examines the efficacy and safety of superselective SRAE for hemorrhoidal disease.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

LigaSure hemorrhoidectomy versus the procedure for prolapse and hemorrhoids: A meta-analysis of randomized controlled trials

BACKGROUND

LigaSure hemorrhoidectomy and the procedure for prolapse and hemorrhoids (PPH) are both relatively new treatments for managing symptomatic hemorrhoids. This review aimed to evaluate and compare their short-term outcomes.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the China National Knowledge Infrastructure database for randomized controlled trials comparing the LigaSure procedure and PPH published in any language from 1998 to October 2013.

RESULTS

A total of 5 studies involving 397 participants were included in this review. Pooled analysis showed that the LigaSure procedure was associated with significantly lower recurrence rate [relative risk (RR) = 0.21, 95% confidence interval (CI): 0.06 to 0.72, P = .01] and significantly shorter operating time [mean difference (MD) = -6.39, 95% CI: -7.68 to -5.10, P < .001]. The analysis showed no significant difference in postoperative pain between the two techniques (MD = 0.55, 95% CI: -0.15 to 1.25, P = .12] or in time off work or away from normal activity [standard MD = 0.13, 95% CI: -1.80 to 2.06, P = .9]. The two techniques did not show significant differences in postoperative complications or other patient-related outcomes (P > .05).

CONCLUSIONS

Our review indicates that both LigaSure hemorrhoidectomy and PPH are safe alternatives for the management of hemorrhoids. Available evidence suggests that the LigaSure technique is associated with shorter operating time and lower hemorrhoid recurrence rate, but these conclusions should be further confirmed in large, multicenter randomized controlled trials with long-term follow-up.

Hemorrhoid embolization: A review of current evidences

Hemorrhoids are local vascular structure dilations in the lower rectum, associated with morbidity and reduced quality of life. Endovascular coil or particle embolization of the superior rectal arteries, known as Emborrhoid technique, is a minimally invasive, image-guided therapy that targets the hemorrhoidal plexus and reduces hemorrhage. The purpose of this review was to analyze the results of published studies to determine the efficacy, clinical outcomes, and morbidities associated with the endovascular occlusion of hemorrhoidal arteries for the treatment of internal hemorrhoids. Current evidences suggest that hemorrhoids treated by Emborrhoid technique using microcoils, embolic particles or a combination is safe with no reported serious complications. Hemorrhoid embolization can preserve the anal tone without direct anorectal trauma and maintain the hemorrhoidal tissue in place requiring minimal local wound care on an outpatient basis. However, due to the paucity of high-quality trials, further research is warranted to evaluate its long-term outcomes, compare its efficacy with other treatment modalities, and fully assess its role in the treatment of hemorrhoid.

Progress in Endoscopic Treatment of Hemorrhoids

Hemorrhoids are one of the most common diseases of the anorectal region. Previously, treatment for hemorrhoids included conservative treatment, outpatient treatment, and surgical treatment. The development of flexible reversible endoscopes has provided precise controllability and imaging, enabling further improvement and development of various endoscopic techniques to treat hemorrhoids. This article discusses several of these endoscopic techniques: rubber band ligation, sclerotherapy, and electrocoagulation. The development, efficacy, and advantages of these treatments are summarized and evaluated. It is expected that going forward, endoscopic technology will be further applied in clinical practice and may become the first-line method for the treatment of hemorrhoids.

Minimal Open Hemorrhoidectomy Versus Transanal Hemorrhoidal Dearterialization: The Effect on Symptoms: An Open-Label Randomized Controlled Trial

BACKGROUND

There is limited evidence on the long-term efficacy of transanal hemorrhoidal dearterialization compared with hemorrhoidectomy. Most studies investigated short-term effects with postoperative pain as the primary outcome. Being a benign disease, the long-term goal of treatment for hemorrhoids is the resolution of symptoms and improvement of quality of life.

OBJECTIVE

The purpose of this study was to compare the effect of minimal open hemorrhoidectomy versus transanal hemorrhoidal dearterialization on patient-reported symptoms.

DESIGN

This was an open-label randomized controlled trial.

SETTINGS

This was a single-center study.

PATIENTS

Patients with symptomatic hemorrhoids grade II to IV (Goligher's classification) were included.

INTERVENTIONS

Patients were randomly allocated to minimal open hemorrhoidectomy or transanal hemorrhoidal dearterialization.

MAIN OUTCOME MEASURES

The primary outcome was symptoms assessed by the Hemorrhoidal Disease Symptom Score 1 year postoperatively. Secondary outcomes included health-related quality of life, patient satisfaction, postoperative pain and recovery, adverse events, recurrence, and hospital costs.

RESULTS

Forty-eight patients received minimal open hemorrhoidectomy, and 50 patients received transanal hemorrhoidal dearterialization. No difference in symptom score at 1-year follow-up was found. Median (range) symptom score was 3 (0-17) after minimal open hemorrhoidectomy and 5 (0-17) after transanal hemorrhoidal dearterialization (median difference = -1.0 (95% CI, -3.0 to 0.0); p = 0.15). Residual hemorrhoidal prolapse was reported more frequently (p = 0.008), and more patients had treatment for recurrence after transanal hemorrhoidal dearterialization (7 vs 0 patients; p = 0.013). Patient satisfaction was higher after minimal open hemorrhoidectomy (p = 0.049). No differences were found in the impact on health-related quality of life, average and peak postoperative pain, recovery, or adverse events (p > 0.05). Transanal hemorrhoidal dearterialization was more expensive (median difference = &OV0556;555 (95% CI, &OV0556;472-&OV0556;693); p < 0.001).

LIMITATIONS

No blinding was included in this study.

CONCLUSION

No difference was found in symptom score 1 year postoperatively. Minimal open hemorrhoidectomy had a better effect on the hemorrhoidal prolapse and higher patient satisfaction. More patients needed treatment for recurrence after transanal hemorrhoidal dearterialization. Minimal open hemorrhoidectomy has an immediate postoperative course similar to transanal hemorrhoidal dearterialization. See Video Abstract at http://links.lww.com/DCR/B152.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02061176. HEMORROIDECTOMíA MíNIMA ABIERTA VERSUS DESARTERIALIZACIóN HEMORROIDAL TRANSANAL: EL EFECTO SOBRE LOS SíNTOMAS: UN ESTUDIO ABIERTO CONTROLADO Y ALEATORIZADO: Hay evidencia limitada sobre la eficacia a largo plazo de la desarterialización hemorroidal transanal en comparación con la hemorroidectomía. La mayoría de los estudios han investigado los efectos a corto plazo con el dolor postoperatorio como el resultado primario. Al ser una enfermedad benigna, el objetivo a largo plazo del tratamiento de la enfermedad hemorroidal es la resolución de los síntomas y la mejora en la calidad de vida.Comparar el efecto de la hemorroidectomía abierta mínima versus la desarterialización hemorroidal transanal en los síntomas reportados por el paciente.Ensayo controlado aleatorizado abierto.Estudio en sede única.Pacientes con enfermedad hemorroidal sintomática de grado II-IV (clasificación de Goligher).Los pacientes fueron asignados aleatoriamente a hemorroidectomía mínima abierta o desarterialización hemorroidal transanal.El resultado primario fueron los síntomas evaluados por el Score de Síntomas de Enfermedad Hemorroidal un año después de la operación. Los resultados secundarios incluyeron calidad de vida relacionada con la salud, satisfacción del paciente, dolor y recuperación postoperatorios, eventos adversos, recurrencia y costos hospitalarios.Cuarenta y ocho pacientes recibieron hemorroidectomía abierta mínima y cincuenta pacientes recibieron desarterialización hemorroidal transanal. No se encontraron diferencias en la puntuación de los síntomas al año de seguimiento. La puntuación mediana (rango) de síntomas fue 3 (0-17) después de una hemorroidectomía mínima abierta y 5 (0-17) después de la desarterialización hemorroidal transanal (diferencia mediana [IC95%]: -1.0 [-3.0-0.0], p = 0.15). El prolapso hemorroidal residual se informó con mayor frecuencia (p = 0.008) y más pacientes recibieron tratamiento por recurrencia después de la desarterialización hemorroidal transanal (7 frente a 0 pacientes, p = 0.013). La satisfacción del paciente fue mayor después de una hemorroidectomía abierta mínima (p = 0.049). No se encontraron diferencias en el impacto sobre la calidad de vida relacionada con la salud, el dolor postoperatorio promedio y máximo, la recuperación o los eventos adversos (p> 0.05). La desarterialización hemorroidal transanal fue más costosa (diferencia mediana [IC95%]: &OV0556; 555 [472-693], p <0.001).Estudio sin cegamiento.No se encontraron diferencias en la puntuación de los síntomas a un año después de la operación. La hemorroidectomía mínima abierta tuvo un mejor efecto sobre el prolapso hemorroidal y una mayor satisfacción del paciente. Más pacientes necesitaron tratamiento para la recurrencia después de la desarterialización hemorroidal transanal. La hemorroidectomía abierta mínima tiene un curso postoperatorio inmediato similar a la desarterialización hemorroidal transanal. Consulte Video Resumen en http://links.lww.com/DCR/B152. (Traducción-Dr. Jorge Silva Velazco).ClinicalTrials.gov Identifier: NCT02061176.

Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease

INTRODUCTION

This prospective, observational study evaluated transanal dearterialization (THD) efficacy and safety in grade 2-4 hemorrhoids (HD).

METHODS

THD was performed under sedation-locoregional anesthesia in 402 outpatients. Patients had follow-up evaluation 3 days, 2 weeks, 1, 6 and 12 months postoperatively. Postoperative complications and recurrence of symptoms at 12 months were analyzed. The relationship between the learning curve and the number of postoperative complications was studied.

RESULTS

Mean patient age was 46.4 (range 20-85) years. A total of 268 patients (66.6%) were male. Sixteen patients (4.0%) had grade 2 HD, 210 (52.2%) had grade 3 and 176 (43.8%) had grade 4 HD. Surgery lasted 23 (17-34) min. A total of 67 patients had complications: bleeding in 10 patients (2.5%), hemorrhoidal thromboses in 10 (2.5%), perianal fistulas in 5 (1.2%), fissures in 14 (3.5%), urinary retention in 3 (0.8%), residual prolapse in 19 (4.7%), severe anal pain in 3 (0.8%), and perianal abscess in 3 patients (0.8%). Recurrent HD occurred in 6.3% (1/16) of grade 2 HD patients, 5.8% (12/210) of grade 3 patients and 9.7% (17/176) of grade 4 patients. Twelve months after THD, bleeding was controlled in 363 patients (90.5%), prolapse was controlled in 391 (97.3%) and pain markedly improved in 390 patients (97%).

CONCLUSION

THD appears safe and effective for grade 2-4 HD, and the number of complications decreased with increasing surgeon experience. THD advantages include mild pain, fast recovery, early return to daily activities and low incidence of complications.

A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids. Methods. This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n = 50) or DGHAL (n = 50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs. Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%, p = 0.030). Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.

Long-term Results of Hemorrhoidal Artery Ligation

Aim of this study is to assess the efficacy, safety, and long-term results of doppler-guided hemorrhoidal artery ligation procedure with a 7-year follow-up period for treatment of grade II and III degree hemorrhoidal diseases. The procedure was performed by a specially designed proctoscope to locate and ligate all terminal branches of superior rectal artery. Patients were followed up at postoperative 1st week and 3rd, 12th, and 24th months by physical examination and 7th year by phone questionnaire using Short Form-36. Between November 2006 and May 2007, 50 patients (29 females, mean age = 38.2) underwent this procedure. All patients discharged at operation day and mean return to work was 2.5 days. There were no major complications and mean postoperative Visual Analogous Scale at first week was 1.72. At 24th month, 44 (88%) and 38 (76%) patients at 7th year were symptom free. Doppler-guided hemorrhoidal artery ligation is a safe, effective, and outpatient procedure, which can be the treatment of choice for second- and third-degree hemorrhoidal diseases with satisfactory long-term results.

Ligation under vision in the management of symptomatic hemorrhoids: A preliminary experience

AIM

To evaluate the surgical outcomes of 47 patients who underwent hemorrhoidal arterial ligation under vision (LUV) for symptomatic Grade II and Grade III hemorrhoids.

METHODS

A total of 47 patients who underwent LUV between May 2005 and February 2009 were analyzed retrospectively. The patients were evaluated with regard to demographic data, grade of the disease, symptoms, medical and/or surgical treatment previously received, operation time, pain scores, analgesic requirement, length of hospital stay, and complications related to the procedure.

RESULTS

The study population (n = 47) included 31 (65.9%) men and 16 (34.1%) women with a median age of 37.4 ± 11.7 (range, 19-63) years. Of these 47 patients, 18 (38.3%) patients had Grade II hemorrhoidal disease (HD) and 29 (61.7%) patients had Grade III HD. On average, six ligatures (range, 3-8) were used. The mean operation time was 27 ± 4.8 (range, 15-35) minutes. No major complication that required surgical intervention occurred in the early postoperative period for any of the patients except for two patients with rectal submucosal hematoma. The mean hospital stay was 1.2 ± 0.65 (range, 1-4) days. The median follow-up period was 21.5 ± 7.7 (range, 12-44) months. At the last follow-up, 38 (80.8%) patients remained asymptomatic; two (4.2%) patients with Grade II HD and four (8.5%) patients with Grade III HD were still suffering from bleeding but with a reduction in the frequency; prolapsed hemorrhoids were detected only in three (6.3%) patients.

CONCLUSION

LUV is a safe and easily applied alternative technique with low postoperative complications for the surgical treatment of symptomatic Grade II and III HD.

Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis

The objective of this article is to systematically analyse the randomized, controlled trials evaluating the effectiveness of local anaesthetic infiltration prior to the rubber band ligation of early symptomatic haemorrhoids. Published randomized, controlled trials comparing the use of local anaesthetic (LA) versus no-local anaesthetic (NLA) for the rubber band ligation of early symptomatic haemorrhoids were analysed using RevMan®, and the combined outcomes were expressed as odds ratios (OR) and standardized mean difference (SMD). Four randomized, controlled trials evaluating 387 patients were retrieved from the standard electronic databases. The risk of treatment failure (OR 0.44; 95% CI 0.07, 2.79; z = 0.87; p = 0.39) and post-procedure complications (OR 0.48; 95% CI 0.08, 2.76; z = 0.83; p = 0.41) was similar between two techniques. However, the post-procedure pain score (SMD -5.19; 95% CI -9.08, -1.30; z = 2.62; p < 0.009) was significantly lower in the group of patients undergoing rubber band ligation of haemorrhoids under local anaesthetic injection. The use of LA appears to have clinically measurable advantages over NLA in the rubber band ligation of early symptomatic haemorrhoids to lessen post-procedure pain.

Evaluation of transanal hemorrhoidal dearterialization: a single surgeon experience

Background

There is an increasing, though still limited, amount of evidence describing the use of the transanal hemorrhoidal dearterialization (THD) device for the treatment of hemorrhoidal disease. This study assesses postoperative outcomes from a single surgeon experience with the THD device.

Methods

From January 2009 to December 2011, 108 THD procedures were performed. With Doppler guidance, the THD device makes possible precise ligation of the branches of the superior hemorrhoidal artery. Patients were seen postoperatively at 3 weeks and 6 months. They underwent physical examination to determine whether there was recurrence of hemorrhoidal prolapse. They were asked to describe any bleeding, to rate pain using the visual analog scale, and to rate their level of satisfaction on a scale of 1–5 (with 5 = highly satisfied). A phone interview was used for follow-up at 1 year to determine the rate of recurrent prolapse.

Results

Of the 108 patients who underwent THD, two were lost to follow-up and excluded. All of the remaining 106 patients completed follow-up at 3 weeks and 6 months. At 3 weeks, 92 % of patients had no pain and 88 % were highly satisfied with the procedure at 3 weeks. This increased to 92 % satisfaction at 1 year. Prolapse recurrence was 7.5 % at 6 months and 10.3 % at 1 year. Bleeding was the most common complication, but did not require re-intervention or transfusion.

Conclusions

THD is a same-day procedure for the treatment of hemorrhoidal disease that is safe and effective, and offers the potential for immediate return to normal activity.

Dearterialization with mucopexy versus haemorrhoidectomy for grade III or IV haemorrhoids: short-term results of a double-blind randomized controlled trial

AIM

There is scepticism regarding anatomical rationale and Doppler guidance for ligation of haemorrhoidal arteries. The null hypothesis of this randomized controlled trial (RCT) was that there is no difference in pain following dearterialization or haemorrhoidectomy for grade III/IV internal haemorrhoids in a minimum of three quadrants.

METHOD

This was a single-centre, double-blind RCT. Patients were allocated to dearterialization or haemorrhoidectomy. Included haemorrhoids were grade III, prolapsing but reducible; and grade IV, chronic non-incarcerated. The primary end-point was pain. Patients with external component, acute incarcerated grade IV or recurrent haemorrhoids were not included. The interventions were dearterialization (with Doppler guidance and mucopexy) or haemorrhoidectomy. The main outcome measure was the Brief Pain Inventory (BPI).

RESULTS

Twenty dearterialization patients were comparable to 20 haemorrhoidectomy patients for age (P = 0.107), body mass index (P = 0.559), race (P = 0.437), American Society of Anesthesiology score (P = 0.569), comorbidities (P = 0.592), grade (P = 0.096), quadrants (P = 0.222), Fecal Incontinence Quality-of-Life Score (FIQOL; P = 0.388), coping (P = 0.532), depression (P = 0.505), embarrassment (P = 0.842), and Short Form Health Survey (SF-12) physical components (P = 0.337), SF-12 mental components (P = 0.396) and constipation (P = 0.628) scores. Dearterialization patients had shorter operative time (36 vs 54 min, P = 0.043) with less pain (P = 0.011) and urinary retention (P = 0.012). Dearterialization patients had first bowel movement earlier (1.3 vs 4.6 days, P = 0.001), less pain (P = 0.011) and lower pain intensity (P = 0.001). Narcotic requirements were reduced in dearterialization patients (25% vs 100%, P = 0.001), with less medication (4.9 vs 112 pills, P = 0.001) and shorter regimen (0 vs 7 days, P = 0.001). BPI did not differ on days 1, 3, 5, 7 and 14 except for less pain in dearterialization patients. At 3 months, symptomatic relief was the same with no differences in BPI, FIQOL or SF-12.

CONCLUSION

Compared with haemorrhoidectomy, dearterialization led to less pain in grade III/IV haemorrhoids.

Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases

PURPOSE

The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique.

MATERIALS AND METHODS

Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018).

RESULTS

Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction.

CONCLUSION

Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.

A prospective, randomized trial comparing the short- and long-term results of doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids

BACKGROUND

Few randomized trials have compared the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy and excisional open hemorrhoidectomy. Few studies have reported long-term results.

OBJECTIVE

The aim of this study is to evaluate the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy compared with excisional open hemorrhoidectomy in patients with grade III hemorrhoids.

DESIGN

This is a prospective randomized study registered at clinicaltrials.gov (NCT01263431). A power analysis assessed the study's sample size. Patients were randomly assigned to undergo either hemorrhoidectomy or Doppler-guided hemorrhoid dearterialization plus mucopexy. The χ test, Mann-Whitney U test, Student t test, and a regression model were used, as appropriate.

SETTINGS

This study was conducted at the Department of Surgery, San Raffaele Scientific Institute, Milan, Italy.

PATIENTS

Fifty consecutive patients were treated for grade III hemorrhoids from July to November 2010.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain. The secondary outcomes included postoperative morbidity, the resumption of social and/or working activity, patient satisfaction, and the relapse of symptoms at 1 and 24 months.

RESULTS

No major complications occurred in either group. The median visual analog scale scores for pain in the hemorrhoidectomy and Doppler-guided dearterialization plus mucopexy groups on days 1, 7, 14, and 30 were 7 vs 5.5, 3 vs 2.5, 1 vs 0, and 0 vs 0 (p> 0.05). The median work resumption day was the 22nd in the hemorrhoidectomy group and the 10th in the Doppler-guided dearterialization plus mucopexy group (p = 0.09). Patient satisfaction at 1 and 24 postoperative months, with the use of a 4-point scale, was 3 vs 4 and 4 vs 4 (p > 0.05). During the follow-up, 2 patients in the dearterialization group required ambulatory treatment, and 1 patient in each group required further surgery for symptom relapse.

LIMITATIONS

Nonvalidated questionnaires were used in the follow-up. Cost analysis was not performed.

CONCLUSION

Compared with hemorrhoidectomy, dearterialization with mucopexy resulted in similar postoperative pain and morbidity, and a similar long-term cure rate.

Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review

AIM

Doppler-guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy.

METHOD

This review was conducted in keeping with PRISMA guidelines. MEDLINE, EMBASE, Google Scholar and Cochrane Library databases were searched. Studies describing DGHL as a primary procedure and reporting clinical outcome were considered. Primary end-points were recurrence and postoperative pain. Secondary end-points included operation time, complications and reintervention rates. Studies were scored for quality with either Jadad score or NICE scoring guidelines.

RESULTS

Twenty-eight studies including 2904 patients were included in the final analysis. They were of poor overall quality. Recurrence ranged between 3% and 60% (pooled recurrence rate 17.5%), with the highest rates for grade IV haemorrhoids. Postoperative analgesia was required in 0-38% of patients. Overall postoperative complication rates were low, with an overall bleeding rate of 5% and an overall reintervention rate of 6.4%. The operation time ranged from 19 to 35 min.

CONCLUSION

DGHL is safe and efficacious with a low level of postoperative pain. It can be safely considered for primary treatment of grade II and III haemorrhoids.

A randomized trial of transanal hemorrhoidal dearterialization with anopexy compared with open hemorrhoidectomy in the treatment of hemorrhoids

BACKGROUND

Doppler guidance in hemorrhoidal surgery has become more frequent during the past decade. The method is mainly studied in nonrandomized trials. Data from randomized controlled trials are lacking.

OBJECTIVE

The aim of this study was to compare early and midterm results of transanal hemorrhoidal dearterialization with anopexy to open hemorrhoidectomy. DESIGN, SETTINGS, PATIENTS, AND INTERVENTIONS: Forty patients with grade 2 to 3 hemorrhoids were randomly assigned to transanal hemorrhoidal dearterialization with anopexy (group A, n = 20) or open hemorrhoidectomy (group B, n = 20). A diary was used during the first 2 postoperative weeks. A self-reported symptom questionnaire was answered, and a clinical examination was performed preoperatively, after 2 to 4 months, and after 1 year.

MAIN OUTCOME MEASURE

The main outcome measure was postoperative pain.

RESULTS

Postoperative peak pain was lower in group A during the first week than in group B (p < 0.05), whereas no difference in overall pain was noted. More patients expressed normal well-being in group A (p = 0.045). Pain, bleeding, and the need for manual reduction of the hemorrhoids were all improved in both groups after 1 year (p < 0.05). Soiling had decreased after both methods at early follow-up. After 1 year, soiling was significantly decreased only after open hemorrhoidectomy. The grade of hemorrhoids was significantly reduced after 1 year for both methods, but there was a trend to more patients with remaining grade 2 hemorrhoids in group A (p = 0.06).

LIMITATIONS

There was no blinding, the sample size was small, and follow-up was for only 1 year. The questionnaire was not validated.

CONCLUSION

The difference in postoperative pain between transanal hemorrhoidal dearterialization with anopexy and open hemorrhoidectomy may be less than expected based on previous literature.

'Distal Doppler-guided dearterialization' is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization

AIM

Transanal haemorrhoidal dearterialization (THD® Doppler) is a surgical procedure involving Doppler-guided ligation of haemorrhoidal arteries to reduce arterial flow. With proximal Doppler-guided dearterialization, arterial ligation is achieved by introducing the proctoscope completely into the anal canal and lower rectum. In the present study, distal Doppler-guided dearterialization (DDD) is performed in the distal 2 cm of the lower rectum. Immediate and short-term results were evaluated.

METHOD

One hundred patients with bleeding haemorrhoids, with or without muco-haemorrhoidal prolapse, underwent THD® Doppler procedure, using DDD of the haemorrhoidal arteries 2 cm above the anorectal junction. Mucopexy was performed in patients with haemorrhoidal prolapse.

RESULTS

The operation time was 20 ± 7 min for dearterialization alone (10 patients), and 30 ± 10 min when mucopexy was added (90 patients). Morbidity included: transient haemorrhoidal thrombosis (two patients); urinary retention (five patients); submucosal abscess (one patient). No patient complained of faecal incontinence. At a median follow-up of 7.3 (3-17) months, all patients reported an improvement in symptoms. No patients reported bleeding.

CONCLUSION

DDD of the haemorrhoidal arteries could be a simplified and more effective method of applying THD.

Is Doppler ultrasonography essential for hemorrhoidal artery ligation?

BACKGROUND

Doppler ultrasonography enables accurate identification of the terminal branches of the superior rectal artery prior to hemorrhoidal artery ligation (HAL). However, since the positions of these branches have been found to be relatively constant, the question arises as to the necessity of ultrasonography for their identification. The aim of the current study was to examine the positions of all arteries identified and ligated during the HAL procedure.

METHODS

We recorded the position of all arteries located and ligated in 135 consecutive patients who underwent the HAL procedure during the years 2003 to 2006.

RESULTS

In all patients, 6-8 terminal arterial branches were located above the dentate line. In 102 (76 %) patients, terminal branches were located in all 6 of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9, and 11 o'clock in the lithotomy position). If we had ligated arteries only at these odd-numbered clock positions, without using Doppler ultrasonography, we would have located all the arteries in 96 (71 %) of our patients.

CONCLUSIONS

The number and location of arterial branches of the superior rectal artery are relatively constant. Nevertheless, if, Doppler ultrasonography had not been performed and, ligation in the HAL procedure had been at the odd-numbered clock positions only, then at least one artery would have been missed in 29 % of our patients.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Doppler-Guided Hemorrhoidal Artery Ligation: Experience with 2 Years Follow-up

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications

BACKGROUND

Dearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries.

METHODS

Fifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated.

RESULTS

Haemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001).

CONCLUSION

This study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization.

Five-year follow-up of Doppler-guided hemorrhoidal artery ligation

BACKGROUND

Doppler-guided hemorrhoidal artery ligation (DGHAL) was described as lower risk and a less painful alternative to hemorrhoidectomy. We report our experience and 5-year follow-up with this procedure.

METHODS

Between May 2003 and December 2004, 100 patients with symptomatic Grade II or III hemorrhoids underwent ultrasound identification and ligation of 6-8 terminal branches of the superior rectal artery above the dentate line by a single surgeon using local, regional, or general anesthesia. There were 42 men and 58 women (mean age 42 years, median duration of symptoms 6/3 years). A 10-point visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at 6 weeks and 3 and 12 months after surgery, with long-term follow-up by a telephone questionnaire at 5 years after the procedure.

RESULTS

The mean operative time was 19 min. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only 5 patients were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative period. The mean pain score decreased from 2.1 at 2 h postoperatively to 1.3 on the first postoperative day. All patients had complete functional recovery by the third postoperative day. Ninety-six patients completed 12 months of follow-up. Eighty-five of these patients (89%) remained asymptomatic at 12 months, though this number dropped to 67/92 (73%) at 5 years.

CONCLUSIONS

Long-term follow-up confirms the effectiveness of the DGHAL procedure for treatment for Grade II hemorrhoids. The DGHAL procedure alone seems less effective for Grade III hemorrhoids.

Outcomes of Doppler-guided hemorrhoid artery ligation: analysis of 90 consecutive patients

BACKGROUND

Doppler-guided hemorrhoid artery ligation is a minimal-invasive surgical treatment option for hemorrhoidal disease. The aim of our study was to evaluate the early and long-term results of the procedure 1 year after the operation.

PATIENTS AND METHODS

In a period of 4 years, 90 patients were included in this study. The Doppler-guided hemorrhoid artery ligation was performed under either spinal anesthesia or local perianal block. We recorded the length of postoperative inpatient care, on-demand analgesics administered apart from the standard analgesic protocol, short- and long-term complications, and, finally, recurrences.

RESULTS

The mean age of patients was 46 ± 12.6 years. The operation was performed under spinal anesthesia in 82 patients and under local perianal block in 8 patients. The mean operative time was 26 ± 4.1 min. On-demand analgesics administration was reported in sixteen patients (17.7%) the first postoperative day and in four patients (4.4%) the second postoperative day. A total of 58 patients (64.4%) were discharged from the hospital the day of the operation, 29 (32.2%) patients stayed overnight, and in three (3.3%) patients, a hospitalization period of 2 days was needed. Four patients (4.4%), two with grade III and two with grade IV hemorrhoids, developed early postoperative complications. Late complications were observed in three patients (3.3%). Recurrences, manifested either as bleeding or as prolapsing piles, were observed in six patients (6.6%), two patients with initial grade III and four with grade IV hemorrhoids.

CONCLUSION

Doppler-guided hemorrhoid artery ligation seems to be a safe and effective treatment option for all grades of hemorrhoidal disease. Further prospective randomized comparative studies are needed in order to fully evaluate the true role of DG-HAL in the surgical armamentarium.

Outcome of stapled hemorrhoidopexy versus doppler-guided hemorrhoidal artery ligation for grade III hemorrhoids

PURPOSE

To evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation (DGHAL).

METHODS

Operative and follow-up patients' data were prospectively collected for patients undergoing either SH or DGHAL by a single surgeon during a 2-year period. A retrospective comparison between patients' outcome operated by one of the two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6 weeks, 6, 12, and 18 months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by a standardized questionnaire that was conducted during the last visit 18 months postoperatively.

RESULTS

A total of 63 patients underwent SH (aged 52 ± 3.2 years) and 51 patients underwent DGHAL (aged 50 ± 7.3 years). DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1 ± 1.4 vs. 5.5 ± 1.9 for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH patients reported greater satisfaction compared with DGHAL patients at 1 year postoperatively.

CONCLUSION

Both SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids. DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence rates and lower satisfaction rates compared with SH.

Doppler-guided hemorrhoidal artery ligation: the experience of a single institution

PURPOSE

This study aims to review the short-term recurrence and complications of Doppler-guided hemorrhoidal artery ligation (DG-HAL) with mucopexy.

METHODS

Approval was obtained for a retrospective chart review of patients who underwent DG-HAL from January 2007 to June 2009. A treatment failure was recorded if internal hemorrhoids were noted at follow up or symptoms persisted. All recurrences were assessed for predictive factors.

RESULTS

The procedures were performed by four surgeons. Ninety-six patients were included. The average age was 63.5 years (21-81 years). The mean follow up was 15 months (3-35 months). Of the patients, 93 (96.8%) reported bleeding pre-operatively. Mucopexy accompanied DG-HAL in 87 (90.6%). Postoperative complications occurred in nine (9%) patients. Residual hemorrhoids were evident in 20 (21%) patients, 13 of whom required further management for symptomatic disease, five with DG-HAL. Fifty percent (10/20) and 70% (9/13) of the recurrences necessitating further treatment transpired during the first 20 procedures of each surgeon. All 13 symptomatic recurrences demonstrated large, circumferential internal hemorrhoids.

CONCLUSIONS

DG-HAL is a simple procedure with a low complication rate. Recurrences are more frequent during the learning curve. Patients with large, circumferential internal hemorrhoids should be counseled about a possible higher rate of recurrence. DG-HAL can be effectively repeated for recurrences.

How we can improve patients’ comfort after Milligan-Morgan open haemorrhoidectomy

AIM: To demonstrate the value of Diosmin (flavonidic fraction) in the management of post-haemorhoidectomic symptoms.

METHODS: Eighty-six consecutive patients with grades III and IV acute mixed hemorrhoids admitted to the Anorectal Surgical Department of First Affiliated Hospital, Xinjiang Medical University from April 2009 to April 2010, were enrolled in this study. An observer-blinded, randomized trial was conducted to compare post-haemorhoidectomic symptoms with use of Diosmin flavonidic fraction vs placebo. Eighty-six patients were randomly allocated to receive Diosmin flavonidic fraction 500 mg for 1 wk (n = 43) or placebo (n = 43). The Milligan-Morgan open haemorrhoidectomy was performed by a standardized diathermy excision method. Pain, bleeding, heaviness, pruritus, wound edema and mucosal discharge were observed after surgery. The postoperative symptoms and hospitalization time were recorded.

RESULTS: The mean age of the Diosmin group and controls was 53.2 and 51.3 years, respectively. In Diosmin group, haemorrhoid piles were of the third degree in 33 patients and the fourth degree in 10; and in the control group, 29 were of the third degree and 14 were of the fourth degree. There was no statistically significance in age, gender distribution, degree and number of excised haemorrhoid piles, and the mean duration of haemorrhoidal disease between the two groups. There was a statistically significant improvement in pain, heaviness, bleeding, pruritus from baseline to the 8th week after operation (P < 0.05). Patients taking Diosmin had a shorter hospitalization stay after surgery (P < 0.05). There was also a significant improvement on the proctoscopic appearance (P < 0.001). However, there was no statistical difference between the two groups in terms of wound mucosal discharge. Two patients experienced minor bleeding at the 8th week in Diosmin group, and underwent surgery.

CONCLUSION: Diosmin is effective in alleviating postoperational symptoms of haemorrhoids. Therefore, it should be considered for the initial treatment after haemorrhoid surgery. However, further prospective randomized trials are needed to confirm the findings of this study.

Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study

AIM

We report a multicentric prospective study which aimed to evaluate Doppler-assisted ligation of the terminal haemorrhoidal arteries (THD) for II and III degree haemorrhoids.

METHOD

A total of 112 patients from five colorectal units, including 81 men, mean age 48 +/- 13 years, with II degree (39) and III degree (73) haemorrhoids were treated by Doppler-guided transanal de-arterialization and anopexy using a new device (THD).

RESULTS

The mean operative time was 33.9 +/- 8.8 minutes, and the mean number of ligatures applied was 7.2 +/- 1.5. Postoperatively, 72% of patients did not need analgesics and the other 28% used nonsteroidal antiinflammatory drugs 1-3 times/day for less than 2 days. All the patients were operated as a day case. Early postoperative complications included haemorrhoidal thrombosis (2 patients), bleeding (1) treated by haemostatic suture, dysuria (6) and acute urinary retention (1). After a mean follow-up of 15.6 +/- 6.5 months (range 6-32), 2/105 (20.9%) patients complained of minor bleeding, while mild pain was still present in 4/51 patients (7.8%). There were no statistically significant differences in the sample population regarding the gender or stage of the disease. Tenesmus was cured in 15/17 patients, dyschaezia in 20/22 patients and mucous soiling in 10/10 patients. No new cases of altered defaecation or faecal incontinence were recorded. Overall, 85.7% of patients were cured and 7.1% improved. Residual haemorrhoids were treated by elastic band ligation in nine (8%) patients and by surgical excision in further five patients (4.5%).

CONCLUSION

Doppler-assisted ligation of the terminal branches of the haemorrhoidal arteries for II and III degree haemorrhoids is highly effective and painless. Complications are few and the technique can be performed as a day case.

Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results

PURPOSE

Haemorrhoidal disease is a frequently occurring entity in the western world. The Procedure for prolapse and haemorrhoids (PPH) and transanal haemorrhoidal dearterialisation (THD) are the most important surgical treatments that respect normal anal anatomy. This is the first randomized trial that compares both techniques in the treatment of grade III and IV haemorrhoids.

METHODS

Patients with grade III or IV haemorrhoids were randomized between PPH and THD. Patients were seen after 1 week, 3 weeks and 6 weeks postoperatively. Primary endpoint was resolved symptoms 6 weeks postoperatively. Secondary endpoints were pain, measured with a visual analogue scale (VAS) after 1 day, 1 week and 3 weeks, and complications.

RESULTS

Eighteen patients were allocated to PPH versus 23 to THD. Success rates after 6 weeks were 83% in the PPH group versus 78% in the THD group. VAS scores were significantly lower after 1 day and 1 week in the THD group, but equalled out after 3 weeks. Twelve percent of the patients after PPH and 4% after THD needed an urgent readmission to treat an acute bleeding. Overall complication rates did not differ significantly.

CONCLUSION

Both PPH and THD are safe treatments for grade III and IV haemorrhoids with acceptable complication rates and good short-term results. THD might be the preferred treatment because it carries the similar complication rate and short-term results, but results in less postoperative pain when compared with PPH. Moreover, it is a less invasive, more easily learned and less costly procedure.

Radiowave ablation and mucopexy for prolapsing hemorrhoids--a pilot study

OBJECTIVE

The author proposes a technique of radiowave ablation and mucopexy of hemorrhoids for patients having symptomatic and prolapsing hemorrhoids and enumerates the events in such patients over 10 years.

MATERIAL AND METHOD

From May 1997 through December 2007, 3148 patients were included in the study. The hemorrhoids were ablated using radiowaves through a Ellman radiowave generator and were followed by suture ligation with absorbable suture material under vision. Operating time, postoperative complications, time to return to work, and outcome of the procedure were analyzed.

RESULTS

The mean procedure time was 8+/-0 min (range, 5-14 min). The mean total analgesic dose and duration of pain control using analgesics was 17+/-5 tablets, and 10+/-4 days respectively. The mean period of incapacity for work was 6 days [range 4-17 days]. Complications were identified in 4.8% patients. The postoperative follow-up after 4 weeks revealed therapeutic success in 3013 patients (95.7%), who presented with hemorrhoidal bleeding. Prolapse was no longer observed in 3085 (98%) of patients and 3022 (96%) patients experienced no pain after defecation. Up to December 2006, a total of 2897 patients were treated with this method. 2246 patients responded to our inquiry conducted at the beginning of 2008. Ninety-six percent of these patients confirmed that they no longer experienced any bleeding or pain during defecation and ninety-two percent patients did not had any prolapse.

CONCLUSIONS

This study shows that radiowave ablation followed by suture ligation of hemorrhoids is a simple, cost effective and convenient modality in treating prolapsing hemorrhoids.