Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial

Haemorrhoid artery ligation - recto anal repair (HAL-RAR) blind versus Doppler: a systematic review and meta-analysis

BACKGROUND

Haemorrhoids remain a highly prevalent condition in Australia, affecting 39% of the adult Australian population. While haemorrhoidectomy remains the gold standard in the management of haemorrhoids, newer techniques such as haemorrhoid artery ligation-recto anal repair (HAL-RAR) are emerging as promising management modalities. We compare the efficacy of non-Doppler guided (non-DG) HAL-RAR versus Doppler-guided (DG) HAL-RAR in the management of haemorrhoids.

METHODS

This study was registered with PROSPERO (CRD42022353806) and adhered to PRISMA 2020 guidelines. We conducted a systematic review using Medline, Embase and Cochrane database for comparative studies between Doppler-guided HAL-RAR and non-Doppler-guided HAL-RAR in accordance with the PRISMA 2020 statement for reporting systematic reviews.

RESULTS

Five studies were included in our systematic review and meta-analysis. There was no clinically significant difference in operative times (SMD 0.46, 9% CI -3.16 0 4.08, P = 0.804) or post-operative bleeding (P = 0.142) between the two groups. DG HAL-RAR patients were more likely to have post-operative urinary retention (P < 0.001). Non-DG patients were less likely to experience recurrence (OR 5.12, P < 0.001).

CONCLUSION

Our review of non-DG HAL-RAR compared to DG HAL-RAR reflects the non-inferiority of the non-DG HALRAR procedure. We hope that these results would provide a guide to clinicians performing HAL-RAR, and would provide some cost savings for institutions who are unable to procure the necessary equipment for DG HAL-RAR.

Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study

BACKGROUND

Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids.

OBJECTIVE

This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease.

DESIGN

Multicenter retrospective study.

SETTINGS

Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study.

PATIENTS

Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period.

MAIN OUTCOME MEASURES

The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up.

RESULTS

Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device.

LIMITATIONS

The retrospective design and the self-reported nature of data from different centers.

CONCLUSIONS

Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).

Results of sclerotherapy and mucopexy with haemorrhoidal dearterialization in II and III degree haemorrhoids. A 4 years' single centre experience

Introduction

Haemorrhoidal disease (HD) affects a considerable portion of the adult population. The aim of this study is to confirm the safety and efficacy of the treatments and to report the long-term outcomes of Sclerotherapy (ST) and Mucopexy and Haemorrhoidal Dearterialization (MHD) performed over the last 4 years in a single tertiary centre. The secondary outcome is to evaluate the usefulness of both techniques and to demonstrate how those can be associated as a bridge to surgery.

Materials and methods

Patients affected by second-third-degree haemorrhoids and undergoing ST or non-Doppler guided MHD between 2018 and 2021 were enrolled. Safety and efficacy, recurrence rate, Haemorrhoid Severity Score (HSS) and pain resulting from both techniques were evaluated.

Results

Out of 259 patients, 150 underwent ST. Further, 122 (81.3%) patients were male and 28 (18.7%) were female. The mean age was 50.8 (range 34-68) years. Most of the patients (103, 68.6%) were affected by second-degree HD, while 47 (31.4%) were affected by third-degree HD. The overall success rate was 83.3%. The median pre-operative HSS score was 3 (IQR 0-4, p = 0.04) and at 2 year the median HSS was 0 (IQR 0-1, p = 0.03). No intraoperative complications and no drug-related side effects occurred. The mean follow-up for ST was 2 years (range 1-4; SD ±0.88). MHD was performed on 109 patients. In detail, 80 patients (73.4%) were male while 29 patients (26.6%) were female. The mean age in this group was 51.3 (range 31-69). Further, 72 patients (66.1%) were affected by third-degree HD and 37 (33.9%) by second-degree HD. The median HSS score was 9 (IQR 8-10, p = 0.001) preoperatively two years after treatment was 0 (IQR 0-1, p = 0.004). Major complications occurred in three patients (2.75%). The overall success rate was 93.5% (second degree 89.2% vs. third degree 95.8%). The mean follow-up for MHD was 2 years (range 1-4; SD ±0.68).

Conclusions

The results confirm the usefulness of those techniques, which can be considered safe and easily repeatable procedures, with a low recurrence rate after 2 years of median follow-up.

Minimally Invasive Treatment for Advanced Hemorrhoids

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Early Postoperative Outcomes of a Novel Nonexcisional Technique Using Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy With Mucopexy on Patients With Grade III Hemorrhoids

Purpose

Aluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids.

Methods

AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial.

Results

The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6–5.5] vs. 7.6 tablets [range 3.3–11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery.

Conclusion

AM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization

BACKGROUND

Arterial hyperflow to haemorrhoids has been implicated as a possible pathophysiological co-factor in haemorrhoidal disease. The purpose of this study was to investigate how transanal haemorrhoidal dearterialization (THD) can influence haemodynamic parameters at the level of the haemorrhoidal piles.

METHODS

Patients with grade III haemorrhoids selected for THD between July and December 2018 were evaluated using endoanal ultrasonography and colour Doppler imaging at the level of internal haemorrhoids before and 1 year after the surgical procedure. Peak systolic velocity, pulsatility index, resistivity index, acceleration time, and end-diastolic velocity were measured, and preoperative and postoperative values compared. Symptom severity was measured using a symptom-based questionnaire (score range 0-20).

RESULTS

Of 21 patients treated, 17 completed the study. Compared with preoperative values, postoperative peak systolic velocity (mean(s.d.) 18.7(1.1) versus 10.3(0.4) cm/s; P < 0.05), pulsatility index (5.5(0.3) versus 2.8(0.4); P < 0.050), and resistivity index (1.0(0.2) versus 0.8(0.5); P < 0.050) decreased significantly, whereas acceleration time increased significantly (65.6(3.6) versus 83.3(4.7) cm/s2; P < 0.050); end-diastolic velocity did not change (1.9(0.2) versus 2.0(0.4); P = 0.753). Symptoms disappeared or had improved significantly in all patients by 1 year after surgery. The mean(s.d.) total symptom severity score decreased from 15.8(1.1) to 1.2(1.6) (P < 0.001).

CONCLUSION

THD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL)

PURPOSE

We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD).

METHODS

The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL.

RESULTS

A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m²). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65).

CONCLUSION

Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.

Improvement in Hemorrhoidal Disease Surgery Outcomes Using a New Anatomical/Clinical-Therapeutic Classification (A/CTC)

Introduction  The introduction and diffusion of new techniques for hemorrhoidal surgery have made it clear how much Goligher classification is inadequate in the modern times, lacking in any correlation between anatomical and clinical features to a surgical procedure. The aim of the study was to evaluate if the application of a new classification of hemorrhoidal diseases might lead to an improvement in the postoperative surgical outcomes.

Methods  From January 2014 to December 2015, all patients undergoing surgery for hemorrhoidal disease were enrolled. The procedures performed were based upon a new anatomical/clinical–therapeutic classification (A/CTC) considering these items: anatomical presentation, symptom types and frequency, associated diseases, and available surgical treatments and their related contraindications. The new classification identified four groups: A (outpatient), B, C, and D (surgical approaches). The overall outcomes were assessed and then stratified by surgical groups. These data were then analyzed in comparison with the published data about all the surgical procedures performed.

Results  A total of 381 patients underwent surgery and they were stratified as follows: Group B (39), C (202), and D (140). Group B underwent Doppler-guided dearterialization with mucopexies or tissue selective therapy, Group C stapled procedures, and Group D hemorrhoidectomy. The mean follow-up was 30 months. The overall outcomes were: success rate 92.4%, recurrences 7.6%, postoperative complications 4.8%, long-term complications 5.4%, and reoperation rate 2.7%. The success rates stratified by groups were: B, 85%); C, 91.4%; and D, 95.7%.

Conclusion  The A/CTC proved to be useful in stratifying the patients and choosing the proper treatment for each case. This classification seems to improve the outcome of different surgical procedures if compared with those already published.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY

Background:

Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades.

Aim:

To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades.

Method:

Seven hundred and five consecutive patients with Goligher’s grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48).

Results:

Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively.

Conclusion:

The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

Scoring systems as outcomes assessment of the treatments for haemorrhoidal disease: a systematic review of the literature

PURPOSE

The comparison between haemorrhoidal treatments is still unclear. Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials. We aimed to systematically review the available outcome scores of haemorrhoidal treatment.

METHODS

MEDLINE/Pubmed, Web of science, Embase and Cochrane were searched from database implementation until the December 6th 2019. All studies describing or referencing a score to assess haemorrhoidal disease treatment were included. Likert scale alone, incontinence score alone, general assessment of quality of life or scores developed for other proctologic disorders were excluded. The main outcome measures were validation of the scores and correlation of the score items to the core outcome set for haemorrhoidal disease developed by the European Society of Coloproctology.

RESULTS

From the 633 records initially screened, 22 studies were included: 8 original articles describing a scoring system and 14 referencing a previously described scoring system. Only 1 score was validated by an external prospective cohort. All the scores evaluated the symptoms of haemorrhoidal disease. No score integrated the disease recurrences or patient's satisfaction. Scores values tended to decrease postoperatively.

CONCLUSIONS

The scores described by Gerjy et al. and by Shanmugan et al. are available questionnaires, which have been validated and used in various studies. These scores might help researchers for comparative studies between treatment modalities and optimize haemorrhoids treatment.

Transanal hemorrhoidal dearterialization: Lessons learned from a personal series of 200 consecutive cases and a proposal for a tailor-made procedure

Background

Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease (HD). However, the surgical technique is not standardized and the results for advanced HD are controversial. The aim of this study was to assess surgical outcomes after a long follow-up and compare total and partial mucopexy.

Materials and methods

Between March 2011 and July 2014, THD was offered to patients with symptomatic prolapsed hemorrhoids (Grades II, III and IV). Dearterialization was performed with the guidance of Ultrasound Doppler and mucopexy for prolapsed piles, and regarded as total or partial (if less than 6 mucopexies). Post-operative complications, long-term results and patients’ satisfaction rates were analyzed.

Results

200 consecutive patients were recruited with a mean follow-up of 43 months (range 29 - 57 months). HD distribution was GII (N = 35, 17.5%), GIII (N = 124, 62%), and GIV (N = 41, 20.5%). Postoperative complications included transient tenesmus (26,5%), pain (14%) and fecal impaction (2,5%). Recurrence rates were 0, 2,4% and 17,1% for prolapse (p < 0,01) and 2,9%, 4% and 9,8% for bleeding (p = 0,33) in grades II, III and IV, respectively. Total mucopexy resulted in more tenesmus (31,2%) than partial mucopexy (14,5%), (p < 0,01). After 12 weeks of follow-up, 85% of patients were either very satisfied or satisfied; 8,5% were dissatisfied.

Conclusion

THD-mucopexy is safe with low overall recurrence. Grade IV HD is associated with more recurrence and postoperative complications. Total mucopexy is associated with more tenesmus, pain and fecal impaction. A tailor-made procedure with selective dearterialization and mucopexy may be the next step in this evolving technique.

•

.THD is safe procedure for hemorrhoids with low overall recurrence of prolapse and bleeding.

•

.THD for grade IV hemorrhoidal disease is associated with more recurrence.

•

.THD with partial mucopexy achieves similar good results compared to total mucopexy.

•

.THD with total mucopexy is associated with more postoperative tenesmus, pain and fecal impaction.

•

.The number of dearterializations and mucopexies should be tailor-made.

Evaluation of Mucopexy-Recto Anal Lifting (MuRAL): A New Method for Treating Hemorrhoids

Objectives:

Ligation and excision remain the commonly recognized standard surgical modality for treating hemorrhoids. Further, impediments to surgical treatment owing to social factors and the need for minimally invasive procedures and other confounders have resulted in the adoption of the mucopexy-recto anal lifting (MuRAL) method which is associated with favorable outcomes. The objective of this study was to describe the procedure and report the outcomes in patients who underwent MuRAL.

Methods:

Between March 2016 and February 2018, 55 patients (26 males and 29 females) underwent MuRAL for hemorrhoids and rectal mucosal prolapse. The duration of the surgical procedure and hospitalization, postoperative complications, and satisfaction were evaluated.

Results:

The mean age of the male patients (n = 26) was 61.5 ± 4.9 years and that of the female patients (n = 29) was 61.5 ± 3.2 years. The mean duration of surgery was 46 ± 23 minutes for males and 53 ± 28 minutes for females, and the mean observation duration was 317 ± 186 days. Intraoperative hemorrhage was low for males and females. The mean hospitalization period was 3.2 ± 1.5 days for males and 4.3 ± 2.1 days for females. Differences in several postoperative complications were observed between male and female patients. Postoperative satisfaction was rated high by the patients.

Conclusions:

Risks of hemorrhage and pain associated with the MuRAL method were low because the procedure does not involve incision or excision. Other than ligation and excision, recurrence is favorable compared with that of other surgical modalities for the treatment of hemorrhoids.

A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD)

BACKGROUND

Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD.

METHODS

Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures.

RESULTS

Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently.

CONCLUSIONS

These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Hemorrhoid laser procedure with suture-pexy (HeLPexx): a novel effective procedure to treat hemorrhoidal disease

BACKGROUND

The hemorrhoid laser procedure with suture-pexy (HeLPexx), consisting of Doppler-guided hemorrhoidal dearterialization with laser and the addition of anal mucopexy, is a novel non-excisional procedure to treat hemorrhoids. The aim of the present study was to describe the technique and report the clinical and long-term results.

METHODS

A prospective study was conducted on patients with grade III hemorrhoids who had HeLPexx from January 2012 to February 2018. Pre- and postoperative assessment included a thorough clinical examination, constipation and incontinence scoring systems and a symptom questionnaire which was administered at all patients before surgery and at each follow-up visit to evaluate bleeding, prolapse, manual reduction, discomfort or pain, and impact on quality of life. Each symptom had a score between 0 and 4, (0 indicates no symptoms and 4 indicates daily symptoms). The sum of the score for each symptom constituted the Hemorrhoid Symptom Score. Resolution of symptoms, pain, morbidity, need for further medical and/or surgical therapy were also recorded.

RESULTS

One hundred and seventy consecutive patients with grade III hemorrhoids [74 females; mean age 49.5 years (range 22-79) years] were included. Median length of follow-up was 36 (range 12-72) months. Postoperative morbidity included urinary retention (7 patients, 4.1%), bleeding not requiring transfusion (1 patient, 0.6%) and thrombosis of hemorrhoidal piles (2 patients, 1.2%). The mean postoperative pain VAS score at 1 week postoperatively was 1.8 ± 1.1 (range 0-5) and 12 (7%) patients used pain medications for more than 1 week postoperatively while none of the patients reported any pain by the end of the third week postoperatively. The Hemorrhoid Symptom Score significantly improved from 15.83 ± 3.04 to 1.3 ± 2.4 (p ≤ 0.001) and showed a statistically significant improvement in all items. Recurrent symptoms were reported in 12 patients (7%) who required further treatment. Severe chronic constipation prior to surgery was found to be a predictive factor of failure (p = 0.04).

CONCLUSIONS

HeLPexx appears to be safe and effective for treatment of symptomatic hemorrhoids. Further studies are needed to confirm our results.

Transanal Hemorrhoidal Dearterialization With Doppler Arterial Identification Versus Classic Hemorrhoidectomy: A Retrospective Analysis of 270 Patients

Purpose

Despite the minimally invasive nature of transanal hemorrhoidal dearterialization (THD) with Doppler arterial identification procedures, hemorrhoidectomy is still considered the gold standard procedure for hemorrhoidal disease. However, the classical techniques of hemorrhoidectomy have a high rate of postoperative complications. The main purpose of this study is to demonstrate the efficacy and complications of these techniques used for grades II and III hemorrhoids.

Methods

A retrospective (case-control) study was carried out from January 2009 to May 2014, and all patients undergoing surgical procedures for hemorrhoidal disease in two French clinics were considered. Application of inclusion and exclusion criteria identified 270 eligible patients (163 undergoing Doppler THD and 107 treated with Milligan Morgan hemorrhoidectomy). Statistical analysis was calculated considering immediate postoperative complications, functional results, chronic complications, and recurrences.

Results

Analysis of primary outcomes showed a significant difference between the 2 groups concerning postoperative pain, which had a lower rate in THD (P = 0.0001) and in postoperative bleeding (P = 0.02) than hemorrhoidectomy. However, long-term follow-up at three years showed a superior rate of recurrence in the THD group (P = 0.009).

Conclusion

The THD technique is a safe and effective procedure for grades II and III hemorrhoids, has lower rates of post-operative pain and bleeding, and allows faster hospital discharge; however, it also shows a higher rate of recurrence at three years of follow-up.

Prospective Randomized Trial Comparing HAL-RAR Versus Excisional Hemorrhoidectomy: Postoperative Pain, Clinical Outcomes, and Quality of Life

PURPOSE

To compare outcomes of hemorrhoid artery ligation with recto-anal repair (HAL-RAR) and excisional hemorrhoidectomy (EH). The primary objective was to compare postoperative pain, and the secondary objectives were the following: symptom resolution rates, postoperative morbidity, recurrence, and changes in quality of life.

METHOD

Prospective randomized controlled trial, including 40 patients with grades III-IV hemorrhoids who were allocated 1:1 to HAL-RAR and EH. Follow-up evaluation was performed at 15 days, 30 days, 6 months, 12 months, and then annually. Pain was measured using a Visual Analogic Scale and was self-recorded by patients. Quality of life was measured with Short Form Survey-36 questionnaire.

RESULTS

Postoperative pain was lower in the HAL-RAR group during the first 30 postoperative days. Moreover, from day 7 onward more patients in the HAL-RAR group reported complete absence of pain (Visual Analogic Scale score = 0). Globally, symptom resolution was significantly higher ( P = .03) in the HAL-RAR group at day 15. Bleeding resolution was observed earlier in the HAL-RAR group than in the EH group ( P = .04), but no differences in the resolution of prolapse, itching, and soiling were observed during the 30-day follow-up. After a mean follow-up of 15 months (range 12-27 months), no differences in postoperative morbidity and no recurrences were observed. An improvement was observed in all sections evaluated by the Short Form Survey-36 questionnaire with both techniques.

CONCLUSION

HAL-RAR provokes less postoperative pain during a shorter period than EH and achieves resolution of hemorrhoidal symptoms with less postoperative complaints. No differences in morbidity and recurrence rate were observed after 12 months of follow-up.

Transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) in treatment of internal hemorrhoids: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Although conventional hemorrhoidectomy proved effective in treatment of hemorrhoidal disease, postoperative pain remains a vexing problem. Alternatives to conventional hemorrhoidectomy as transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidopexy (SH) were described. The present meta-analysis aimed to review the randomized trials that compared THD and SH to determine which technique is superior in terms of recurrence of hemorrhoids, complications, and postoperative pain.

METHODS

Electronic databases were searched for randomized trials that compared THD and SH for internal hemorrhoids. The PRISMA guidelines were followed when reporting this meta-analysis. The primary endpoint of the analysis was persistence or recurrence of hemorrhoidal disease. Secondary endpoints were postoperative pain, complications, readmission, return to work, and patients' satisfaction.

RESULTS

Six randomized trials including 554 patients (THD = 280; SH = 274) were included. The mean postoperative pain score of THD was significantly lower than SH (2.9 ± 1.5 versus 3.3 ± 1.6). 13.2% of patients experienced persistent or recurrent hemorrhoids after THD versus 6.9% after SH (OR = 1.93, 95%CI = 1.07-3.51, p = 0.029). Complications were recorded in 17.1% of patients who underwent THD and 23.3% of patients who underwent SH (OR = 0.68, 95%CI 0.43-1.05, p = 0.08). The average duration to return to work after THD was 7.3 ± 5.2 versus 7.7 ± 4.8 days after SH (p = 0.34). Grade IV hemorrhoids was significantly associated with persistence or recurrence of hemorrhoidal disease after both procedures.

CONCLUSION

THD had significantly higher persistence/recurrence rate compared to SH whereas complication and readmission rates, hospital stay, return to work, and patients' satisfaction were similar in both groups.

Transanal Hemorrhoidal Dearterialization Versus Stapled Hemorrhoidopexy: Long-Term Follow-up of a Prospective Randomized Study

Aim. This study aims to compare the early and late outcomes of transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) for the treatment of hemorrhoidal disease. Methods. From January 2013 to December 2014, 100 patients—50 patients on each arm—were randomly allocated to THD or SH groups. The inclusion criteria were grade III and IV hemorrhoids diagnosed by clinical examination and proctoscopy. The primary outcome was to compare the recurrence rate with a minimum follow-up of 2 years, and the secondary outcome was to compare complications rate, time to return to work postsurgery, procedure length, and patient’s satisfaction between the 2 techniques. Results. The mean follow-up period was 33.7 ± 7.6. The recurrence rate was 4% in the SH group and 16% in the THD group ( P = .04). There was no difference in the intraoperative and postoperative complications rate; the pain score was significantly higher in the THD group. The mean operative time was significantly shorter in the SH group compared with the THD group. Patients in the THD group returned to work or routine activities significantly later compared with patients in the SH group. The overall satisfaction rate was also higher in the SH group. Conclusion. Both procedures are simple and easy to perform for the treatment of grade III and IV hemorrhoids. SH showed better results in terms of lower rate of recurrence, lower postoperative pain, quicker return to work, and higher patient satisfaction.

Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: a single-center study on 1000 consecutive cases and a review of the literature

Background

The transanal hemorrhoidal dearterialization (THD) Doppler procedure is a minimally invasive technique to treat symptomatic hemorrhoids. The aim of the study was to assess the clinical efficacy and the satisfaction of patients in a large series treated with THD and to review the relevant literature.

Methods

In this retrospective, single-institution, study consecutive patients with grade 2, 3, or 4 hemorrhoidal disease were treated with the THD Doppler procedure. Dearterialization was performed in all cases and mucopexy in case of prolapse. The dearterialization procedure evolved from “proximal artery ligation” to “distal Doppler-guided dearterialization.” Follow-up was scheduled at 15 days, 1, 3, 12 months, and once a year thereafter. Complications were recorded. Clinical efficacy was assessed comparing both frequency of symptoms and disease grading (Goligher’s classification) at baseline versus last follow-up. Uni-/multivariate analysis evaluated factors affecting the outcome.

Results

There were 1000 patients (619 men; mean age: 48.6 years, range 19–88 years). Acute postoperative bleeding was observed in 14 patients (1.4%), pain/tenesmus in 31 patients (3.1%), and urinary retention in 23 patients (2.3%). At mean follow-up duration of 44 ± 29 months, the symptomatic recurrence rate was 9.5% (95 patients; bleeding in 12 (1.2%), prolapse in 46 (4.6%), and bleeding and prolapse in 37 (3.7%) patients). The recurrence rate was 8.5, 8.7, and 18.1% in patients with grade 2, 3, and 4 hemorrhoids, respectively. Seventy out of 95 patients with recurrence needed surgery (reoperation rate: 7.0%). At final follow-up and taking into account the reoperations, 95.7% of patients had no hemorrhoidal disease on examination. Younger age, grade 4 disease, and high artery ligation affected the outcome negatively.

Conclusions

Our results show that the THD Doppler procedure is safe and effective in patients with hemorrhoidal disease and associated with low morbidity and recurrence rates and a high rate percentage of treatment success.

Comparison of two procedures for symptomatic hemorrhoidal disease: Ligation under Vision and Ferguson Hemorrhoidectomy - a retrospective cohort study

OBJECTIVE

To compare Ligation under Vision (LUV) with Ferguson Hemorrhoidectomy (FH) in patients with Grade II, III and IV hemorrhoidal diseases according to their postoperative outcomes.

METHODS

Between July 2008 and August 2014, 155 patients underwent FH and 120 patients LUV, in Sakarya University Teaching and Research Hospital. Our retrospective analysis focuses on postoperative complications, postoperative pain and rate of recurrence. In LUV procedure, submucosal tissue of the hemorrhoidal pile base was transfixed using absorbable sutures under direct vision through anoscope in the Jackknife position.

RESULTS

In a mean postoperative follow-up period of 51.76+/-22.3 months; ectropion, anal fissure, and anal incontinence were the most frequent complications. The overall complication rate was significantly less after LUV than FH, (6.7% vs. 14.2%, P=0.047). The complication rate and need for a second or third surgery did not significantly differ between the two procedures with the increase in affected quadrants (P>0.05). The visual analog scale (VAS) at 24 hours was similar in both groups (P=0.267).

CONCLUSIONS

LUV is a safe, and practical procedure with similar outcomes compared to FH. LUV may be a better choice than excisional hemorrhoidectomies when three or four quadrants of the anal canal are involved with hemorrhoids as this reduces mucosal defect related possible complications such as ectropion and anal stenosis.

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.

Hubble trial: time to stick to basics for treatment of haemorrhoids?

The results of the Hubble trial, a randomised controlled trial comparing haemorrhoidal artery ligation with rubber band ligation for early-grade prolapsing haemorrhoids, are discussed. The difficulties in defining treatment success are debated along with the trial design highlighting the pitfalls of previous research. A finding that haemorrhoidal artery ligation is not necessarily superior to cheap alternatives has implications for current practice and future commissioning of surgeons.

Aluminum potassium sulfate and tannic acid sclerotherapy for Goligher Grades II and III hemorrhoids: Results from a multicenter study

AIM: To show that aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy has a high success rate for Grade II and III hemorrhoids.

METHODS: This study was based on the clinical data of 604 patients with hemorrhoids who underwent ALTA sclerotherapy between January 2009 and February 2015. The objective of this study was to assess the efficacy of this treatment for Grades II and III hemorrhoids. Preoperative and postoperative symptoms, complications and success rate were all assessed retrospectively. Follow-up consisted of a simple questionnaire, physical examination and an anoscopy. Patients were followed-up at one day, one week, two weeks, one month, one year, two years, three years, four years and five years after the ALTA sclerotherapy.

RESULTS: One hundred and sixty-nine patients were diagnosed with Grade II hemorrhoids and 435 patients were diagnosed with Grade III hemorrhoids. The one year, three year and five year cumulative success rates of ALTA sclerotherapy for Grades II and III hemorrhoids were 95.9% and 93.1%; 89.3% and 83.7%; and 89.3% and 78.2%, respectively. No significant differences were observed in the cumulative success rates after ALTA sclerotherapy between Grades II and III hemorrhoids (P = 0.09). There were forty-seven post-operative complications (low grade fever; anal pain; urinary retention; rectal ulcer; and others). No serious or life-threatening complications occurred and all cases improved through conservative treatment. At univariate analysis there were no predictive factors of failure.

CONCLUSION: ALTA sclerotherapy has had a high success rate for Grade II and III hemorrhoids during five years of post-operative treatment. However, additional studies are needed to evaluate the efficacy of this ALTA sclerotherapy in the management of hemorrhoidal disease.

Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient?

Background

Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation.

Methods

During a 53-month period (February 2009–July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery.

Results

During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455–3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study’s 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049).

Conclusions

These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.

HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up

PURPOSE

To analyse prospectively results of HAL-RAR technique by evaluating pain, perioperative complications and clinical outcome after two years followup.

METHODS

A prospective study design including 30 consecutive patients with haemorrhoids grade III-IV treated from June 2012. After discharge, patients received a specific questionnaire to record postoperative pain, delayed complications, evolution/disappearance of the symptoms that led to the surgical intervention (bleeding, prolapse, itching, pain and soiling). A visual analog scale (VAS) was used to measure pain. Outpatient follow-up was carried out at 7 days, and 1, 6 and 12 months and annually thereafter. Pre, intra and postoperative data (including physical examination) had been recorded prospectively.

RESULTS

The median operating time (range) was 40 (26-60) minutes. Average hospital stay (range) was 11 (3-25) hours. No postoperative complications were observed in 29 cases (96.6%). Median follow-up was 26 (12-36) months. All the patients attended the follow-up. Mean postoperative pain was VAS = 1.7 on the seventh day and it was practically non-existent (VAS = 0.7) 1 month after the procedure. 87.5% of patients confirmed complete relief of symptoms after 30 days and 93% of patients feel free of symptoms 6 months after the procedure. No patient has experienced late complications as dyschezia, urgency, soiling or faecal incontinence. After 24 months follow-up, recurrence of bleeding and prolapse was observed in only 1 patient; 93% of patients have considered results of HAL-RAR as very good or excellent.

CONCLUSION

HAL-RAR is safe and almost painless technique and it has very good results in the control of haemorrhoidal symptoms. This procedure should be considered as an effective first treatment option for haemorrhoids.

Advantages and limits of hemorrhoidal dearterialization in the treatment of symptomatic hemorrhoids

In the last two decades, hemorrhoidal dearterialization has become universally accepted as a treatment option for symptomatic hemorrhoids. The rationale for this procedure is based on the assumption that arterial blood overflow is mainly responsible for dilatation of the hemorrhoidal plexus due to the absence of capillary interposition between the arterial and venous systems within the anal canal. Dearterialization, with either suture ligation (Doppler-guided hemorrhoid artery ligation/transanal hemorrhoidal dearterialization) or laser (hemorrhoidal laser procedure), may be successfully performed alone or with mucopexy. Although the added value of Doppler-guidance in association with dearterialization has recently been challenged, this imaging method still plays an important role in localizing hemorrhoidal arteries and, therefore, minimizing the effect of anatomic variation among patients. However, it is important to employ the correct Doppler transducer. Some Doppler transducers may not easily detect superficial arteries due to inadequate frequency settings. All techniques of dearterialization have the advantage of preserving the anatomy and physiology of the anal canal, when compared to other surgical treatments for hemorrhoids. This advantage cannot be underestimated as impaired anal function, including fecal incontinence and other defecation disorders, may occur following surgical treatment for hemorrhoids. Furthermore, this potentially devastating problem can occur in patients of all ages, including younger patients.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Recombinant streptokinase vs hydrocortisone suppositories in acute hemorrhoids: A randomized controlled trial

AIM: To compare the efficacy and safety of recombinant streptokinase (rSK) vs hydrocortisone acetate-based suppositories in acute hemorrhoidal disease.

METHODS: A multicenter (11 sites), randomized (1:1:1), open, controlled trial with parallel groups was performed. All participating patients gave their written, informed consent. After inclusion, patients with acute symptoms of hemorrhoids were centrally randomized to receive, as outpatients, by the rectal route, suppositories of rSK 200000 IU of one unit every 8 h (first 3 units) and afterwards every 12 h until 8 administrations were completed (schedule A), one unit every 8 h until 6 units were completed (schedule B), or 25 mg hydrocortisone acetate once every 8 h up to a maximum of 24 administrations. Evaluations were performed at 3, 5, and 10 d post-inclusion. The main end-point was the 5^th-day response (disappearance of pain and bleeding, and ≥ 70% reduction of the lesion size). Time to response and need for thrombectomy were secondary efficacy variables. Adverse events were also evaluated.

RESULTS: Groups were homogeneous with regards to demographic and baseline characteristics. Fifth day complete response rates were 156/170 (91.8%; 95%CI: 87.3-96.2), 155/170 (91.2%; 95%CI: 86.6%-95.7%), and 46/170 (27.1%; 95%CI: 20.1%-34.0%) with rSK (schedule A and B) and hydrocortisone acetate suppositories, respectively. These 64.6% and 63.9% differences (95%CI: 56.7%-72.2% and 55.7%-72.0%) were highly significant (P < 0.001). This advantage was detected since the early 3^rd day evaluation (68.8% and 64.1% vs 7.1% for the rSK and active control groups, respectively; P < 0.001) and was maintained even at the late 10^th day assessment (97.1% and 93.5% vs 67.1% for rSK and hydrocortisone acetate, respectively; P < 0.001). Time to response was 3 d (95%CI: 2.9-3.1) for both rSK groups and 10 d (95%CI: 9.3-10.7) in the hydrocortisone acetate group. This difference was highly significant (P < 0.001). All subgroup stratified analyses (with or without thrombosis and hemorrhoid classification) showed a statistically significant advantage for the rSK groups. Thrombectomy was necessary in 4/251 and 14/133 patients with baseline thrombosis in the rSK and hydrocortisone acetate groups, respectively (P < 0.001). There were no adverse events attributable to the experimental treatment.

CONCLUSION: rSK suppositories showed a significant advantage over a widely-used over-the-counter hydrocortisone acetate preparation for the treatment of acute hemorrhoidal illness, as well as having an adequate safety profile.