Anorectal physiology is not changed following transanal haemorrhoidal dearterialization for haemorrhoidal disease: clinical, manometric and endosonographic features

Hemorrhoidal Artery Ligation for the Treatment of Grade II-III Hemorrhoids: Is it Worth the Use of Doppler Guide in Long-Term Follow-Up?: A Single-Center Cohort Study

Background

Hemorrhoidal artery ligation (HAL) may reduce postoperative pain and complications and shorten patients' recovery when compared to standard hemorrhoidectomy. It is unclear if the Doppler guide (DG) is useful in reducing recurrence risk.

Objective

To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade.

Methods

Between January 1, 2014 and January 31, 2021, 122 patients affected by grade II-III hemorrhoidal prolapse underwent DG-HAL or HAL at Chivasso Hospital, Italy. Mucopexy was routinely performed. After discharge, patients were subjected to 1-week, 1-, 3-, 6-, and 12-month clinical assessment. Thereafter, they were interviewed by telephone annually.

Results

Seventy-six (62.3%) DG-HAL and 46 (37.7%) HAL procedures were performed. Median surgical time was 30 (15-45) minutes for DG-HAL versus 25 (15-40) minutes for HAL (P = 0.005). No intraoperative complications occurred. Postoperative bleeding needing surgery occurred in 2 (1.6%) patients in the DG-HAL group. During a median follow-up of 46 months (6-86), we registered 18 (23.7%) recurrences in the DG-HAL group and 13 (28.3%) in the HAL one (P = 0.574). No cases of incontinence or anal stenosis occurred. No significant difference was observed between the two groups in terms of patients' satisfaction. At multivariate analysis, age ≥ 65 years resulted a protective factor for recurrence (odds ratio 0.31; 95% confidence interval 0.09-0.98; P = 0.047).

Conclusions

In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.

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.

Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam

INTRODUCTION

Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment.

METHODS

This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure.

RESULTS

A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence.

CONCLUSION

The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.

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.

Transanal anopexy with HemorPex System (HPS) is effective in treating grade II and III hemorrhoids: medium-term follow-up

BACKGROUND

Hemorrhoidal disease is a common proctologic disorder. The HemorPex System(®) (HPS) (Angiologica, S. Martino Siccomario PV, Italy) is an innovative surgical technique based on muco-hemorrhoidopexy without Doppler guidance. The aim of this study was to evaluate the efficacy of HPS in on the treatment of grade II and III hemorrhoids.

METHODS

One hundred patients with grade II and III hemorrhoidal disease were included in the study and operated on using HPS without Doppler guidance. The procedure consists of a mucopexy carried out by means of a dedicated rotating anoscope in the 6 relatively constant positions of the terminal branches of the superior hemorrhoidal artery. A direct follow-up was carried out on 100 patients for up to 3 months. A late analysis (>12 months postoperatively) was conducted by telephone interview. At follow-up the following parameters were considered: pain, bleeding, prolapse, difficulties with hygiene and patient satisfaction with treatment.

RESULTS

Operative time was 16 ± 5 min. Three-month follow-up showed significant improvement of symptoms: pain was present in 10 (10 %) patients versus 45 (45 %) preoperatively; bleeding in 13 (13 %) of patients versus 57 (57 %) preoperatively; prolapse in 13 (13 %) of patients versus 45 (45 %) preoperatively and difficulties with hygiene in 1 (1 %) versus 24 (24 %) preoperatively (all p < 0.05). At longer follow-up which was available in 67 patients, 5 patients (7.5 %) had recurrence and were reoperated on at 8, 10, 24, 26 and 36 months, respectively after the first procedure. As regards patient satisfaction, complete satisfaction was reported by 95/100 patients (95 %) at 3 months, 62/67 (92.5 %) at 12 months and 8/56 (85.7 %) at 24 months; partial satisfaction was reported by 3/100 patients (3 %) with intermittent bleeding at 3 months, 3/67 (4.4 %) patients at 12 months and 6/56 (10.7 %) patients at 24 months, all with either intermittent bleeding or prolapse. Dissatisfaction with the procedure was reported by in 1/100 (1 %) patient at 3 months, 2/67 (2.9 %) at 12 months and 2/56 (3.6 %) at 24 months including patients who underwent reintervention.

CONCLUSIONS

HPS can be used in the treatment of grade II and III hemorrhoidal disease. Our results show that this simple technique may be an effective but due to the important limitations of this study (loss to follow-up, non-comparative study) further studies are required.

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.

Doppler-guided ligation of hemorrhoidal arteries with mucopexy: A technique for the future

PURPOSE

The transanal hemorrhoidal de-arterialization (THD) procedure is an effective treatment of hemorrhoidal disease. The ligation of hemorrhoidal arteries ("de-arterialization") can provide a significant reduction of arterial blood flow to the hemorrhoidal tissues. Plication of redundant rectal mucosa/submucosa ("mucopexy") can reposition prolapsing tissue to its original anatomical site. In this paper the surgical technique using a specific device (THD(®) Doppler) and peri-operative patient management are illustrated.

METHODS

After appropriate clinical assessment, patients undergo the THD procedure under general or spinal anesthesia, in either the dorsal lithotomy or prone jackknife position. A specifically designed device is used. In all patients, THD is performed, consisting of selective ligation of hemorrhoidal arteries identified by Doppler and marked with a mucosal stitch overlying the artery. In patients with hemorrhoidal or mucosal prolapse, a mucopexy is also performed using continuous suture(s) that include the redundant prolapsing mucosa and submucosa.

RESULTS

In long-term follow-up, THD results in resolution of symptoms in the majority of patients. The most common complication is transient but sometimes-painful tenesmus. Rectal bleeding occurs in only a very limited number of patients. There is little or no risk of fecal incontinence or chronic pain. Ano-rectal manometry and endo-anal ultrasound show no evidence of injury to physiologic sphincteric function.

CONCLUSIONS

THD is a safe procedure and is, at present, one of the most effective treatments of hemorrhoidal disease.

THD Doppler procedure for hemorrhoids: the surgical technique

Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease. The ligation of hemorrhoidal arteries (called “dearterialization”) can provide a significant reduction of the arterial overflow to the hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called “mucopexy”) can provide a repositioning of prolapsing tissue to the anatomical site. In this paper, the surgical technique and perioperative patient management are illustrated. Following adequate clinical assessment, patients undergo THD under general or spinal anesthesia, in either the lithotomy or the prone position. In all patients, distal Doppler-guided dearterialization is performed, providing the selective ligation of hemorrhoidal arteries identified by Doppler. In patients with hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a continuous suture including the redundant and prolapsing mucosa and submucosa. The description of the surgical procedure is complemented by an accompanying video (see supplementary material). In long-term follow-up, there is resolution of symptoms in the vast majority of patients. The most common complication is transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal bleeding occurs in a very limited number of patients. Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure. When accurately performed and for the correct indications, THD is a safe procedure and one of the most effective treatments for hemorrhoidal disease.