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Tutino R, Stecca T, Farneti F, Massani M, Santoro GA. Transanal eco-Doppler evaluation after hemorrhoidal artery embolization. World J Gastroenterol 2024; 30:2332-2342. [PMID: 38813050 PMCID: PMC11130570 DOI: 10.3748/wjg.v30.i17.2332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/27/2024] [Indexed: 04/30/2024] Open
Abstract
BACKGROUND Hemorrhoidal artery embolization (Emborrhoid) is a novel method for the treatment of severe hemorrhoidal bleeding. Despite having a technical success rate of 93%-100%, the clinical success ranges between 63% and 94%, with a rebleeding rate of 13.6%. AIM To evaluate the effectiveness of this procedure in reducing hemorrhoidal flow and hemorrhoidal bleeding. METHODS This prospective observational pilot study was conducted at Division of General Surgery 1 and Tertiary Referral Pelvic Floor Center, Treviso Regional Hospital, Italy. In a 2 months period (February-March 2022), consecutive patients with hemorrhoidal bleeding scores (HBSs) ≥ 4, Goligher scores of II or III, failure of non-operative management, and a candidate for Emborrhoid were included. Endoanal ultrasound with eco-Doppler was performed preoperatively and 1 month after the procedure. The primary endpoint was to quantify the changes in arterial hemorrhoidal flow after treatment. The secondary endpoint was to evaluate the correlation between the flow changes and the HBS. RESULTS Eleven patients underwent Emborrhoid. The overall pretreatment mean systolic peak (MSP) was 14.66 cm/s. The highest MSP values were found in the anterior left lateral (17.82 cm/s at 1 o'clock and 15.88 cm/s at 3 o'clock) and in the posterior right lateral (14.62 cm/s at 7 o'clock and 16.71 cm/s at 9 o'clock) quadrants of the anal canal. After treatment, the overall MSP values were significantly reduced (P = 0.008) although the correlation between MSP and HBS changes was weak (P = 0.570). A statistical difference was found between distal embolization compared with proximal embolization (P = 0.047). However, the coil landing zone was not related to symptoms improvement (P = 1.000). A significant difference in MSP changes was also reported between patients with type 1 and type 2 superior rectal artery (SRA) anatomy (P = 0.040). No relationship between hemorrhoidal grades (P = 1.000), SRA anatomy (P = 1.000) and treatment outcomes was found. CONCLUSION The preliminary findings of this pilot study confirm that Emborrhoid was effective in reducing the arterial hemorrhoidal flow in hemorrhoidal disease. However, the correlation between the post-operative MSP and HBS changes was weak. Hemorrhoidal grade, SRA anatomy and type of embolization were not related to treatment outcomes.
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Affiliation(s)
- Roberta Tutino
- Dipartimento Chirurgia Generale e Specialistica, AOU Città della Salute e della Scienza di Torino, Torino 10126, Italy
- Division of General Surgery 1, Treviso Regional Hospital, AULSS 2 Marca Trevigiana, Treviso 31100, Italy
| | - Tommaso Stecca
- Division of General Surgery 1, Treviso Regional Hospital, AULSS 2 Marca Trevigiana, Treviso 31100, Italy
| | - Fabrizio Farneti
- Division of Radiology, Treviso Regional Hospital, AULSS 2 Marca Trevigiana, Treviso 31100, Italy
| | - Marco Massani
- Division of General Surgery 1, Treviso Regional Hospital, AULSS 2 Marca Trevigiana, Treviso 31100, Italy
| | - Giulio Aniello Santoro
- Tertiary Referral Pelvic Floor Center, Division of General Surgery 2, AULSS 2 Marca Trevigiana, Treviso 31100, Italy
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Gao Y, Lodh SP, Ahmadi N. Pelvic arteriovenous malformation causing per rectal haemorrhage - A case report. Int J Surg Case Rep 2024; 115:109291. [PMID: 38280343 PMCID: PMC10839948 DOI: 10.1016/j.ijscr.2024.109291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/29/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE We present the case of a 17 years old girl with per rectal haemorrhage secondary to pelvic arteriovenous malformations (AVM) and potentially haemorrhoids. Pelvic AVMs are rare and extremely variable in their clinical presentation, size and location and pose a therapeutic challenge. Focus has turned towards interventional radiological procedures with angioembolisation as the main treatment form for pelvic AVMs. CASE PRESENTATION A 17 years old girl presented to a rural hospital with significant per rectal bleeding requiring transfer to a tertiary centre with interventional radiology capabilities. Diagnostic imaging determined the presence of a pelvic AVM as well as haemorrhoid. She had no prior history of haemorrhoids, per rectal bleeding or per vaginal bleeding. Further diagnostic imaging including a digital subtraction angiography and MRI pelvis was performed and her case was discussed at a multidisciplinary meeting where the decision was made for angioembolisation of a large right rectal AVM as well as precautionary banding of haemorrhoids that had developed secondary to outflow obstruction. A repeat CT mesenteric angiogram a month later demonstrated diminished appearances of the rectal AVM. CLINICAL DISCUSSION Pelvic AVMs are a rare entity and are not a common cause for per rectal bleeding. There is currently no direct consensus on the optimum management of complex pelvic AVMs particularly those that present with a second pathology such as haemorrhoids. Surgical management often results in recurrence or rapid progression of the AVM lesion and recruitment of new blood supply further complicates the problem. Selective embolisation allows for control of haemorrhage and utilises chemical agents as well as detachable coils and balloons. However, postoperative pain and swelling can still be expected and multiple transcatheter embolisations may be required. CONCLUSION The treatment of symptomatic pelvic AVMs is complex and requires a multidisciplinary approach with careful radiological planning prior to embolisation. Angioembolisation is becoming increasingly prevalent and multiple embolisation procedures may be required to reach the desired therapeutic effect.
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Affiliation(s)
- Yijun Gao
- St George Peritonectomy Unit, St George Public Hospital, Sydney, NSW 2217, Australia; University of New South Wales, St George & Sutherland Clinical School, Sydney, NSW 2217, Australia.
| | - Suhrid P Lodh
- St George Peritonectomy Unit, St George Public Hospital, Sydney, NSW 2217, Australia
| | - Nima Ahmadi
- St George Peritonectomy Unit, St George Public Hospital, Sydney, NSW 2217, Australia
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Bonomo LD, Falletto E, Cuccomarino S, Nicotera A, Jannaci A. 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. ANNALS OF SURGERY OPEN 2023; 4:e296. [PMID: 37601476 PMCID: PMC10431348 DOI: 10.1097/as9.0000000000000296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/03/2023] [Indexed: 08/22/2023] Open
Abstract
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.
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Affiliation(s)
| | - Ezio Falletto
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | | | - Antonella Nicotera
- From the General Surgery Unit, S.S. Pietro e Paolo Hospital, Borgosesia, Italy
| | - Alberto Jannaci
- Department of General Surgery, Chivasso Hospital, Chivasso, Italy
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Parello A, Litta F, De Simone V, Campennì P, Orefice R, Marra AA, Goglia M, Santoro L, Santoliquido A, Ratto C. Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization. BJS Open 2021; 5:6220256. [PMID: 33839752 PMCID: PMC8038259 DOI: 10.1093/bjsopen/zrab012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/02/2021] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- A Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - P Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - R Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - A A Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - M Goglia
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - L Santoro
- Medical Vascular Disease Clinic Unit, Fondazione Policlinico A. Gemelli IRCSS, Rome, Italy
| | - A Santoliquido
- Medical Vascular Disease Clinic Unit, Fondazione Policlinico A. Gemelli IRCSS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - C Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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Sobrado CW, Klajner S, Hora JAB, Mello A, Silva FMLD, Frugis MO, Sobrado LF. TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY. ACTA ACUST UNITED AC 2020; 33:e1504. [PMID: 32844877 PMCID: PMC7448859 DOI: 10.1590/0102-672020190001e1504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Carlos Walter Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
| | | | | | | | | | | | - Lucas Faraco Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
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Ratto C, Parello A, Litta F, De Simone V, Campennì P, Orefice R, Marra A. The evolving role of THD in hemorrhoids. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Trilling B, Mancini A, Reche F, Pflieger H, Sage PY, Faucheron JL. Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications. ANZ J Surg 2019; 89:E288-E291. [PMID: 31264350 DOI: 10.1111/ans.15143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 01/17/2019] [Accepted: 01/28/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. METHODS All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. RESULTS A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). CONCLUSIONS The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.
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Affiliation(s)
- Bertrand Trilling
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
| | - Adrian Mancini
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
| | - Fabian Reche
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
| | - Hannah Pflieger
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France
| | - Pierre-Yves Sage
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France
| | - Jean-Luc Faucheron
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France.,UMR 5525, CNRS, TIMC-IMAG, University Grenoble Alps, Grenoble, France
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Abstract
A broad spectrum of disease, from benign processes to life-threatening pathologies, can cause anal pain. MR imaging (MRI) has become increasingly widely used method over the past two decades for the evaluation of individuals with anorectal symptoms. Although imaging is rarely necessary to determine the etiology of the majority of cases, MRI is particularly useful as a noninvasive method of excluding severe neoplastic conditions. In this article, MRI findings of a number of pathologies such as anal and perianal neoplasms, hemorrhoidal disease, arteriovenous malformation of the perianal region, and anal sphincter lesions (defects, scarring, atrophy) which may lead to fecal incontinence are presented.
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Affiliation(s)
- Ayşe Erden
- Department of Radiology, School of Medicine, Ankara University, Talatpaşa Bulvarı, Sıhhiye, 06100, Ankara, Turkey.
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Ratto C, Campennì P, Papeo F, Donisi L, Litta F, Parello A. Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: a single-center study on 1000 consecutive cases and a review of the literature. Tech Coloproctol 2017; 21:953-962. [PMID: 29170839 PMCID: PMC5830492 DOI: 10.1007/s10151-017-1726-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 09/19/2017] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Carlo Ratto
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Paola Campennì
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesco Papeo
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Lorenza Donisi
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesco Litta
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Angelo Parello
- Proctology Unit, University Hospital "A. Gemelli", Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
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Aimaiti A, A Ba Bai Ke Re MMTJ, Ibrahim I, Chen H, Tuerdi M, Mayinuer. Sonographic appearance of anal cushions of hemorrhoids. World J Gastroenterol 2017; 23:3664-3674. [PMID: 28611519 PMCID: PMC5449423 DOI: 10.3748/wjg.v23.i20.3664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/20/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the diagnostic value of different sonographic methods in hemorrhoids.
METHODS Forty-two healthy volunteers and sixty-two patients with grades I-IV hemorrhoids received two different sonographic examinations from January 2013 to January 2016 at the First and Second Hospitals of Xinjiang Medical University in a prospective way. We analyzed the ultrasonographic findings of these participants and evaluated the outcomes. Resected grades III and IV hemorrhoid tissues were pathologically examined. The concordance of ultrasonographic results with pathology results was assessed with the Cohen’s kappa coefficient.
RESULTS All healthy volunteers and all patients had no particular complications related to sonography. There were no statistically significant differences between the participants regarding age (P = 0.5919), gender (P = 0.4183), and persistent symptoms (P > 0.8692). All healthy control participants had no special findings. However, 30 patients with hemorrhoids showed blood signals around the dentate line on ultrasonography. When grades I and II hemorrhoids were analyzed, there were no significant differences between transrectal ultrasound (TRUS), transperianal ultrasound (TPUS), and transvaginal ultrasound (TVUS) (P > 0.05). Grades III and IV hemorrhoids revealed blood flow with different directions which could be observed as a “mosaic pattern”. In patients with grades III and IV hemorrhoids, the number of patients with “mosaic pattern” as revealed by TRUS, TPUS and TVUS was 22, 12, and 4, respectively. Patients with grades III and IV disease presented with a pathologically abnormal cushion which usually appeared as a “mosaic pattern” in TPUS and an arteriovenous fistula in pathology. Subepithelial vessels of resected grades III and IV hemorrhoid tissues were manifested by obvious structural impairment and retrograde and ruptured changes of internal elastic lamina. Some parts of the Trietz’s muscle showed hypertrophy and distortion. Arteriovenous fistulas and venous dilatation were obvious in the anal cushion of hemorhoidal tissues. After pathological results with arteriovenous fistulas were taken as the standard reference, we evaluated the compatibility between the two methods according to the Cohen’s kappa co-efficiency calculation. The compatibility (Cohein kappa co-efficiency value) between “mosaic pattern” in the TPUS and arteriovenous fistula in pathology was very good (ĸ = 0.8939). When compared between different groups, TRUS presented the advantage that the mosaic pattern could be confirmed in more patients, especially for group A. There was a statistical difference when comparing group A with group B or C (P < 0.05 for both). There were obvious statistical differences between group A and group B with regard to the vessel diameter and blood flow velocity measured by TRUS (P < 0.05).
CONCLUSION Patients with grades III and IV hemorrhoids present with a pathologically abnormal cushion which usually appears as a “mosaic pattern” in sonography, which is in accord with an arteriovenous fistula in pathology. There are clearly different hemorrhoid structures shown by sonography. “Mosaic pattern” may be a parameter for surgical indication of grades III and IV hemorrhoids.
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Bjelanovic Z, Draskovic M, Veljovic M, Lekovic I, Karanikolas M, Stamenkovic D. Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. Cir Esp 2016; 94:588-594. [PMID: 27771095 DOI: 10.1016/j.ciresp.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/30/2016] [Accepted: 07/09/2016] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Zoran Bjelanovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia.
| | - Miroljub Draskovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia
| | - Milic Veljovic
- Clinic for Anesthesiology and Intensive Care, Military Medical Academy, Belgrado, Serbia
| | - Ivan Lekovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, San Luis, Misuri, Estados Unidos
| | - Dusica Stamenkovic
- Clinic for Anesthesiology and Intensive Care, Military Medical Academy, Belgrado, Serbia
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Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L, Pratschke J, Peer S, Gruber H. Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial. Colorectal Dis 2016; 18:710-6. [PMID: 26787597 DOI: 10.1111/codi.13280] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/19/2015] [Indexed: 02/08/2023]
Abstract
AIM Novel minimally invasive techniques aimed to reposition the haemorrhoidal zone have been established for prolapsing haemorrhoids. We present a prospective randomized controlled trial to evaluate the efficacy of additional Doppler-guided ligation of submucosal haemorrhoidal arteries (DG-HAL) in patients with symptomatic Grade III haemorrhoids. The trial was registered as ClinicalTrials.gov identifier NCT02372981. METHOD All consecutive patients with symptomatic Grade III haemorrhoids were randomly allocated to one of the two study arms: (i) Group A, DG-HAL with mucopexy or (ii) Group B, mucopexy alone. End-points were postoperative pain, faecal incontinence, bleeding, residual prolapse and alterations of the vascularization of the anorectal vascular plexus. Vascularization of the anorectal vascular plexus was assessed by transperineal contrast enhanced ultrasound. Patients recorded their symptoms in a diary maintained for a month. RESULTS Forty patients were recruited and randomized to the two study groups. Patients in Group A had less pain in the first two postoperative weeks. At the 12-month follow-up, two patients in Group A (10%) and one in Group B (5%) showed recurrent Grade III haemorrhoids (P = 0.274). No significant morphological changes were observed in the transperineal ultrasound findings between the preoperative assessment and the assessment at 1 and 6 months in either group (P > 0.05). CONCLUSION Mucopexy techniques for treating prolapsing haemorrhoids are effective, but DG-HAL does not add significantly to the results achieved by mucopexy. Repositioning the haemorrhoidal zone is the key to success, and mucopexy should be placed at the sites of the largest visible prolapse.
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Affiliation(s)
- F Aigner
- Department for General, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Berlin, Germany.,Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - I Kronberger
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - M Oberwalder
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - A Loizides
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - H Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Innsbruck, Austria
| | - L Gruber
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - J Pratschke
- Department for General, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Berlin, Germany.,Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - S Peer
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - H Gruber
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
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Basile M, Di Resta V, Ranieri E. Transanal anopexy with HemorPex System (HPS) is effective in treating grade II and III hemorrhoids: medium-term follow-up. Tech Coloproctol 2016; 20:353-359. [PMID: 27156521 DOI: 10.1007/s10151-016-1451-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 06/09/2015] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- M Basile
- Department of General Surgery, "Spirito Santo" General Hospital, Via Fonte Romana, 65124, Pescara, Italy.
| | - V Di Resta
- Department of Experimental and Clinical Science, "G. D'Annunzio" University, Chieti, Italy
| | - E Ranieri
- Department of Experimental and Clinical Science, "G. D'Annunzio" University, Chieti, Italy
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14
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Figueiredo MN, Campos FG. Doppler-guided hemorrhoidal dearterialization/transanal hemorrhoidal dearterialization: Technical evolution and outcomes after 20 years. World J Gastrointest Surg 2016; 8:232-237. [PMID: 27022450 PMCID: PMC4807324 DOI: 10.4240/wjgs.v8.i3.232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 12/19/2015] [Accepted: 01/22/2016] [Indexed: 02/06/2023] Open
Abstract
In the setting of Hemorrhoidal Disease treatment, the option of conventional hemorrhoidectomy is highly effective, but it is still associated with postoperative pain and discomfort. For this reason, technical alternatives have been developed in order to reduce complications and to provide better postoperative recovery. To accomplish this aim, non-excisional techniques such as stapled hemorrhoidectomy and Doppler-guided hemorrhoidal ligation have been introduced into clinical practice with high expectations. The aim of this article is to revise the literature about transanal hemorrhoidal dearterialization technique in the treatment of hemorrhoidal disease, looking into its evolution, results and possible benefits over other modalities of surgical treatment. The literature review showed that Doppler-guided hemorrhoidal dearterialization is a safe and effective method to treat grades II to IV hemorrhoidal disease. Outcomes in patients presenting prolapse are satisfactory and the association of anopexy is an important aspect of this operation. Anal physiology disturbances are rarely observed and mainly transitory. This technique is an excellent option for every patient, especially in those with previous anal surgeries and in patients with previous alterations of fecal continence, when an additional procedure might represent a risk of definitive incontinence.
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Noguerales F, Díaz R, Salim B, Piniella F, Landaluce A, Garcea A, de Mata López Pérez J. Tratamiento de la enfermedad hemorroidal mediante desarterialización y hemorroidopexia. Experiencia de varias unidades especializadas☆. Cir Esp 2015; 93:236-40. [DOI: 10.1016/j.ciresp.2014.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 03/28/2014] [Accepted: 04/11/2014] [Indexed: 01/19/2023]
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LaBella GD, Main WPL, Hussain LR. Evaluation of transanal hemorrhoidal dearterialization: a single surgeon experience. Tech Coloproctol 2015; 19:153-7. [PMID: 25637412 PMCID: PMC4369582 DOI: 10.1007/s10151-015-1269-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/20/2014] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- G D LaBella
- Division of Colon and Rectal Surgery and Trauma Surgery, Department of Surgery, Bethesda North and Good Samaritan TriHealth Hospital, Cincinnati, OH, USA,
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Ratto C, Parello A, Veronese E, Cudazzo E, D'Agostino E, Pagano C, Cavazzoni E, Brugnano L, Litta F. Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis 2015; 17:O10-9. [PMID: 25213152 DOI: 10.1111/codi.12779] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/20/2014] [Indexed: 12/11/2022]
Abstract
AIM This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome. METHOD Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni- and multivariate analyses of the potential predictive factors for failure were performed. RESULTS The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 ± 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively. Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome. CONCLUSION THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.
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Affiliation(s)
- C Ratto
- Proctology Unit, Department of Surgical Sciences, Catholic University, Rome, Italy
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Abstract
We analyzed the results of treatment of 432 patients with chronic hemorrhoids using different variants of latex ligation. New technique including ligation of mucosa and submucosa of low-ampullar rectum providing ligation of hemorrhoidalvessels, lifting and recto-anal repair is developed and suggested. This method is advisable to use in case of chronic internal hemorrhoids stages I and II. The authors recommend simultaneous combined ligation of mucosa of low-ampullar rectum and internal hemorrhoids for stages III and IV. Different variants of latex ligation with external hemorrhoids excision were used in 103 patients. Pointed variants of latex ligation preserve important advantages including mini-invasiveness, simplicity and wide availability, low cost. Good remote results were obtained after these procedures in 87.3% of observations. Suggested tactics extends use of latex ligation and increases its effectiveness in treatment of different stages and forms of chronic hemorrhoids.
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Affiliation(s)
- V N Ektov
- Chair of surgical diseases, N.N. Burdenko Voronezh State Medical Academy, Voronezh, Russia
| | - K A Somov
- Chair of surgical diseases, N.N. Burdenko Voronezh State Medical Academy, Voronezh, Russia
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Ratto C, de Parades V. Doppler-guided ligation of hemorrhoidal arteries with mucopexy: A technique for the future. J Visc Surg 2014; 152:S15-21. [PMID: 25262549 DOI: 10.1016/j.jviscsurg.2014.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- C Ratto
- Proctology Unit, Catholic University, 8, Largo A. Gemelli, 00168 Rome, Italy.
| | - V de Parades
- Service de Proctologie Médico-Chirurgicale, Groupe hospitalier Paris Saint-Joseph, Institut Léopold-Bellan, 185, rue Raymond-Losserand, 75014 Paris, France
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Giordano P, Tomasi I, Pascariello A, Mills E, Elahi S. Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids. Colorectal Dis 2014; 16:373-6. [PMID: 24460621 PMCID: PMC4283720 DOI: 10.1111/codi.12574] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/02/2013] [Indexed: 12/24/2022]
Abstract
AIM Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids. METHOD The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique. RESULTS From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms. CONCLUSION Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids.
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Affiliation(s)
- P Giordano
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - I Tomasi
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - A Pascariello
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - E Mills
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - S Elahi
- Department of Colorectal Surgery, Barts HealthLondon, UK
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Miyamoto H, Asanoma M, Miyamoto H, Takasu C, Masamune K, Shimada M. Visualization and hypervascularization of the haemorrhoidal plexus in vivo using power Doppler imaging transanal ultrasonography and three-dimensional power Doppler angiography. Colorectal Dis 2013; 15:e686-91. [PMID: 24034699 DOI: 10.1111/codi.12406] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/07/2013] [Indexed: 01/13/2023]
Abstract
AIM The purpose of this study was to demonstrate the distribution of haemorrhoidal arteries and the relationship between vascularity and growth of haemorrhoids. METHOD One-hundred and three patients with haemorrhoids were studied. Using power Doppler imaging (PDI) transanal ultrasound and three-dimensional power Doppler angiography (3D-PDA), the course of the arteries supplying the haemorrhoids was identified. Measurement of the PDI area was made using the cursor to outline the power Doppler signal of the haemorrhoid, approximately 1 cm above the dentate line. RESULTS The haemorrhoidal arteries were seen as branches of the superior rectal artery and were detected in 75.7, 71.8, 68.0 and 62.1% of the 11, 7, 3 and 1 o'clock positions in the lithotomy position. The median number of haemorrhoidal arteries significantly increased from three to six with progression of the Goligher classification from Grade 1 to Grade 4 (P < 0.0001). The PDI areas in Grades 1, 2, 3 and 4 were 0.04 ± 0.03, 0.18 ± 0.07, 0.38 ± 0.18 and 0.96 ± 0.32 cm(2) (P < 0.05). CONCLUSION The distribution of haemorrhoidal arteries varies widely in both number and position. Using PDI transanal ultrasonography and 3D-PDA it was possible to visualize the haemorrhoid plexus and the course of the haemorrhoidal artery in vivo.
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Affiliation(s)
- H Miyamoto
- Department of Surgery and Proctologic Surgery, Miyamoto Hospital, Anan, Japan; Department of Digestive and Pediatric Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
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Ratto C. THD Doppler procedure for hemorrhoids: the surgical technique. Tech Coloproctol 2013; 18:291-8. [PMID: 24026315 PMCID: PMC3950605 DOI: 10.1007/s10151-013-1062-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy,
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Stadiengerechte Therapie des Hämorrhoidalleidens. COLOPROCTOLOGY 2013. [DOI: 10.1007/s00053-013-0368-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cavazzoni E, Bugiantella W, Graziosi L, Silvia Franceschini M, Cantarella F, Rosati E, Donini A. Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding. Colorectal Dis 2013; 15:e89-92. [PMID: 23045996 DOI: 10.1111/codi.12053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/28/2012] [Indexed: 01/29/2023]
Abstract
AIM The effectiveness of Doppler guided transanal haemorrhoidal dearterialization (THD) for arresting persistent haemorrhoidal bleeding in patients admitted as an emergency was studied. METHOD Eleven patients with severe anal bleeding underwent emergency THD as definitive treatment for haemorrhoids. In the majority of patients antiplatelet or anticoagulant therapy was ongoing and severe anaemia was present in six patients. RESULTS The mean operative time was 39.7 min. Six to nine feeding arteries were ligated. Intra-operative blood loss was nil. Bleeding was well controlled in all patients. No blood transfusion was required. Mean pain score per verbal numeric scale was 3.6 and 1.4 on day 1 and day 3 respectively. The mean time to resumption of normal activities was 8 days. No major complications were experienced. Six months follow-up demonstrated good control of haemorrhoidal disease. CONCLUSION THD is effective in controlling acute haemorrhoidal bleeding with a low incidence of postoperative complications.
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Affiliation(s)
- E Cavazzoni
- Department of Surgery, University of Perugia, Perugia, Italy.
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Miyamoto H, Asanoma M, Miyamoto H, Takasu C, Shimada M. Three-dimensional power Doppler transanal ultrasonography, to monitor haemorrhoidal blood flow after Doppler-guided ALTA sclerosing therapy. Colorectal Dis 2013; 15:e84-8. [PMID: 22966905 DOI: 10.1111/codi.12024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to use power Doppler imaging (PDI) transanal ultrasonography to produce three-dimensional power Doppler angiography images of haemorrhoidal tissue and to monitor the effects of Doppler-guided aluminium potassium sulfate and tannic acid (DGALTA) sclerotherapy. METHOD Ninety-six haemorrhoids in 43 patients were examined using PDI transanal ultrasonography, and DGALTA sclerotherapy was performed from April 2011 to April 2012. DGALTA sclerotherapy was conducted using a four-step injection process with pulse wave Doppler ultrasound under perianal local anaesthesia. RESULTS A three-dimensional power Doppler angiography image of the blood flow in haemorrhoidal tissue was produced using PDI transanal ultrasonography. The cross-sectional area of blood flow in the haemorrhoidal tissue (PDI area) significantly decreased after DGALTA sclerotherapy. The PDI areas in the preoperative state and 1 and 3 months after treatment were 0.35±0.27, 0.03±0.05 and 0.04±0.05 cm(2) (P<0.0001). CONCLUSION A three-dimensional power Doppler angiography image of the haemorrhoidal tissue was technically possible and showed blood flow in the haemorrhoidal tissue to be significantly decreased after DGALTA sclerotherapy.
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Affiliation(s)
- H Miyamoto
- Department of Proctologic Surgery, Miyamoto Hospital, Tokushima, Japan.
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Middle rectal artery: myth or reality? Retrospective study with CT angiography and digital subtraction angiography. Surg Radiol Anat 2013; 35:517-22. [DOI: 10.1007/s00276-012-1068-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
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Ratto C, Donisi L, Parello A, Litta F, Zaccone G, De Simone V. 'Distal Doppler-guided dearterialization' is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization. Colorectal Dis 2012; 14:e786-9. [PMID: 22731786 DOI: 10.1111/j.1463-1318.2012.03146.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Rome, Italy.
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J. Deutsch C, Chan K, Alawattegama H, Sturgess J, J. Davies R. Doppler-Guided Transanal Haemorrhoidal Dearterialisation is a Safe and Effective Daycase Procedure for All Grades of Symptomatic Haemorrhoids. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ss.2012.311107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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