Embolization of a Hemorrhoid Following 18 Hours of Life-Threatening Bleeding

The Utility of Submucosal Linear Enhancement on Dynamic Computed Tomography for Patients With Internal Hemorrhoids

OBJECTIVE

The purpose of this study was to evaluate the utility of submucosal linear enhancement on dynamic computed tomography (CT) for patients with internal hemorrhoids.

METHODS

We retrospectively reviewed patients who were admitted to our institution due to acute lower gastrointestinal bleeding and underwent both dynamic CT and colonoscopy. The presence of submucosal linear enhancement of the intestinal wall from the lower rectum to the anal canal was evaluated using arterial-phase CT images. Based on these images, patients were then classified into 2 groups by 2 blinded radiologists, as follows: group A (absence of submucosal linear enhancement) and group B (presence of submucosal linear enhancement). The relationship between the groups and the risk of bleeding in internal hemorrhoids was evaluated using the size and range of internal hemorrhoids measured during colonoscopy as reference standards.

RESULTS

A total of 94 patients were reviewed; of these, 62 patients without submucosal linear enhancement were classified into group A, and 32 patients with submucosal linear enhancement were classified into group B. Group B showed a significantly greater range (P = 0.017) and size (P = 0.002) of internal hemorrhoids. The Cohen κ coefficient value for the group classifications between the 2 radiologists was 0.66.

CONCLUSIONS

Submucosal linear enhancement on arterial-phase CT images could be a predictive finding suggesting the presence of internal hemorrhoids with a high risk of bleeding.

Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model

OBJECTIVE

To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids.

MATERIALS AND METHODS

Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination.

RESULTS

At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally.

CONCLUSION

Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.

Comparison of different embolic particles for superior rectal arterial embolization of chronic hemorrhoidal bleeding: gelfoam versus microparticle

BACKGROUND

Whether different embolic particles with comparable diameter lead to similar beneficial effects in endovascular embolization of hemorrhoidal disease remains to be established. We sought to evaluate the efficacy and safety of different types of agents for superior rectal arterial embolization (SRAE) in patients with bleeding hemorrhoids.

METHODS

Patients with recurrent episodes of internal hemorrhoidal bleeding and chronic anemia treated by SRAE in three tertiary hospitals between March 2017 and June 2020 were retrospectively evaluated. The patients were divided into two study groups based on the embolic materials: embolization with coils (2-3 mm) + gelfoam particles at 350-560 μm (Group A, n = 23), embolization with coils (2-3 mm) + microparticles at 300-500 μm (Group B, n = 18). The technical success, preliminary clinical efficacy (percentage of patients without hematochezia), postoperative complications and short-term follow-up outcomes were analysed.

RESULTS

A total of 41 patients (27 males) with symptomatic hemorrhoids were included in the study, mean age was 47 ± 12 years (range 25-72). 39% (16) patients with grade II hemorrhoids while 61% (25) patients with grade III. The technical success rate of the embolization procedure was 100%, and the preliminary clinical efficacy (87.0% vs 88.9%) showed no significant difference between the 2 groups (p = 0.098). No patients reported post-procedural and short-term serious complications, such as infection, intestinal ischemia or massive hemorrhage during the follow-up period (range 6-15 months).

CONCLUSIONS

Both gelfoam particles and microparticles with comparable diameter in the endovascular treatment of hemorrhoidal bleeding demonstrated similarly good short-term efficacy and safety profile.

Hemorrhoid embolization: A review of current evidences

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

Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far?

Haemorrhoids are abnormally enlarged anal cushions within the lower rectum. They are common, and have potential to significantly impact patients' quality of life. Superior rectal artery embolisation is a technique which has been discussed in the literature as far back as 40 years ago. More recently, there has been interest in the role of embolisation in the treatment for haemorrhoids, as an alternative to established minimally invasive and conventional surgical techniques. In this review, we discuss the current literature on the topic, with particular focus on technique, clinical outcomes and complications. Emerging procedural and technical considerations are discussed, with further review of the role of coil vs. particle embolisation.

Superior rectal artery embolization for bleeding internal hemorrhoids

BACKGROUND

The aim of the present study was to evaluate clinical efficacy and safety of superselective embolization of the superior rectal artery (SRA) for the treatment of internal hemorrhoidal bleeding.

METHODS

Patients with stage II and stage III internal hemorrhoids, treated by interventional embolization of the SRA in our department between January 2017 and June 2019 were retrospectively evaluated. All patients suffering from disabling chronic hematochezia and some with relative contraindications for operation (n = 17) or rejection of conventional hemorrhoidectomy (n = 15). Superselective SRA branch embolization was performed using gelatin sponge particles (350-560 μm) and metallic coils (2-3 mm). This treatment process was planned by a multidisciplinary team consisting of proctologist, gastroenterologist and radiologist. The surgical efficacy, postoperative complications and follow-up outcomes were observed.

RESULTS

There were 32 patients (18 males, mean age 52 ± 12 years, range: 22-78 years), 12 (37%) with stage II hemorrhoids and 20 (63%) with stage III hemorrhoids. Embolization was successful in all patients, and bleeding symptoms resolved in 27 (84.4%) patients. The remaining 5 (15.6%) patients underwent either stapled hemorrhoidopexy (n = 4) or sclerotherapy (n = 1). Some patients experienced different degrees of pain (n = 4;12.5%), low fever (n = 11;34.4%), and tenesmus (n = 17;53.1%), which all spontaneously regressed without further treatment. All patients were followed up for at least 1 year. There were no serious complications, such as infection, intestinal ischemia or massive hemorrhage. Four patients (14.8%) had rebleeding during the first months of follow-up. All patients with re-bleeding were successfully treated with internal iliac arteriography and branch embolization and did not experience further bleeds after a minimum follow up 3 months follow-up.

CONCLUSIONS

The short-term efficacy of superselective SRA embolization for grade II-III internal hemorrhoids is good, and this method is safe and feasible.

Future of IR: Emerging Techniques, Looking to the Future…and Learning from the Past

Innovation has been the cornerstone of interventional radiology since the early years of the founders, with a multitude of new therapeutic approaches developed over the last 50 years. What is the future holding for us? This article presents an overview of the in-coming developments that are catching on at this moment, particularly focusing on three items: the new applications of existing techniques, particularly embolotherapy and interventional oncology; the cutting-edge devices; the imaging technologies at the forefront of the image-guidance. Besides this, clinical vision and patient relation remain crucial for the future of the discipline.

Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients

PURPOSE

To evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment.

MATERIALS AND METHODS

This prospective study was conducted between 2014 and 2015 on 25 consecutive patients (16 men and 9 women with a mean age of 53 y [range, 30-76 y]) with grade II-III hemorrhoids refractory to medical treatment. A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils. Over the following 12 months, clinical outcomes were evaluated using the French bleeding score, Goligher prolapse score, visual analog scale (VAS) score for pain, quality-of-life score. The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score.

RESULTS

At 12 months after embolization, clinical success was obtained in 18 patients (72%), 8 of whom had 2 embolizations. VAS score decreased from 4.6 to 2.3 (P < .01), and bleeding score decreased from 5.5 to 2.3 (P < .01). Quality-of-life and prolapse scores also showed improvement (P < .05), and no patients experienced any early or late complications. Complete clinical failure was observed in 7 patients. After coil embolization, the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence (P = .001).

CONCLUSIONS

Hemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II-III hemorrhoids.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease

AIM

The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery.

METHODS

Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life.

RESULTS

Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%).

CONCLUSION

Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Safety and efficacy of superior rectal artery embolization with particles and metallic coils for the treatment of hemorrhoids (Emborrhoid technique)

PURPOSE

The purpose of this study was to comprehensively evaluate the short-term outcomes after percutaneous embolization of the superior rectal artery (SRA) with metallic coils and particles for the management of hemorrhoids.

MATERIALS AND METHODS

Forty patients (15 men, 25 women) with a mean age of 35±5 years (SD) (range: 25-65 years) were prospectively enrolled. All patients had symptomatic hemorrhoids. The distribution of internal hemorrhoids was as follows: grade I (n=6, 16%); grade II (n=28, 69%) and grade III (n=6; 15%). All patients had percutaneous embolization of the SRA with metallic coils and synthetic polyvinyl alcohol particles. Follow-up evaluation included clinical examination, rectoscopy, histopathological analysis of rectal mucosa, duplex Doppler blood flow quantification, electromyography, sphincterometry of the anal sphincter and analysis of patient satisfaction.

RESULTS

No immediate complications were observed and no patients had anal pain syndrome after embolization. Hemorrhoids showed a 43% size reduction after embolization (P<0.05). Taking into account the symptom resolutions such as irritation, discomfort, bloody discharge and pain, satisfaction was observed in 5/6 (83%) patients with grade III hemorrhoids and 32/34 patients (94%) with grades I-II hemorrhoids. One month after embolization, anal sphincter contractility normalized and no changes in anal electromyography were observed. Blood flow in the hemorrhoidal plexus dropped from 109±1.2ml/min/100g (SD) before treatment to 60.2±4.4ml/min/100g (SD) (P<0.05) the day after embolization and remained unchanged one month after embolization.

CONCLUSION

Our study demonstrates that embolization of SRA with particle and coils does not lead to ischemia in patients with symptomatic hemorrhoids. Short-term results with regard to symptom management for hemorrhoidal disease are very encouraging and should stimulate further prospective and multicenter studies.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding

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.

Ano-rectal pathologies encountered under special circumstances

This paper represents the summary of the anorectal pathology in patients who have special conditions or are in certain age. Author offers his experience in handling the proctological entities in children, elderly, pregnant women, and patients with haemorrhoids who have inflammatory bowel conditions, malignancy or are HIV positive. These patients reqire special approach and are not seen every day in proctological ambulances, what rises many questions in the appropriatenes of standard treatments.