Outpatient Transradial Emborrhoid Technique: A Pilot Study

Transanal eco-Doppler evaluation after hemorrhoidal artery embolization

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.

Translation and validation of Indonesian hemorrhoidal disease symptom score (HDSS) and short health scale hemorrhoidal disease (SHSHD)

Objectives

Hemorrhoidal disease, which affects nearly 40% of people, is characterized by pathological alterations and distal displacement of hemorrhoidal tissue. The short health scale (SHSHD) and the hemorrhoidal disease symptom score (HDSS) are two tools that can be utilized to assess the quality of life of hemorrhoidal patients. The present study aims to translate, modify, and validate the HDSS and SHSHD questionnaires in Indonesian.

Material and Methods

This cross-sectional study assessed the validity and reliability of the HDSS and SHSHD Indonesian adaptation instrument in hemorrhoidal patients from April 15, 2022, and April 1, 2023.

Results

There were 91 study subjects, 55 males and 36 females. The study showed that the subscale interpretations of the R-values and the full scale scored above 0.25, indicating weak to very strong correlations. These results mean that the HDSS and SHSHD questionnaires are valid for use. Based on the study's results, the R-value of each item, domain, and total score ≥0.8 (p <0.05) indicates that the HDSS and SHSHD instruments are reliable.

Conclusion

The Indonesian adaptation of the HDSS and SHSHD demonstrates validity and reliability as an assessment tool for measuring the healthrelated quality of life in Indonesian patients diagnosed with hemorrhoidal disease.

Catheter-directed hemorrhoidal embolization for rectal bleeding due to hemorrhoids (Goligher grade I-III): prospective outcomes from a Spanish emborrhoid registry

OBJECTIVES

To evaluate the safety and efficacy of catheter-directed hemorrhoidal embolization (CDHE) by microcoil embolization for rectal bleeding due to hemorrhoids classified as Goligher grade I-III.

METHODS

Eighty patients (62.5% males) with a mean age of 48 ± 9 years were recruited prospectively. All patients had symptomatic bleeding hemorrhoids. All patients were classified according to Goligher classification: grade I (13.7%), grade II (71.1%), grade III (15%), and no grade IV were recruited in this study. In all cases, microcoils were used to embolize the superior rectal artery(SRA), and microspheres if recurrence of bleeding occurred. Follow-up evaluation (1, 3, 6, and 12 months) included clinical examination and anoscopy. A questionnaire was conducted to determine improvement regarding bleeding, quality of life before, and the degree of patient satisfaction of each participant.

RESULTS

Technical success was achieved in 100% of the cases. Fifty-five (68.7%) participants had the absence of rectal bleeding after 12 months of embolization. VAS and QL improved 4 points and 1.5 respectively after embolization. A total of 25/80 (31.3%) had a recurrence in rectal bleeding. Seventeen (21.3%) patients underwent a second embolization, and four patients (5%) were treated with open hemorrhoidectomy. No major complications were observed. Sixteen participants had minor complications. Subjective post-treatment symptom and QL surveys showed significant differences from the baseline survey. Likewise, the degree of satisfaction in the telephone survey at 12 months revealed a high degree of patient satisfaction (8.3±1.1).

CONCLUSIONS

The present study demonstrates that CDHE is a feasible, well-tolerated, ambulatory, anal sphincter-sparing procedure for the treatment of internal hemorrhoids.

CLINICAL RELEVANCE STATEMENT

CDHE is a simple procedure, well tolerated and accepted by patients, that preserves the anal sphincter and presents few complications when metal devices or microspheres are used as embolic agents.

KEY POINTS

• The technical success rate of CDHE, defined as the closure of all the SRA in their distal segment, was achieved 100% of all patients. However, a second embolization treatment was required since 21.25% of the patients experienced rectal bleeding. • Overall, CDHE's safety profile is acceptable. After the procedure and 1 year of follow-up, no significant complications were observed. • Encouraging clinical outcomes have demonstrated CDHE in individuals with hemorrhoids and mild prolapse Goligher grades I-III with persistent rectal bleeding.

Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend

PURPOSE

Hemorrhoidal disease (HD) is a common condition, and several surgical techniques have been proposed to date without being able to achieve definitive consensus on their use and indications. Laser hemorrhoidoplasty (LHP) is a minimally invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser limiting the postoperative discomfort and pain. The aim of the current study was to evaluate the postoperative outcomes of HD patients undergoing LHP vs conventional Milligan-Morgan hemorrhoidectomy (MM).

METHOD

Postoperative pain, wound care management, symptoms' resolution, patients' quality of life, and length of return to daily activity of grade III symptomatic HD patients undergoing LHP vs MM were retrospectively evaluated. The patients were followed-up for recurrence of prolapsed hemorrhoid or symptoms.

RESULT

From January 2018 to December 2019, 93 patients received conventional Milligan Morgan as control group and 81 patients received laser hemorrhoidoplasty treatment using a 1470-nm diode laser. No significant intraoperative complications occurred in both groups. Laser hemorrhoidoplasty patients experienced lower postoperative pain score (p < 0.0001) and smoother wound management. After 25 ± 8 months follow-up, the recurrence of symptoms occurred in 8.1% after Milligan-Morgan and 21.6% after laser hemorrhoidoplasty (p < 0.05) with a similar Rorvik score (7.8 ± 2.6 in LHP group vs 7.6 ± 1.9 in MM group, p = 0.12).

CONCLUSION

LHP demonstrated high efficacy in selected HD patients guaranteeing lower postoperative pain, easier wound care, higher rate of symptoms resolution, and greater patient appreciation compared to MM, even though it had a higher recurrence rate. Larger comparative studies are needed to address this issue.

Prevalent Technique and Results of Hemorrhoidal Embolization

Hemorrhoids are blood cushions located in the anus and lower rectum, acknowledged as a common cause of bleeding, which can reduce quality of life. The development of minimally invasive techniques such as endovascular embolization of superior rectal artery, "Emborrhoid technique", is an effective treatment, with no pain or ischemic complications, and allows quick patient recovery. Our purpose is to describe the general technique and discuss the results of the current literature.

The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk

The Emborrhoid is an innovative non-surgical technique for the treatment of severe hemorrhoidal bleeding. Patient selection and the impact on quality of life have not been fully investigated. This prospective observational study aims to evaluate the clinical outcomes after Emborrhoid in patients with high surgical risk. All patients with high surgical risk and anemia due to hemorrhoids were enrolled. Clinical data and previous blood transfusions were collected. The Hemorrhoidal Disease Symptom Score and Short Health Scala were completed before the procedure and during the follow-up visits at 1, 6 and 12 months. Transfusions and serum hemoglobin level variations were registered. Perioperative complications and the recurrence of bleeding were assessed. Trans-radial/femoral embolization of superior rectal artery, and/or middle rectal artery was performed with Interlock and Detachable Embolization Coils. From September 2020 to February 2022, 21 patients underwent a superselective embolization of all branches of the superior rectal artery. The transradial approach was most frequently performed compared to transfemoral access. After the procedure, no signs of ischemia were identified; three minor complications were observed. The mean follow-up was 18.5 ± 6.0 months. At the last follow-up, the mean increase of hemoglobin for patients was 1.2 ± 1.6 g/dL. Three patients needed transfusions during follow-up for recurrent hemorrhoidal bleeding. The Hemorrhoidal Disease Symptom Score and Short Health Scala decreased from 11.1 ± 4.2 to 4.7 ± 4.6 (p < 0.0001) and from 18.8 ± 4.8 to 10.2 ± 4.9 (p < 0.0001), respectively. Patients who had given up on their daily activities due to anemia have returned to their previous lifestyle. Emborrhoid seems to be a safe and effective option for the treatment of bleeding hemorrhoids in frail patients. The low complication rate and the significant reduction of post-defecation bleeding episodes are related to the improvement of the hemorrhoidal symptoms and patients’ quality of life.

Safety and Effectiveness of a New Electrical Detachable Microcoil for Embolization of Hemorrhoidal Disease, November 2020–December 2021: Results of a Prospective Study

Purpose: The purpose of this study was to prospectively evaluate the efficacy and safety of a new, bare platinum, detachable microcoil as a metallic embolization agent in the treatment of hemorrhoidal disease. Material and Methods: This prospective single-center study evaluated a new, bare platinum, electrical, detachable microcoil (Prestige plus coil (Balt Montmorency France)) for use in vascular embolization in patients with hemorrhoidal disease. Between January 2020 and January 2021, 24 embolization procedures were performed in 21 patients (12 males, 9 females; mean age 44.3 ± 7.3). The inclusion criteria were: (a) participants with grade I, II and III hemorrhoidal disease on the Goligher classification; (b) patients older than 18 years of age with a score of greater than 4 on the French bleeding score (FBS) scale; (c) patients with scores greater than 2 on the scale of discomfort proposed by Tradi and Farfallah. (d) patients who underwent treatment that included the use of the new novel coil (Prestige plus coil (Balt)) as an embolic material. The exclusion criteria were participants who failed to provide informed consent and participants diagnosed with rectal bleeding due to other causes (cancer, fissures or others). Participants with severe renal insufficiency, non-correctable coagulation abnormalities and adverse reactions to the contrast medium not correctable with medication were also excluded. The symptoms, technical aspects, the transarterial approach, clinical and technical success complications and short-term outcomes were assessed. Results: Technical success was obtained in 100% of the cases. Seventeen (80.9%) patients experienced improvements in their hemorrhoidal disease. The VAS and QL scores improved by 4 and 1.5 points (81.2% and 87.5%), respectively, after embolization (pV: 0001). Three (14.2%) patients underwent a second embolization due to rebleeding. One patient (4.7%) underwent surgery. No major complications were observed. Three patients had minor complications. The assessment of subjective post-treatment symptoms and QL surveys showed significant differences from the baseline survey. Likewise, the measurement of the degree of satisfaction using a telephone survey at 12 months revealed a high degree of patient satisfaction over 10 points (mean 8.3 ± 1.1). Conclusions: The present study demonstrates that the use of the new, platinum, detachable, electrical microcoil is safe and well-tolerated in the treatment of hemorrhoidal disease. Key points: Catheter-directed hemorrhoidal dearterialization (CDHD) is the procedure of embolization with embolic agents for the treatment of internal hemorrhoids. CDHD is a simple and safe procedure that is accepted by patients and preserves the anal sphincter; it presents few complications when metal devices or microspheres are used as embolic agents. As the recommended embolization agent in treatments, the Prestige electrical, detachable coil is a safe, easy-to-use and effective arterial embolic device.

Clinical Outcomes Following Rectal Artery Embolisation for the Treatment of Internal Haemorrhoids: A Systematic Review and Meta-Analysis

OBJECTIVES

Haemorrhoidal disease (HD) is a common anorectal disorder which can substantially impair quality of life. Rectal artery embolisation (RAE) is a recently described technique for the management of HD, however, its clinical efficacy and safety are unclear at present. The objective of this systematic review and meta-analysis is to evaluate the clinical outcomes following RAE.

METHODS

The PubMed, MEDLINE and EMBASE databases were searched for studies specifying the management of haemorrhoids with RAE from January 2000 to October 2021. Primary outcomes were: French bleeding score (FBS), Visual analogue scale (VAS) for pain, general quality of life (QoL) score, and the Goligher prolapse score (GPS). Secondary outcomes were technical success, clinical success, postoperative complications, and technical outcomes. A random-effects meta-analysis was conducted. Study heterogeneity was evaluated, and sensitivity analysis was performed.

RESULTS

Thirteen eligible studies were identified including 381 patients. Rectal artery embolisation was associated with improvements in the FBS (mean difference [MD] 2.66; 95% confidence interval [CI] 2.10-3.23), VAS (MD 1.92; 95% CI 1.58-2.27) and QoL (MD 1.41; 95% CI 1.20-3.80), although the grade of internal haemerrhoids increased with uncertain clinical significance (MD 0.30; 95% CI 0.23-0.36). Technical success was achieved in almost all procedures (99%; 95% CI 94-100%) however clinical efficacy was lower (82%; 95% CI 73-89%). Procedural duration and radiation exposure were heterogeneous. No major complications occurred.

CONCLUSION

RAE demonstrates early clinical efficacy with low rates of peri-procedural complications or morbidity. RAE is a promising addition to the treatment options available for HD and warrants ongoing research.

Annoyed with Haemorrhoids? Risks of the Emborrhoid Technique

Haemorrhoids, a common ailment afflicting mostly Western patients, can produce bothersome symptoms, in particular pain, pruritus, and bleeding. There is a wide choice of surgical treatment options available for haemorrhoids in patients that cannot be treated with medical therapy, such as those that are prolapsed. Many patients refuse surgery due to the fear of potential complications; to overcome this obstacle, novel alternative techniques have been developed in recent years that are focussed on ligation or occlusion of haemorrhoidal arterial blood flow. We describe a patient who developed recto-sigmoidal ischaemia after embolization of the haemorrhoidal arteries, known as the "emborrhoid" technique, with persistence of rectal bleeding and progressive rectal stenosis.