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Trenti L, Biondo S, Espin-Basany E, Barrios O, Sanchez-Garcia JL, Landaluce-Olavarria A, Bermejo-Marcos E, Garcia-Martinez MT, Alias Jimenez D, Jimenez F, Alonso A, Manso MB, Kreisler E. Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: Long-term Outcomes From the THDLIGA Randomized Controlled Trial. Dis Colon Rectum 2023; 66:e818-e825. [PMID: 35239526 DOI: 10.1097/dcr.0000000000002272] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Both transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy are safe for grade III to IV hemorrhoid treatment. Whether one of them is superior regarding long-term results remains unclear. OBJECTIVE To compare long-term results after transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy. DESIGN Multicenter randomized controlled trial. SETTINGS This study was conducted at 6 centers. PATIENTS Patients ≥18 years of age with grade III to IV hemorrhoids were included in the study. INTERVENTIONS Patients were randomly assigned to transanal hemorrhoidal dearterialization (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41). MAIN OUTCOME MEASURES The primary outcome was hemorrhoid symptom recurrence assessed by a specific questionnaire 2 years postoperatively. Secondary outcomes included long-term complications, reoperations, fecal continence, and patient satisfaction and quality of life. RESULTS Five of the 80 patients included in the study were lost to follow-up. Thirty-six patients randomly assigned to transanal hemorrhoidal dearterialization and 39 patients randomly assigned to vessel-sealing device hemorrhoidectomy were included in the long-term analysis. The differences between mean baseline and mean 2-year score in the 2 groups were similar (-11.0, SD 3.8 vs -12.5, SD 3.6; p = 0.080). Three patients in the transanal hemorrhoidal dearterialization group underwent supplementary procedures for hemorrhoid symptoms, compared with none in the vessel-sealing device hemorrhoidectomy group ( p = 0.106). Four patients in the vessel-sealing hemorrhoidectomy group and none in the transanal hemorrhoidal dearterialization group experienced chronic opened wound ( p = 0.116). LIMITATIONS Lack of stratification for hemorrhoid grade and power calculation based on the main outcome trial but not on the end point of this long-term study. CONCLUSIONS Transanal hemorrhoidal dearterialization with mucopexy is associated with hemorrhoid symptom recurrence similar to vessel-sealing device hemorrhoidectomy at 2 years. See Video Abstract at http://links.lww.com/DCR/B933 . REGISTRATION Clinicaltrials.gov ; ID: NCT02654249. DESARTERIALIZACIN HEMORROIDAL TRANSANAL CON MUCOPEXIA VERSUS HEMORROIDECTOMA CON DISPOSITIVO DE SELLADO DE VASOS PARA HEMORROIDES DE GRADO IIIIV RESULTADOS A LARGO PLAZO DEL ENSAYO CLNICO ALEATORIZADO THDLIGARCT ANTECEDENTES:Tanto la desarterialización hemorroidal transanal como la hemorroidectomía con dispositivo de sellado de vasos son seguras y bien toleradas para el tratamiento de las hemorroides de grado III-IV. La primera se asocia con una necesidad más breve de analgesia posoperatoria que la hemorroidectomía con dispositivo de sellado de vasos. No está claro si uno de ellos es superior con respecto a los resultados a largo plazo.OBJETIVO:El objetivo fue comparar los resultados a largo plazo después de la desarterialización hemorroidal transanal y la hemorroidectomía con dispositivo de sellado de vasos.DISEÑO:Se realizó un ensayo clínico aleatorizado multicéntrico.AJUSTE:Este estudio se realizó en 6 centros.PACIENTES:Se incluyeron en el estudio pacientes de ≥18 años con hemorroides de grado III-IV.INTERVENCIONES:Los pacientes fueron asignados al azar a desarterialización hemorroidal transanal (n = 39) o hemorroidectomía con dispositivo de sellado de vasos (n = 41).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia de los síntomas de hemorroides evaluada mediante un cuestionario específico 2 años después de la operación. Los resultados secundarios incluyeron complicaciones a largo plazo, reoperaciones, continencia fecal, satisfacción del paciente y calidad de vida.RESULTADOS:Cinco de los 80 pacientes incluidos en el estudio se perdieron durante el seguimiento. En el análisis a largo plazo se incluyeron 36 pacientes aleatorizados a desarterialización hemorroidal transanal y 39 aleatorizados a hemorroidectomía con dispositivo de sellado de vasos. Las diferencias entre la puntuación inicial media y la puntuación media a los 2 años en los dos grupos fueron similares (-11,0, DE 3,8 frente a -12,5, DE 3,6; p = 0,080). Tres pacientes en el grupo de desarterialización hemorroidal transanal se sometieron a procedimientos complementarios por síntomas de hemorroides, en comparación con ninguno en el grupo de hemorroidectomía con dispositivo de sellado de vasos (p = 0,106). Cuatro pacientes en el grupo de hemorroidectomía con sellado de vasos y ninguno en el grupo de desarterialización hemorroidal transanal experimentaron herida abierta crónica (p = 0,116). No se encontraron diferencias en cuanto a continencia fecal (p = 0,657), satisfacción del paciente (p = 0,483) y calidad de vida.LIMITACIONES:No hay estratificación para el grado de hemorroides ni el cálculo del poder basado en el resultado principal del ensayo, pero no en el criterio de valoración de este estudio a largo plazo.CONCLUSIONES:La desarterialización hemorroidal transanal con mucopexia se asocia con una recurrencia de síntomas de hemorroides similar a la hemorroidectomía con dispositivo de sellado de vasos a los dos años. See Video Abstract at http://links.lww.com/DCR/B933 . (Traducción- Dr. Francisco M. Abarca-Rendon )REGISTRO DE PRUEBA:Clinicaltrials.gov (NCT02654249).
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Affiliation(s)
- Loris Trenti
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Sebastiano Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Eloy Espin-Basany
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
| | - Oriana Barrios
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Jose L Sanchez-Garcia
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
| | | | | | | | - David Alias Jimenez
- Department of Surgery, Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Fernando Jimenez
- Department of Surgery, Galdakao Usansolo Hospital, Vizcaya, Spain
| | - Adolfo Alonso
- Department of Surgery, La Princesa University Hospital, Madrid, Spain
| | - Maria B Manso
- Department of Surgery, Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Esther Kreisler
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
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Verre L, Gallo G, Grassi G, Bussolin E, Carbone L, Poto GE, Carpineto Samorani O, Marano L, Marrelli D, Roviello F. Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review. Front Surg 2022; 9:1088546. [PMID: 36620384 PMCID: PMC9811001 DOI: 10.3389/fsurg.2022.1088546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Methods Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2 weeks, 1 month and 6 months after surgery. Results Forty-seven out of 75 patients were male, and the mean age was 50 (± 17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. Conclusions THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.
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Affiliation(s)
- Luigi Verre
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy,Correspondence: Luigi Verre
| | - Gaetano Gallo
- Department of Surgical Sciences, La Sapienza University of Roma, Roma, Italy
| | - Giulia Grassi
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Edoardo Bussolin
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Osvaldo Carpineto Samorani
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
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Prevalent Technique and Results of Hemorrhoidal Embolization. J Clin Med 2022; 11:jcm11226631. [PMID: 36431108 PMCID: PMC9698593 DOI: 10.3390/jcm11226631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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El-Kelani MZ, Kerdahi R, Raghib S, Shawkat MA, Abdelnazer N, Mudawi I, Mahmoud M, Abi Hussein W, Tawfik M, Wahdan W. Recommendations and best practice on the management of hemorrhoidal disease in Saudi Arabia. Hosp Pract (1995) 2022; 50:104-109. [PMID: 35188048 DOI: 10.1080/21548331.2022.2042150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several techniques were developed for managing hemorrhoidal disease, but their use in clinical practice and the general management of the condition, seems highly variable in Saudi Arabia. CONSENSUS PANEL To develop consensus recommendations that ensure the best possible diagnosis and treatment of hemorrhoidal disease in Saudi Arabia, the consensus panel consisted of experts in surgery in Saudi Arabia who met from December 2017 to September 2018. CONSENSUS FINDINGS The discussions focused on the need: to set up a proctology society in Saudi Arabia to assess the prevalence of hemorrhoidal disease and to regulate the role of healthcare professionals (HCPs) in the management of the disease; to initiate guidelines to ensure proper diagnosis (considering symptoms, medical history and physical/clinical examination) and treatment (topical creams and suppositories should be limited as no strong evidence supports their efficacy); to educate patients on diet and lifestyle modifications using education materials and social media during and after the treatment (regular physical activity, drinking enough fluids, regular meal time with food rich in fibers, and regular bowel habit with non-straining defecation); to refer patients to a general/colorectal surgeon when needed; and to teach junior surgeons the best use of surgical techniques. CONCLUSION These recommendations can be a step forward towards a recognized guidance for all HCPs in Saudi Arabia for a better management of hemorrhoidal disease. They will be of a great value for general practitioners, family medicine doctors, junior surgeons and pharmacists who are the gate keepers and first contact with patients.
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Affiliation(s)
| | - Raouf Kerdahi
- Department of General, Laproscopic and Paediatric Surgeon, Olaya Medical Center (OMC), Riyadh, Saudi Arabia
| | - Samir Raghib
- Department of Surgery, United Doctors Hospital, Jeddah, Saudi Arabia
| | | | - Naser Abdelnazer
- Department of General Surgery, Dallah Hospital, Riyadh, Saudi Arabia
| | - Ishag Mudawi
- Department of General Surgery, King Fahd Armed Force, Jeddah, Saudi Arabia
| | - Magdy Mahmoud
- Department of General Surgery, King Khaled National Guard, Jeddah, Saudi Arabia
| | - Wassim Abi Hussein
- Department of General and Laparoscopic Surgery, Al Ahsa Hospital, Dammam, Saudi Arabia
| | - Mohamed Tawfik
- Department of Surgery, Erfan Hospital, Jeddah, Saudi Arabia
| | - Waleed Wahdan
- Department of General Surgery, Riyadh National Hospital, Riyadh, Saudi Arabia
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Pata F, Gallo G, Pellino G, Vigorita V, Podda M, Di Saverio S, D'Ambrosio G, Sammarco G. Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview. Front Surg 2021; 8:727059. [PMID: 34527700 PMCID: PMC8435716 DOI: 10.3389/fsurg.2021.727059] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/16/2021] [Indexed: 01/22/2023] Open
Abstract
Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.
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Affiliation(s)
- Francesco Pata
- General surgery Unit, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy
- La Sapienza University, Rome, Italy
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Science, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Vincenzo Vigorita
- Coloproctology Unit and General and Digestive Surgery Unit, Vigo University Hospital Complex, Vigo, Spain
| | - Mauro Podda
- Department of emergency surgery, Cagliari University Hospital “Policlinico D. Casula”, Cagliari, Italy
| | - Salomone Di Saverio
- Department of General Surgery, University Hospital of Varese, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Giancarlo D'Ambrosio
- Department of General Surgery, Surgical Specialties and Organ Transplantation, La Sapienza University, Rome, Italy
| | - Giuseppe Sammarco
- Department of Health Science, University of Catanzaro, Catanzaro, Italy
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Mazzeo A, Migliorini G, Portale G, Fiscon V. Easy, safe and fast knot tying technical variation ('siphoning') in the transanal haemorrhoidal dearterialization procedure - a video vignette. Colorectal Dis 2021; 23:2215-2216. [PMID: 34028950 DOI: 10.1111/codi.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 02/08/2023]
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Karkalemis K, Chalkias PL, Kasouli A, Chatzaki E, Papanikolaou S, Dedemadi G. Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease. Langenbecks Arch Surg 2021; 406:2489-2495. [PMID: 33959805 DOI: 10.1007/s00423-021-02190-0] [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: 03/03/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE A wide variety of methods has been proposed for treating hemorrhoidal disease. The aim of the study is to assess the safety and effectiveness of hemorrhoidal artery ligation with rectoanal repair (HAL-RAR). METHODS Retrospective study from January 2010 to November 2019 of patients who underwent HAL-RAR for grade II, resistant to conservative treatment, and grades III and IV hemorrhoidal disease. Demographics, degree of disease, hospital stay, postoperative pain, complications, and recurrence were recorded. Patients were followed up at postoperative days 1 and 8 and at 1, 6, and 12 months. RESULTS A total of 105 patients (60 men, 45 women) underwent HAL-RAR. Median age was 49 (range, 20-86) years. Two patients with hemorrhoidal thrombosis underwent emergent excision of the hemorrhoid. Median length of hospital stay was 2 (range, 1-13) days. Patients reported median visual analog scale pain score 3 (range, 1-5) on the 1st postoperative day. At 1 month, no patient reported pain, 84.76% of patients confirmed complete resolution of symptoms, while complication rate was 7.61%: 2 patients presented urinary retention, 3 dyschezia, 2 bleeding, and 1 hemorrhoidal necrosis. At 6 months, 2 patients presented mild symptoms and 7 recurrence. At 12 months, 92.4% of patients experienced complete resolution of symptoms, 2 patients intermittent bleeding, and 2 recurrence. Overall recurrence and re-intervention rate were 8.57% rate and 10.5%, respectively. CONCLUSION HAL-RAR is a safe and effective minimal invasive operative technique related to a high percentage of success, low complication, and recurrence rates. Long-term follow-up is lacking and would better establish the results of this technique. TRIAL REGISTRATION Trial registration number NCT04778124 Date of registration 26/02/2021 "retrospectively registered".
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Affiliation(s)
- Konstantinos Karkalemis
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Petros Loukas Chalkias
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Anna Kasouli
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Elina Chatzaki
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Spilios Papanikolaou
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Georgia Dedemadi
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece.
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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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Zenger S, Gurbuz B, Can U, Yalti T. A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL). Surg Today 2020; 51:612-618. [PMID: 33098443 DOI: 10.1007/s00595-020-02164-7] [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: 05/31/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD). METHODS The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL. RESULTS A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m2). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65). CONCLUSION Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.
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Affiliation(s)
- Serkan Zenger
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.
| | - Bulent Gurbuz
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Ugur Can
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Tunc Yalti
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.,Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
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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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12
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Ferrer Puchol M, Esteban Hernández E, Blanco González F, Ramiro Gandia R, Solaz Solaz J, Pacheco Usmayo A. Embolización intraarterial selectiva como tratamiento de la patología hemorroidal. RADIOLOGIA 2020; 62:313-319. [DOI: 10.1016/j.rx.2019.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/15/2019] [Accepted: 12/19/2019] [Indexed: 11/25/2022]
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13
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Ferrer Puchol M, Esteban Hernández E, Blanco González F, Ramiro Gandia R, Solaz Solaz J, Pacheco Usmayo A. Selective intra-arterial embolisation to treat haemorrhoids. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Ng KS, Holzgang M, Young C. Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020. Ann Coloproctol 2020; 36:133-147. [PMID: 32674545 PMCID: PMC7392573 DOI: 10.3393/ac.2020.05.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.
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Affiliation(s)
- Kheng-Seong Ng
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Melanie Holzgang
- Department of Colorectal Surgery, St. James's University Hospital, Leeds, UK
| | - Christopher Young
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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15
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Patel R, Rehman A, Baig M, Kazem MA, Khan A. A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD). Surgeon 2020; 19:72-76. [PMID: 32223930 DOI: 10.1016/j.surge.2020.02.008] [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: 08/08/2019] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. METHODS Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. RESULTS Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. CONCLUSIONS These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.
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Affiliation(s)
- Rikesh Patel
- Aintree University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Adeeb Rehman
- Aintree University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Mirza Baig
- Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, CW1 4QJ, UK
| | - M Ali Kazem
- Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, CW1 4QJ, UK
| | - Arif Khan
- Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, CW1 4QJ, UK
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16
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Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam. Adv Ther 2020; 37:1136-1144. [PMID: 31997241 DOI: 10.1007/s12325-020-01238-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment. METHODS This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure. RESULTS A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence. CONCLUSION The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.
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17
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Mascagni D, Eberspacher C, Mascagni P, Arezzo A, Selvaggi F, Sturiale A, Milito G, Naldini G. From high volume to "zero" proctology: Italian experience in the COVID era. Int J Colorectal Dis 2020; 35:1777-1780. [PMID: 32468103 PMCID: PMC7255907 DOI: 10.1007/s00384-020-03622-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic hit Italy early and strongly, challenging the whole health care system. Proctological patients and surgeons are experiencing a previously unseen change in care with unknown repercussion. Here we discuss the proctological experience of 4 Italian hospitals during the COVID-19 pandemic. METHODS Following remote brainstorming, the authors summarised their experience in managing proctological patients during the COVID-19 pandemics and put forward some practical observations to further investigate. RESULTS The 4 hospitals shifted from a high-volume proctological activity to almost "zero" visits and surgery. Every patient accessing the hospital must respect a specific COVID-19 protocol. Proctological patients can be stratified based on presentation and management considerations into (1) neoplastic patients, the only allowed to be surgically treated, (2) the ones requiring urgent care, operated only in highly selected cases and (3) the stable, already known patients, managed remotely. Changes in the clinical management of the proctological disease are presented together with some considerations to be explored. CONCLUSIONS In the absence of scientific evidence, these practical considerations may be valuable to proctological surgeons starting to face the COVID-19 pandemics. Beside the more clinical considerations, this crisis produced unexpected consequences such as an improvement of the therapeutic alliance and a shift towards telemedicine that may be worth exploring also in the post-COVID-19 era.
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Affiliation(s)
- Domenico Mascagni
- Department of Surgical Sciences, Policlinico Umberto I, “Sapienza” University of Rome, Viale Regina Elena 324, 00100 Rome, Italy
| | - Chiara Eberspacher
- Department of Surgical Sciences, Policlinico Umberto I, “Sapienza” University of Rome, Viale Regina Elena 324, 00100 Rome, Italy
| | - Pietro Mascagni
- IHU Strasbourg – Institute of Image-Guided Surgery, Strasbourg, France
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Francesco Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alessandro Sturiale
- Proctological and Perineal Surgical Unit, Universitary Hospital of Pisa, Pisa, Italy
| | | | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, Universitary Hospital of Pisa, Pisa, Italy
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18
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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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19
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Short-term Outcomes of Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: A Prospective Randomized Multicenter Trial. Dis Colon Rectum 2019; 62:988-996. [PMID: 30807456 DOI: 10.1097/dcr.0000000000001362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy seem to reduce postoperative pain compared with classic excisional hemorrhoidectomy, but whether one of them is superior remains unclear. OBJECTIVE We compared transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy. DESIGN This was a multicenter, randomized controlled trial. SETTING The study was conducted at 6 Spanish centers. PATIENTS Patients aged ≥18 years with grade III to IV hemorrhoids were included. INTERVENTIONS Patients were randomly assigned to transanal hemorrhoidal dearterialization with mucopexy (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41). MAIN OUTCOME MEASURES Primary outcome was the mean postoperative number of days in which patients needed nonsteroidal anti-inflammatory drugs. Secondary outcomes were postoperative pain, 30-day morbidity, patient satisfaction, Vaizey score, hemorrhoid symptoms score, return to work, and quality of life. RESULTS More patients were still taking analgesia in the vessel-sealing device hemorrhoidectomy group during the second postoperative week compared with the transanal hemorrhoidal dearterialization with mucopexy group (87.8% vs 53.8%; p = 0.002). For the transanal hemorrhoidal dearterialization with mucopexy group, analgesia consumption continued until day 10.1 (mean; SD = 7.22 d), whereas in the vessel-sealing device hemorrhoidectomy group it continued until day 15.2 (mean; SD = 8.70 d; p = 0.006). The mean daily average pain was similar during the first (p = 0.900) and second postoperative weeks (p = 0.265). Mean operative time was higher for the transanal hemorrhoidal dearterialization with mucopexy group versus the vessel-sealing device hemorrhoidectomy group (45 min; range, 40-60 vs 20 min; range, 15-41 min; p < 0.001). Postoperative complications rate, use of laxatives, patient satisfaction, Vaizey score, hemorrhoids symptoms score, return to work, and quality of life at 1 month after surgery were similar between groups. LIMITATIONS The main limitation of this study was that the 2 groups did not contain equal numbers of grade III and IV hemorrhoids. CONCLUSIONS Transanal hemorrhoidal dearterialization with mucopexy is associated with a shorter need for postoperative analgesia compared with vessel-sealing device hemorrhoidectomy. See Video Abstract at http://links.lww.com/DCR/A915. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02654249.
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20
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Cuong LM, Ha TT, Anh NN, Thanh NT, Kien VD, Lam ND. Comparison of Doppler-Guided Transanal Hemorrhoidal Dearterialization for Grade III and IV Hemorrhoids in Vietnam. Adv Ther 2019; 36:1388-1397. [PMID: 30972656 DOI: 10.1007/s12325-019-00948-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION This study aimed to assess the short- and long-term outcomes of Doppler-guided transanal hemorrhoidal dearterialization (THD) for grade III and IV hemorrhoidal disease in Vietnam. METHODS In a prospective observational design, patients treated for grade III and IV hemorrhoidal disease with the THD method at the National Hospital of Traditional Medicine (Hanoi, Vietnam) were included between June 2012 and December 2013. Patients were evaluated postoperatively at the time they were discharged from the hospital (short-term outcome) and 6 months after surgery (long-term outcome). RESULTS A total of 128 patients were enrolled in the study, 94 were classified with grade III disease and 34 with grade IV. Grade IV hemorrhoidal patients reported on average 18.2 years of disease symptom duration, while grade III hemorrhoidal patients reported 11.2 years. All patients with grade III and grade IV hemorrhoidal disease had good outcomes at discharge day and reported to return to work in a median of 6 days after THD. At long-term follow-up, the results were good for 80.9% of patients from grade III hemorrhoidal disease and 61.8% of patients from grade IV hemorrhoidal disease. Patient satisfaction with the procedure and outcomes was 93.6% for grade III and 85.3% for grade IV hemorrhoidal patients. CONCLUSIONS The THD technique was shown to be safe for both grade III and IV hemorrhoidal patients. The THD technique showed better results with grade III hemorrhoidal patients as compared to grade IV hemorrhoidal patients.
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21
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Xu L, Chen H, Gu Y. Stapled Hemorrhoidectomy Versus Transanal Hemorrhoidal Dearterialization in the Treatment of Hemorrhoids: An Updated Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:75-81. [DOI: 10.1097/sle.0000000000000612] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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22
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Altomare DF, Picciariello A, Pecorella G, Milito G, Naldini G, Amato A, Ratto C, Perinotti R. Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years. Colorectal Dis 2018; 20:1117-1124. [PMID: 30004171 DOI: 10.1111/codi.14339] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
AIM The management of haemorrhoids has changed significantly in the last two decades as a result of new insights into their pathophysiology and the availability of new surgical devices. The aim of this survey was to evaluate changes in the management of haemorrhoids in Italy over the last 17 years. METHOD An electronic database which recorded details of management relating to the severity of haemorrhoids between 2000 and 2016 was obtained from 18 of 34 colorectal surgeons who were invited to participate. RESULTS A total of 32 458 patients were treated for haemorrhoids by 18 expert coloproctologists during a 17-year period. Patients were classified as Grade II (7542, 23.2%), Grade III(15 360, 47.3%) and Grade IV (9556, 29.4%). Grade II haemorrhoids were treated with rubber band ligation in over 90% of the cases, and patients with Grade IV had a Milligan-Morgan (MM) haemorrhoidectomy in over 90% of the cases. In Grade III, the use of stapled haemorrhoidopexy progressively decreased from 30% to 35% (between 2000 and 2007) to 5% of the cases. Meanwhile, commencing from 2006 the use of Doppler-guided haemorrhoid artery ligation (DGHAL) with mucopexy increased progressively from 6% to 24%. Over the years, the percentage of MM haemorrhoidectomy remained consistent at between 65% and 70% of the cases. CONCLUSION Relevant changes in the surgical choice of haemorrhoid treatment have occurred in Italy over the last 17 years. MM haemorrhoidectomy remains the most frequently performed procedure for Grade III haemorrhoids. Stapled haemorrhoidopexy has become much less popular in contrast to DGHAL with mucopexy which is being performed much more frequently.
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Affiliation(s)
- D F Altomare
- Functional and Oncologic Colorectal Unit, Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy.,Interdepartmental Research Unit for Pelvic Floor Disease (CIRPAP), University Aldo Moro of Bari, Bari, Italy
| | - A Picciariello
- Functional and Oncologic Colorectal Unit, Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy.,Interdepartmental Research Unit for Pelvic Floor Disease (CIRPAP), University Aldo Moro of Bari, Bari, Italy
| | - G Pecorella
- Department of General Surgery Coloproctological Unit, University of Catania, Catania, Italy
| | - G Milito
- Department of Surgery, University Hospital of Tor Vergata 'PTV', Rome, Italy
| | - G Naldini
- Proctological and Perineal Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - A Amato
- Unit of Coloproctology, Department of General Surgery, Sanremo Hospital, Sanremo, Italy
| | - C Ratto
- Proctology Unit, University Hospital 'A. Gemelli', Catholic University, Rome, Italy
| | - R Perinotti
- Department of General Surgery, Degli Infermi Hospital, Biella, Italy
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23
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Sturiale A, Cafaro D, Fabiani B, Ferro U, Naldini G. Rectal perforation after Doppler-guided hemorrhoidal dearterialization treated with diverting sigmoidostomy. Tech Coloproctol 2018; 22:553-554. [PMID: 30062433 DOI: 10.1007/s10151-018-1824-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- A Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Via Paradisa 2, Pisa, Italy.
| | - D Cafaro
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Via Paradisa 2, Pisa, Italy
| | - B Fabiani
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Via Paradisa 2, Pisa, Italy
| | - U Ferro
- Proctological and Endoscopic Unit, Casa di Cura Santa Zita, Lucca, Italy
| | - G Naldini
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Via Paradisa 2, Pisa, Italy
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24
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Ratto C. Mystifications in Methods Produce Fake Results! Surg Innov 2018; 25:540-541. [PMID: 30047300 DOI: 10.1177/1553350618788946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Carlo Ratto
- 1 University Hospital "A. Gemelli," Catholic University, Rome, Italy
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25
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Giarratano G, Toscana E, Toscana C, Petrella G, Shalaby M, Sileri P. No Mystification, Perhaps Some Misunderstanding. Surg Innov 2018; 25:538-539. [PMID: 30020030 DOI: 10.1177/1553350618788941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | - Mostafa Shalaby
- 2 University of Rome Tor Vergata, Rome, Italy.,3 Mansoura University, Mansoura, Dakahlia, Egypt
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26
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Forouzanfar A, Smith J, Chapple KS. Outcome following repeat haemorrhoid artery ligation surgery. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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27
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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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Abstract
INTRODUCTION A needle was retained during transanal hemorrhoidal dearterialization. This rare complication has not been described before. TECHNIQUE A spinal needle was inserted from the perianal skin to localize the retained foreign body that was located at 7 cm from the anal margin. A decision was made to proceed to intersphincteric dissection, and a 3-cm incision was made in the perianal skin from 2 to 4 o'clock. Deep pararectal dissection continued, and the needle was eventually found lying in the muscular layer, parallel to the plane of the dissection. RESULTS The needle was retrieved intact, and repeat x-ray confirmed that no foreign body was retained. The patient made an uneventful recovery and was discharged home on postoperative day 1 with a 5-day course of oral antibiotics; she was examined in clinic 4 weeks following surgery and reported significant symptomatic improvement with no perianal pain or rectal bleeding. No anal fistula was found on the examination. CONCLUSIONS X-ray guidance is a helpful adjunct to facilitate 3-dimensional localization. Intersphincteric dissection is a reliable alternative to the transanal approach, particularly when the needle cannot be seen arising from the mucosa or felt on palpation. Repeated attempts to palpate the needle should be avoided, because there is a potential risk of displacing it deeper or higher, making retrieval more difficult.
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29
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Trenti L, Biondo S, Galvez A, Bravo A, Cabrera J, Kreisler E. Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes. Tech Coloproctol 2017; 21:337-344. [DOI: 10.1007/s10151-017-1620-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/29/2017] [Indexed: 12/14/2022]
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Hemorrhoids and the recurrent attempts to destroy them. Tech Coloproctol 2016; 21:69-71. [PMID: 27999954 DOI: 10.1007/s10151-016-1569-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 11/28/2016] [Indexed: 12/17/2022]
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Haskins IN, Holzmacher J, Obias V, Agarwal S. The Use of Transanal Hemorrhoidal Dearterialization for Treatment of Hemorrhoid Disease at a Single Institution. Am Surg 2016. [DOI: 10.1177/000313481608201220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.
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Affiliation(s)
- Ivy N. Haskins
- From the Department of Surgery, The George Washington University, Washington, District of Columbia
| | - Jeremy Holzmacher
- From the Department of Surgery, The George Washington University, Washington, District of Columbia
| | - Vincent Obias
- From the Department of Surgery, The George Washington University, Washington, District of Columbia
| | - Samir Agarwal
- From the Department of Surgery, The George Washington University, Washington, District of Columbia
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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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Huang HX, Yao YB, Tang Y. Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids. Exp Ther Med 2016; 12:1022-1028. [PMID: 27446315 PMCID: PMC4950541 DOI: 10.3892/etm.2016.3339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/12/2016] [Indexed: 12/22/2022] Open
Abstract
The aim of the present study was to examine the clinical value of ‘tying, binding and fixing operation’ in treating severe mixed hemorrhoids. A total of 160 patients with severe mixed hemorrhoids were selected and randomly divided into the experimental (n=80) and control (n=80) groups. The groups were treated using ‘tying, binding and fixing operation’ and Doppler ultrasound-guided hemorrhoidal artery ligation (DG-HAL), respectively. The results showed that the average operative time of the experimental group (35.57±6.17) was significantly higher than that of the control group (12.73±4.92). There was no significant difference of blood loss during the operation between the two groups (P>0.05). There was also no significant difference in improving the hemorrhage symptom between the two groups (P>0.05). In addition, concerning improvement of prolapse symptoms and reduction of the volume of hemorrhoids, the experimental group were significantly improved as compared to the control group. No anal function damage in the two groups was identified, and the length of stay in hospital for the two groups was not significantly different (P>0.05). However, the hospitalization cost in the experimental group (5,334.77±875.54) was significantly lower than that of the control group (8,551.81±1,806.54) and satisfaction degree was significantly higher than that of the control group. The incidences of perianal pain, anal edema and dysuria between two groups were not significantly different (P>0.05). There were 10 cases of secondary hemorrhage and 18 cases of infection in the experimental group, and 12 cases of secondary hemorrhage and 14 cases of infection in the control group, although the differences between the two groups were not statistically significant (P>0.05). The incidence rate of local hematoma in the experimental group (1.2%) was significantly lower than that in the control group (15.0%). The recurrence rate of the control group (22.5%) was also significantly higher than that of the experimental group (2.5%). In conclusion, tying, binding and fixing operation is a promising method that may be employed for the treatment of sever mixed hemorrhoids, and it is better than DG-HAL in improving the prolapse and reducing the volume of hemorrhoids.
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Affiliation(s)
- Hong-Xiang Huang
- Department of Anorectal Surgery, Xin Hua Hospital Affilliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Yi-Bo Yao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, P.R. China
| | - Ying Tang
- Department of Anorectal Surgery, Xin Hua Hospital Affilliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
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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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Titov AI, Abritsova MV, Mudrov AA. [Comparison of Doppler-assisted dearterialization with mucopexy and hemorrhoidectomy]. Khirurgiia (Mosk) 2016:24-32. [PMID: 26977864 DOI: 10.17116/hirurgia2016224-28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIM To compare two methods of hemorrhoid treatment. MATERIAL AND METHODS This prospective study included 240 patients with hemorrhoids stage III-IVA. Stages III and IVA were diagnosed in 156 (65%) and 84 (35%) patients respectively. Randomization was performed using envelopes method in one to one distribution. In group 1 (n=120) Doppler-assisted dearterialization of internal hemorrhoids with mucopexy was performed (DDM), in group 2 (n=120) - hemorrhoidectomy using harmonic scalpel (HE). RESULTS Duration of surgery was 17.9±6.1 and 34.5±10.1 minutes in DDM and HE groups respectively (p<0.01). Postoperative pain severity was higher in group 2 (4.8 compared with 2.5 scores of the first group (p<0.01). Narcotic analgesics were used less often in DDM group (1.3 doses compared with 6.1 doses in HE group (p<0.01). Disability period was 14.4±5.2 and 30.3±5.4 days in both groups respectively (p<0.01). Immediate postoperative complications occurred in 9 (7.5%) and 19 (15.8%) patients of DDM and HE groups respectively. Recurrent prolapse of internal hemorrhoids was diagnosed in 2 (1.7%) patients of the 1st group in terms of up to 45 days. CONCLUSION DDM is reliable minimally invasive method of hemorrhoids stage III-IVA treatment and has similar efficacy with HE. DDM reduces postoperative pain severity, hospital stay and disability period.
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Affiliation(s)
- A Iu Titov
- A.N. Ryzhykh State Research Center of Coloproctology, Health Ministry of the Russian Federation, Moscow
| | - M V Abritsova
- A.N. Ryzhykh State Research Center of Coloproctology, Health Ministry of the Russian Federation, Moscow
| | - A A Mudrov
- A.N. Ryzhykh State Research Center of Coloproctology, Health Ministry of the Russian Federation, Moscow
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Rivere AE, Chiasson KF, Corsetti RL, Fuhrman GM. An Assessment of Margins after Lumpectomy in Breast Cancer Management. Am Surg 2016. [DOI: 10.1177/000313481608200220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen ( P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant ( P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.
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Affiliation(s)
- Amy E. Rivere
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | | | - Ralph L. Corsetti
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
- the Ochsner Clinical School, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - George M. Fuhrman
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
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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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Yeo D, Tan KY. Hemorrhoidectomy - making sense of the surgical options. World J Gastroenterol 2014; 20:16976-16983. [PMID: 25493010 PMCID: PMC4258566 DOI: 10.3748/wjg.v20.i45.16976] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 05/27/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn’t a “one size fits all” option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.
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Elshazly WG, Gazal AE, Madbouly K, Hussen A. Ligation anopexy versus hemorrhoidectomy in the treatment of second- and third-degree hemorrhoids. Tech Coloproctol 2014; 19:29-34. [PMID: 25421703 DOI: 10.1007/s10151-014-1235-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 06/07/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND The aim of the study was to compare ligation anopexy (LA) and conventional hemorrhoidectomy (CH) in treatment of second- and third-degree hemorrhoids. METHODS A prospective controlled randomized clinical trial included 100 patients who underwent CH (CH group) and 100 patients who underwent LA (LA group). A detailed history was taken from all the patients. The effectiveness, safety, postoperative complications, operative time, length of hospital stay, time until first bowel movement, time until return to work, and postoperative pain score were assessed. RESULTS There was no significant difference between groups regarding age, sex, and preoperative symptoms. The LA group had significantly shorter operative times, earlier first bowel movement, and an earlier return to work/activities. The postoperative pain score in the LA group was significantly lower than that in the CH group on days 1, 3, 7, and 14 after surgery. There was no significant difference between groups as regards postoperative complications. CONCLUSIONS LA is safe, and as effective as CH in the treatment of grade II and grade III hemorrhoids, with shorter operative times, earlier mobilization, and lower postoperative pain scores.
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Affiliation(s)
- W G Elshazly
- Colorectal Unit, Department of Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt,
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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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Loganathan A, Das A, Luck A, Hewett P. Transanal haemorrhoidal dearterialization for the treatment of grade III and IV haemorrhoids: a 3-year experience. ANZ J Surg 2014; 86:59-62. [DOI: 10.1111/ans.12816] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Arun Loganathan
- Department of Colorectal Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - Atandrilla Das
- Department of Colorectal Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - Andrew Luck
- Department of Colorectal Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
| | - Peter Hewett
- Department of Colorectal Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
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Tempel MB, Pearson EG, Page M, Pollock D, Gilmore-Lynch K, Peche W, Sklow B, Snyder M. Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings. Tech Coloproctol 2013; 18:607-10. [PMID: 24352923 DOI: 10.1007/s10151-013-1104-x] [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] [Received: 05/22/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transanal hemorrhoidal dearterialization (THD) is a recently developed procedure to minimize postoperative pain from hemorrhoidectomy. This technique utilizes Doppler signals to aid ligation of hemorrhoidal arteries followed by mucopexy of redundant mucosa if needed. The aim of the present study was to assess patient satisfaction after THD. METHODS This is a retrospective cohort study of patients who underwent THD at three different sites from April 2007 through October 2010. All procedures were performed in ambulatory settings according to protocol. Telephone surveys were conducted after a minimum of 1-month follow-up to assess patients' satisfaction on a scale of 1-10. Patients were asked whether the procedure had alleviated their symptoms. Patients were asked to recall duration of pain and time from surgery to return to work. RESULTS Between April 2007 and October 2010, 216 patients with grade III-IV hemorrhoids underwent THD. There were 165 males and 61 females. Average age was 52.2 ± 14.2 years. All patients were discharged the same day after meeting ambulatory surgery center discharge criteria. Postoperative difficulty urinating occurred in 37 (17 %) patients, and six of them required temporary urinary catheterization. Transitory postoperative bleeding was reported by 38 (18 %) patients. Transitory incontinence to stool and flatus occurred in 18 (9 %) and 16 patients (8 %), respectively. Pelvic muscle spasms occurred in 21 (10 %) patients. Median follow-up was 23 months (range 1-42 months) with 143 (66 %) having at least 9 months between procedure and interview. Mean patient satisfaction was 8.5 ± 0.7 (on a scale of 1-10 with 10 being the best), and 91.5 % of patients felt the procedure had "helped" them. Average number of days with discomfort was 6.7 ± 2.1. Patients returned to work after an average of 10.3 ± 3.2 days. Our study is limited by lack of long-term follow-up and by retrospective complication assessment. CONCLUSIONS Patient satisfaction with THD performed in ambulatory settings is high. Our data support performance of this procedure in an ambulatory setting.
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Affiliation(s)
- M B Tempel
- Colon and Rectal Clinic of Houston, Houston, TX, USA,
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