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Puigdollers A, de Balle M, Rovira-Argelagues M. Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance. Cir Esp 2024; 102:69-75. [PMID: 37949364 DOI: 10.1016/j.cireng.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/09/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. METHODS The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. RESULTS In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. CONCLUSIONS While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.
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Affiliation(s)
- Anicet Puigdollers
- Proctology and Pelvic Floor Unit, Hospital de Barcelona, Avinguda Diagonal 660, 08034 Barcelona, Spain.
| | - Mercedes de Balle
- Proctology and Pelvic Floor Unit, Hospital de Barcelona, Avinguda Diagonal 660, 08034 Barcelona, Spain
| | - Montserrat Rovira-Argelagues
- Coloproctology Unit, Department of General Surgery, Hospital de Mollet, Ronda Pinetons 6, 08100 Mollet del Vallès, Barcelona, Spain
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The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk. J Clin Med 2022; 11:jcm11195533. [PMID: 36233395 PMCID: PMC9571675 DOI: 10.3390/jcm11195533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Giordano P, Schembari E. Transanal Hemorrhoidal Dearterialization (THD) Anolift-Prospective Assessment of Safety and Efficacy. Front Surg 2021; 8:704164. [PMID: 34631778 PMCID: PMC8493063 DOI: 10.3389/fsurg.2021.704164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/31/2021] [Indexed: 01/12/2023] Open
Abstract
The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2–32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.
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Affiliation(s)
- Pasquale Giordano
- Department of Colorectal Surgery, Barts Health NHS Trust, London, United Kingdom
| | - Elena Schembari
- Department of Colorectal Surgery, Barts Health NHS Trust, London, United Kingdom
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Sobrado CW, Sobrado LF, Nahas SC, Cecconello I. A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE. ACTA ACUST UNITED AC 2021; 34:e1560. [PMID: 34008704 PMCID: PMC8121048 DOI: 10.1590/0102-672020210001e1560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/20/2020] [Indexed: 12/05/2022]
Abstract
Background:
Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly.
Aim:
To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique.
Methods:
Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence.
Results:
Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed.
Conclusion:
Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.
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Affiliation(s)
- Carlos Walter Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Faraco Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ivan Cecconello
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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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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Boukris Toledano A, Blanchard P, Zaleski A, Benfredj P, Fathallah N, Sultan S, Pommaret E, de Parades V. Lessons from the first 70 patients operated by doppler-guided haemorrhoidal artery ligation with mucopexy in a French team specialising in surgical proctology. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2017.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background Doppler-guided haemorrhoidal artery ligation with mucopexy is a minimal-invasive surgical technique. It is both effective and less painful than conventional haemorrhoidectomy.
Methods We gathered records on all patients operated on between November 2012 and June 2014. Pre- and postoperative scores were calculated during consultation and then by phone. Unsuccessful surgical treatment was defined by persistent haemorrhoid symptoms within three months following the procedure and relapse defined by recurrent symptoms after the third postoperative month.
Results During the period analysed, 70 patients underwent consecutive surgical procedures for haemorrhoid prolapse (52%), bleeding (29%), or both (17%). Hospitalisation was outpatient or overnight for 87% of patients. There were no complications in 92.7% of cases. The average period away from work was 11 days (± 6.5). The time between the procedure and last postoperative consultation, followed by telephone contact, was respectively 2.7 months (± 5.8) and 16.5 months (± 4.9). At the time of the postoperative telephone call, the Thaha et al. score decreased by 5.6 (p < 0.001), while the quality of life score decreased by 2 (p < 0.001). The Wexner score remained the same or improved for all patients except one. Treatment was unsuccessful for 6/67 patients (9%) and 10/61 patients (16.4%) experienced a subsequent recurrence in haemorrhoid symptoms. Only those over 51 years old were statistically associated with more frequent recurrences (p = 0.044).
Conclusion Doppler-guided haemorrhoidal artery ligation with mucopexy is an effective technique in the medium-term. Good tolerance in makes this treatment an attractive alternative to conventional haemorrhoidectomy.
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Affiliation(s)
- Alexia Boukris Toledano
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
| | - Pierre Blanchard
- Institut Gustave Roussy, Epidemiology and Biostatistics, Villejuif, France
| | | | - Paul Benfredj
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
- Clinique du Louvre, Paris, France
| | - Nadia Fathallah
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
| | - Samy Sultan
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
| | - Elise Pommaret
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
| | - Vincent de Parades
- Institut Léopold Bellan, Groupe hospitalier Paris Saint-Joseph, Department of Medical and Surgical Proctology, Paris, France
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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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Transanal hemorrhoidal dearterialization: Lessons learned from a personal series of 200 consecutive cases and a proposal for a tailor-made procedure. Ann Med Surg (Lond) 2020; 55:207-211. [PMID: 32518642 PMCID: PMC7272515 DOI: 10.1016/j.amsu.2020.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023] Open
Abstract
Background Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease (HD). However, the surgical technique is not standardized and the results for advanced HD are controversial. The aim of this study was to assess surgical outcomes after a long follow-up and compare total and partial mucopexy. Materials and methods Between March 2011 and July 2014, THD was offered to patients with symptomatic prolapsed hemorrhoids (Grades II, III and IV). Dearterialization was performed with the guidance of Ultrasound Doppler and mucopexy for prolapsed piles, and regarded as total or partial (if less than 6 mucopexies). Post-operative complications, long-term results and patients’ satisfaction rates were analyzed. Results 200 consecutive patients were recruited with a mean follow-up of 43 months (range 29 - 57 months). HD distribution was GII (N = 35, 17.5%), GIII (N = 124, 62%), and GIV (N = 41, 20.5%). Postoperative complications included transient tenesmus (26,5%), pain (14%) and fecal impaction (2,5%). Recurrence rates were 0, 2,4% and 17,1% for prolapse (p < 0,01) and 2,9%, 4% and 9,8% for bleeding (p = 0,33) in grades II, III and IV, respectively. Total mucopexy resulted in more tenesmus (31,2%) than partial mucopexy (14,5%), (p < 0,01). After 12 weeks of follow-up, 85% of patients were either very satisfied or satisfied; 8,5% were dissatisfied. Conclusion THD-mucopexy is safe with low overall recurrence. Grade IV HD is associated with more recurrence and postoperative complications. Total mucopexy is associated with more tenesmus, pain and fecal impaction. A tailor-made procedure with selective dearterialization and mucopexy may be the next step in this evolving technique. .THD is safe procedure for hemorrhoids with low overall recurrence of prolapse and bleeding. .THD for grade IV hemorrhoidal disease is associated with more recurrence. .THD with partial mucopexy achieves similar good results compared to total mucopexy. .THD with total mucopexy is associated with more postoperative tenesmus, pain and fecal impaction. .The number of dearterializations and mucopexies should be tailor-made.
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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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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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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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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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Shelygin YA, Frolov SA, Titov AY, Blagodarny LA, Vasilyev SV, Veselov AV, Grigoriev EG, Kashnikov VN, Kostarev IV, Kostenko NV, Kuzminov AM, Kulikovskiy VF, Moskalev AI, Mudrov AA, Muravyev AV, Polovinkin VV, Timerbulatov VM, Khubezov DA, Yanovoy VV. THE RUSSIAN ASSOCIATION OF COLOPROCTOLOGY CLINICAL GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF HEMORRHOIDS. ACTA ACUST UNITED AC 2019. [DOI: 10.33878/2073-7556-2019-18-1-7-38] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Landaluce-Olavarria A, Ugarte-Sierra B, Mugica-Alcorta I, Onandia-Alberdi JR, Portugal-Porras V, Ibañez-Aguirre FJ. Transanal hemorroidal desarterialization: technique developments and mid-terms results. MINERVA CHIR 2019; 74:111-112. [PMID: 30646678 DOI: 10.23736/s0026-4733.18.07778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Brown S, Tiernan J, Biggs K, Hind D, Shephard N, Bradburn M, Wailoo A, Alshreef A, Swaby L, Watson A, Radley S, Jones O, Skaife P, Agarwal A, Giordano P, Lamah M, Cartmell M, Davies J, Faiz O, Nugent K, Clarke A, MacDonald A, Conaghan P, Ziprin P, Makhija R. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technol Assess 2018; 20:1-150. [PMID: 27921992 DOI: 10.3310/hta20880] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Optimal surgical intervention for low-grade haemorrhoids is unknown. Rubber band ligation (RBL) is probably the most common intervention. Haemorrhoidal artery ligation (HAL) is a novel alternative that may be more efficacious. OBJECTIVE The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids. DESIGN A multicentre, parallel-group randomised controlled trial. PERSPECTIVE UK NHS and Personal Social Services. SETTING 17 NHS Trusts. PARTICIPANTS Patients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL. INTERVENTIONS HAL with Doppler probe compared with RBL. OUTCOMES Primary outcome - recurrence at 1 year post procedure; secondary outcomes - recurrence at 6 weeks; haemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness. RESULTS A total of 370 participants entered the trial. At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [adjusted odds ratio (OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51; p = 0.0005]. The main reason for the difference was the number of extra procedures required to achieve improvement/cure. If a single HAL is compared with multiple RBLs then only 37.5% recurred in the RBL arm (adjusted OR 1.35, 95% CI 0.85 to 2.15; p = 0.20). Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL), suggesting significant deterioration in both groups over the year. Symptom score, EQ-5D-5L and Vaizey score improved in both groups compared with baseline, but there was no difference between interventions. Pain was less severe and of shorter duration in the RBL group; most of the HAL group who had pain had mild to moderate pain, resolving by 3 weeks. Complications were low frequency and not significantly different between groups. It appeared that HAL was not cost-effective compared with RBL. In the base-case analysis, the difference in mean total costs was £1027 higher for HAL. Quality-adjusted life-years (QALYs) were higher for HAL; however, the difference was very small (0.01) resulting in an incremental cost-effectiveness ratio of £104,427 per additional QALY. CONCLUSIONS At 1 year, although HAL resulted in fewer recurrences, recurrence was similar to repeat RBL. Symptom scores, complications, EQ-5D-5L and continence score were no different, and patients had more pain in the early postoperative period after HAL. HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY. LIMITATIONS Blinding of participants and site staff was not possible. FUTURE WORK The incidence of recurrence may continue to increase with time. Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness. The polysymptomatic nature of haemorrhoidal disease requires a validated scoring system, and the data from this trial will allow further assessment of validity of such a system. These data add to the literature regarding treatment of grade II/III haemorrhoids. The results dovetail with results from the eTHoS study [Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 2016, in press.] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy. Combined results will allow expansion of analysis, allowing surgeons to tailor their treatment options to individual patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN41394716. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 88. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim Tiernan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Katie Biggs
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Neil Shephard
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abualbishr Alshreef
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Lizzie Swaby
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Radley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Oliver Jones
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Paul Skaife
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Anil Agarwal
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | | | - Marc Lamah
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Justin Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Omar Faiz
- North West London Hospitals NHS Trust, London, UK
| | - Karen Nugent
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | | | - Paul Ziprin
- Imperial College Healthcare NHS Trust, London, UK
| | - Rohit Makhija
- Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
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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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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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18
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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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19
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Brown SR. Hubble trial: time to stick to basics for treatment of haemorrhoids? Tech Coloproctol 2016; 21:65-67. [PMID: 27699495 DOI: 10.1007/s10151-016-1535-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 08/14/2016] [Indexed: 11/28/2022]
Abstract
The results of the Hubble trial, a randomised controlled trial comparing haemorrhoidal artery ligation with rubber band ligation for early-grade prolapsing haemorrhoids, are discussed. The difficulties in defining treatment success are debated along with the trial design highlighting the pitfalls of previous research. A finding that haemorrhoidal artery ligation is not necessarily superior to cheap alternatives has implications for current practice and future commissioning of surgeons.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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20
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Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis 2016; 18:441-58. [PMID: 26990602 DOI: 10.1111/codi.13330] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 12/11/2022]
Abstract
AIM Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula. METHOD A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken. RESULTS We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study. CONCLUSION Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - E Tan
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - A Darzi
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - S D Wexner
- Department of Colorectal Surgery in the Digestive Disease Center, Cleveland Clinic, Weston, FL, USA
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Giamundo P. Advantages and limits of hemorrhoidal dearterialization in the treatment of symptomatic hemorrhoids. World J Gastrointest Surg 2016; 8:1-4. [PMID: 26843909 PMCID: PMC4724583 DOI: 10.4240/wjgs.v8.i1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/09/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
In the last two decades, hemorrhoidal dearterialization has become universally accepted as a treatment option for symptomatic hemorrhoids. The rationale for this procedure is based on the assumption that arterial blood overflow is mainly responsible for dilatation of the hemorrhoidal plexus due to the absence of capillary interposition between the arterial and venous systems within the anal canal. Dearterialization, with either suture ligation (Doppler-guided hemorrhoid artery ligation/transanal hemorrhoidal dearterialization) or laser (hemorrhoidal laser procedure), may be successfully performed alone or with mucopexy. Although the added value of Doppler-guidance in association with dearterialization has recently been challenged, this imaging method still plays an important role in localizing hemorrhoidal arteries and, therefore, minimizing the effect of anatomic variation among patients. However, it is important to employ the correct Doppler transducer. Some Doppler transducers may not easily detect superficial arteries due to inadequate frequency settings. All techniques of dearterialization have the advantage of preserving the anatomy and physiology of the anal canal, when compared to other surgical treatments for hemorrhoids. This advantage cannot be underestimated as impaired anal function, including fecal incontinence and other defecation disorders, may occur following surgical treatment for hemorrhoids. Furthermore, this potentially devastating problem can occur in patients of all ages, including younger patients.
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Doppler-guided hemorrhoidal artery ligation with hemorrhoidopexy: source and prevention of postoperative pain. Int J Colorectal Dis 2015; 30:625-30. [PMID: 25652879 DOI: 10.1007/s00384-015-2148-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Transanal hemorrhoidal dearterialization, although it showed reliability, has not completely removed the issue of postoperative pain. OBJECTIVE We investigated the causes of postoperative pain and proposed some changes of the technique in order to eliminate it. PATIENTS One hundred six out of 188 operated patients were considered. Postoperative pain was investigated using a Visual Analogue Score dividing patients into three groups: 0 to 3, 4 to 6, and 7 to 10. On the basis of these results, we proposed some variations of the technique. A second group of 25 patients was therefore treated with the modified technique. Statistical analysis was conducted using the Fisher's exact test, two-tailed. MAIN OUTCOME Pain intensity, surgical approach, and changes in the technique were analyzed, and a new proposal for a modified technique has been developed. RESULTS The group of 106 patients, 64 males and 42 females, were divided: 71 III grade and 35 IV grade. Pain was detected in 37 cases (35%).Fifteen males (23.50%) were divided as follows: 8 mild and 7 medium or intense. Twenty-two females (52.38%) were divided as follows: 11 mild and 11 with medium or intense. For what concerns the variable grade, the pain was present in 15 III G and 22 IV G with statistic significant difference (p value 0.00333). Among the 18 patients (7 males and 11 females) who had severe pain, they all had a number of mucopexies >4, while among 19 patients (8 males and 11 females) with mild pain, only 5 had a number of mucopexies >4, resulting in a statistic significant difference (p value 0.031). In the second group, pain was drastically reduced. LIMITATIONS We believe it is necessary to extend the sample in order to definitively adopt the proposed amendments. CONCLUSIONS The review of the causes of postoperative pain and the changes adopted compared with those proposed in literature have allowed us to greatly reduce postoperative pain.
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LaBella GD, Main WPL, Hussain LR. Evaluation of transanal hemorrhoidal dearterialization: a single surgeon experience. Tech Coloproctol 2015; 19:153-7. [PMID: 25637412 PMCID: PMC4369582 DOI: 10.1007/s10151-015-1269-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/20/2014] [Indexed: 02/08/2023]
Abstract
Background
There is an increasing, though still limited, amount of evidence describing the use of the transanal hemorrhoidal dearterialization (THD) device for the treatment of hemorrhoidal disease. This study assesses postoperative outcomes from a single surgeon experience with the THD device. Methods From January 2009 to December 2011, 108 THD procedures were performed. With Doppler guidance, the THD device makes possible precise ligation of the branches of the superior hemorrhoidal artery. Patients were seen postoperatively at 3 weeks and 6 months. They underwent physical examination to determine whether there was recurrence of hemorrhoidal prolapse. They were asked to describe any bleeding, to rate pain using the visual analog scale, and to rate their level of satisfaction on a scale of 1–5 (with 5 = highly satisfied). A phone interview was used for follow-up at 1 year to determine the rate of recurrent prolapse. Results Of the 108 patients who underwent THD, two were lost to follow-up and excluded. All of the remaining 106 patients completed follow-up at 3 weeks and 6 months. At 3 weeks, 92 % of patients had no pain and 88 % were highly satisfied with the procedure at 3 weeks. This increased to 92 % satisfaction at 1 year. Prolapse recurrence was 7.5 % at 6 months and 10.3 % at 1 year. Bleeding was the most common complication, but did not require re-intervention or transfusion. Conclusions THD is a same-day procedure for the treatment of hemorrhoidal disease that is safe and effective, and offers the potential for immediate return to normal activity.
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Affiliation(s)
- G D LaBella
- Division of Colon and Rectal Surgery and Trauma Surgery, Department of Surgery, Bethesda North and Good Samaritan TriHealth Hospital, Cincinnati, OH, USA,
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Ratto C, Parello A, Veronese E, Cudazzo E, D'Agostino E, Pagano C, Cavazzoni E, Brugnano L, Litta F. Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis 2015; 17:O10-9. [PMID: 25213152 DOI: 10.1111/codi.12779] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/20/2014] [Indexed: 12/11/2022]
Abstract
AIM This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome. METHOD Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni- and multivariate analyses of the potential predictive factors for failure were performed. RESULTS The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 ± 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively. Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome. CONCLUSION THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.
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Affiliation(s)
- C Ratto
- Proctology Unit, Department of Surgical Sciences, Catholic University, Rome, Italy
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Cerato MM, Cerato NL, Passos P, Treigue A, Damin DC. Surgical treatment of hemorrhoids: a critical appraisal of the current options. ACTA ACUST UNITED AC 2014; 27:66-70. [PMID: 24676303 PMCID: PMC4675486 DOI: 10.1590/s0102-67202014000100016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/28/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence. AIM To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease. METHODS A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate. RESULTS Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates. CONCLUSION Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results.
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Affiliation(s)
| | - Nilo Luiz Cerato
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Daniel C Damin
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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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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Tsang YP, Fok KLB, Cheung YSH, Li KWM, Tang CN. Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Tech Coloproctol 2014; 18:1017-22. [PMID: 24906978 DOI: 10.1007/s10151-014-1170-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 05/10/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND The aim of this study was to evaluate and compare transanal haemorrhoidal dearterialisation (THD) and stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)] in the management of haemorrhoidal disease, in terms of short-term outcomes and efficacy. METHODS Patients presenting with symptomatic haemorrhoids were treated with THD. Patient demographics, pre-operative data, post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. These data were compared with the historical data of PPH. RESULTS Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH taken from a medical records database. There were no significant differences in terms of demographic data, type of anaesthesia, operative time, and blood loss. Length of hospital stay, time to first post-operative bowel movement, and complications were similar between the two groups. The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000). There was a significant improvement in bleeding and prolapse scores after THD. THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group. Upon follow-up, patients in both groups had similar satisfaction scores, and complication and recurrence rates. CONCLUSIONS Both THD and PPH appear to be safe procedures for haemorrhoidal disease, and they appear to have similar short-term outcomes. In particular, THD seems to be associated with a lower pain score than PPH, an earlier return to normal daily activities, and similar rates of complication and recurrence.
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Affiliation(s)
- Y P Tsang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hongkong, SAR, China,
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Giordano P, Tomasi I, Pascariello A, Mills E, Elahi S. Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids. Colorectal Dis 2014; 16:373-6. [PMID: 24460621 PMCID: PMC4283720 DOI: 10.1111/codi.12574] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/02/2013] [Indexed: 12/24/2022]
Abstract
AIM Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids. METHOD The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique. RESULTS From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms. CONCLUSION Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids.
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Affiliation(s)
- P Giordano
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - I Tomasi
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - A Pascariello
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - E Mills
- Department of Colorectal Surgery, Barts HealthLondon, UK
| | - S Elahi
- Department of Colorectal Surgery, Barts HealthLondon, UK
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Miyamoto H, Asanoma M, Miyamoto H, Takasu C, Masamune K, Shimada M. Visualization and hypervascularization of the haemorrhoidal plexus in vivo using power Doppler imaging transanal ultrasonography and three-dimensional power Doppler angiography. Colorectal Dis 2013; 15:e686-91. [PMID: 24034699 DOI: 10.1111/codi.12406] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/07/2013] [Indexed: 01/13/2023]
Abstract
AIM The purpose of this study was to demonstrate the distribution of haemorrhoidal arteries and the relationship between vascularity and growth of haemorrhoids. METHOD One-hundred and three patients with haemorrhoids were studied. Using power Doppler imaging (PDI) transanal ultrasound and three-dimensional power Doppler angiography (3D-PDA), the course of the arteries supplying the haemorrhoids was identified. Measurement of the PDI area was made using the cursor to outline the power Doppler signal of the haemorrhoid, approximately 1 cm above the dentate line. RESULTS The haemorrhoidal arteries were seen as branches of the superior rectal artery and were detected in 75.7, 71.8, 68.0 and 62.1% of the 11, 7, 3 and 1 o'clock positions in the lithotomy position. The median number of haemorrhoidal arteries significantly increased from three to six with progression of the Goligher classification from Grade 1 to Grade 4 (P < 0.0001). The PDI areas in Grades 1, 2, 3 and 4 were 0.04 ± 0.03, 0.18 ± 0.07, 0.38 ± 0.18 and 0.96 ± 0.32 cm(2) (P < 0.05). CONCLUSION The distribution of haemorrhoidal arteries varies widely in both number and position. Using PDI transanal ultrasonography and 3D-PDA it was possible to visualize the haemorrhoid plexus and the course of the haemorrhoidal artery in vivo.
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Affiliation(s)
- H Miyamoto
- Department of Surgery and Proctologic Surgery, Miyamoto Hospital, Anan, Japan; Department of Digestive and Pediatric Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
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Ratto C. THD Doppler procedure for hemorrhoids: the surgical technique. Tech Coloproctol 2013; 18:291-8. [PMID: 24026315 PMCID: PMC3950605 DOI: 10.1007/s10151-013-1062-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease. The ligation of hemorrhoidal arteries (called “dearterialization”) can provide a significant reduction of the arterial overflow to the hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called “mucopexy”) can provide a repositioning of prolapsing tissue to the anatomical site. In this paper, the surgical technique and perioperative patient management are illustrated. Following adequate clinical assessment, patients undergo THD under general or spinal anesthesia, in either the lithotomy or the prone position. In all patients, distal Doppler-guided dearterialization is performed, providing the selective ligation of hemorrhoidal arteries identified by Doppler. In patients with hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a continuous suture including the redundant and prolapsing mucosa and submucosa. The description of the surgical procedure is complemented by an accompanying video (see supplementary material). In long-term follow-up, there is resolution of symptoms in the vast majority of patients. The most common complication is transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal bleeding occurs in a very limited number of patients. Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure. When accurately performed and for the correct indications, THD is a safe procedure and one of the most effective treatments for hemorrhoidal disease.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy,
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Cavazzoni E, Bugiantella W, Graziosi L, Silvia Franceschini M, Cantarella F, Rosati E, Donini A. Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding. Colorectal Dis 2013; 15:e89-92. [PMID: 23045996 DOI: 10.1111/codi.12053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/28/2012] [Indexed: 01/29/2023]
Abstract
AIM The effectiveness of Doppler guided transanal haemorrhoidal dearterialization (THD) for arresting persistent haemorrhoidal bleeding in patients admitted as an emergency was studied. METHOD Eleven patients with severe anal bleeding underwent emergency THD as definitive treatment for haemorrhoids. In the majority of patients antiplatelet or anticoagulant therapy was ongoing and severe anaemia was present in six patients. RESULTS The mean operative time was 39.7 min. Six to nine feeding arteries were ligated. Intra-operative blood loss was nil. Bleeding was well controlled in all patients. No blood transfusion was required. Mean pain score per verbal numeric scale was 3.6 and 1.4 on day 1 and day 3 respectively. The mean time to resumption of normal activities was 8 days. No major complications were experienced. Six months follow-up demonstrated good control of haemorrhoidal disease. CONCLUSION THD is effective in controlling acute haemorrhoidal bleeding with a low incidence of postoperative complications.
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Affiliation(s)
- E Cavazzoni
- Department of Surgery, University of Perugia, Perugia, Italy.
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