Hemorrhoidal artery ligation without Doppler navigation in surgical treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is a condition characterized by enlarged normally present anal cushions or nodules accompanied by clinical symptoms. HD of grade I and II, is primarily treated conservatively with medication (creams and phlebotonics) as well as by office-based procedures, such as rubber band ligation, injection sclerotherapy, infrared coagulation, cryotherapy, and radiofrequency ablation. Indications for a surgical treatment of hemorrhoidal disease are: persistent and recurrent bleeding that does not respond to conservative treatment and office-based interventions, prolapse of hemorrhoids causing significant difficulties and discomfort (Grade III and IV), failure of conservative treatment methods, presence of complications (anemia, infection, or fistula). There are two types of surgical interventions, non-excisional and excisional. The group of non-excisional surgical procedures includes: stapled hemorrhoidopexy, Doppler-guided ligation of hemorrhoidal arteries and laser treatment of hemorrhoids. The group of excisional surgical procedures includes: open (Milligan-Morgan) hemorrhoidectomy, closed (Ferguson’s) hemorrhoidectomy Ligasure and Harmonic hemorrhoidectomy and Park’s hemorrhoidectomy. Non-excisional surgical methods represent potential options in the treatment of stage III hemorrhoids and patients with early stage IV disease. Non-excisional methods are characterized by lower postoperative pain intensity, faster recovery, and fewer postoperative complications, but they are also associated with a significantly higher rate of recurrence.Excisional methods in surgical treatment represent the method of choice for stage IV hemorrhoidal disease. They are characterized by intense postoperative pain and a higher frequency of complications such as bleeding, urinary retention, anal canal stenosis or stricture, and anal incontinence. There is no single best and most effective method for treating hemorrhoids.

To assess the usefulness of hemorrhoidal artery ligation (HAL) for internal hemorrhoids with a newly devised instrument (the Moricorn). We devised a new instrument (the Moricorn) that is used in conjunction with a Doppler flowmeter. This instrument allows for easy and safe ligation of the hemorrhoidal artery. HAL with the Moricorn was performed on 116 patients with internal hemorrhoids who had episodes of anal pain, bleeding, and prolapse. One month after treatment, the effect was evaluated on the basis of improvement of symptoms and the shrinkage of hemorrhoidal tissue. The treatment's effect was observed in 50 of 52 patients (96%) with pain, 50 of 64 (78%) with prolapse, and 92 of 96 (95%) with bleeding. No patient required anesthesia throughout the entire procedure. No major complications were encountered with this treatment. HAL with the Moricorn is a simple, safe, and effective method. However, further observations predicated on a longer follow-up, a larger number of patients, and comparisons with other conventional treatments are called for.

Hemorrhoidal artery ligation (HAL) with Doppler guidance and suture fixation of hemorrhoidal nodes (RAR) is a popular minimally invasive technique for hemorrhoidal disease (HD) treatment which uses an ultrasound probe to detect hemorrhoidal arteries for further ligation. We hypothesized that ultrasound guidance has no advantages over manual hemorrhoidal arteries detection for HD treatment.The aim is to compare the results of HAL-RAR procedure in patients with stage II-III HD with Doppler and manual HA detection.In this ongoing randomized, controlled, single center clinical study 204 patients randomly divides into group A (HAL-RAR with Doppler US navigation) and group B (HAL with manual HA detection and mucopexy) are planned to be included. The primary endpoint was recurrence of any symptoms of HD; secondary endpoints were pain syndrome severity, treatment satisfaction (1 to 5 points), and need for the drug therapy in 30 days and 8 weeks after surgery. Ultrasound guidance technology of HAL with mucopexy could have the same efficacy the manual HA detection regarding the HD treatment effectiveness and patient satisfaction.

Purpose: Doppler-guided hemorrhoidal artery ligation (HAL) is an alternative technique to the standard Milligan-Morgan hemorrhoidectomy. The purpose of this pilot study is to introduce the HAL technique for grade 2-3 internal hemorrhoids and to evaluate the efficacy of this technique in Korea in terms of results and patient satisfaction. Methods: The HAL procedure was performed on 29 patients with grade 2 or 3 internal hemorrhoids. Twenty-eight procedures were performed under local anesthesia with lidocaine, and one procedure was performed under general anesthesia due to synchronous surgery for gallstones. With the lithotomy position, the pulsation of the hemorrhoidal artery was localized using a doppler probe, and 3-6 branches of the hemorrhoidal artery were ligated with vicryl 2-0. Patient course was evaluated before and after the procedure by using questionnaires with a visual analog scale. Results: The mean age of the patients was 4424 yr. There were no significant complications with this procedure. At 3 mo after the operation, symptom scores of anal pain, anal bleeding, and anal prolapse were significantly improved (0.4, 1.0, and 2.4, respectively) compared to the symptom scores before the operation (3.4, 4.6, and 5.9, respectively). The postoperative satisfaction score was 8.1, and the recommendation score was 8.5. Conclusion: HAL is a safe and effective technique to relieve anal pain, bleeding, and prolapse of internal hemorrhoids. A comparative study with other procedures and a long-term follow-up after HAL should be the basis for valdating the efficacy of this procedure.

Hemorrhoidal disease is the most common of all diseases of the rectum, the first mention of which dates back to the XVIII century BC. Methods of surgical treatment of hemorrhoidal disease are aimed at both minimizing the pain syndrome and early postoperative rehabilitation. They have evolved over many centuries and currently continue to improve. This historical review presents the changes in trends in the surgical treatment of hemorrhoidal disease.

BACKGROUND:Nowadays, minimally invasive procedures are mainly performed in the treatment of hemorrhoidal diseases. However, the feasibility of using ultrasound navigation for hemorrhoidal artery ligation-rectoanal repair (HAL-RAR) is still discussed because digital palpation of hemorrhoidal arteries for ligation is safe and easy to perform. AIM:To evaluate the long-term results of HAL with mucopexy by digital examination in comparison with traditional HAL-RAR in the surgical treatment stage II–III hemorrhoidal disease. MATERIALS AND METHODS:The controlled randomized trial included 150 patients with stage II–III hemorrhoidal disease. The study group (n=75) included patients who underwent surgery using digital palpation with mucopexy, and in the control group (n=75), the HAL-RAR was used. The primary endpoint was a recurrence of the main symptoms. Secondary endpoints included patient satisfaction and discomfort, pain intensity, prolapse of hemorrhoidal piles, and rectal bleeding. RESULTS:The groups did not differ in sex, age, body mass index, and stage, and symptoms of hemorrhoidal disease. During the 12-month follow-up, no difference in the prolapse of hemorrhoidal piles (p=0.49), patient satisfaction (p=0.95), and discomfort (p=0.67) was found. Periodic bleeding occurred in 5.3% and 17.3% of the patients in the study and control groups, respectively (p=0.037). After 2 months of follow-up, pain recurred in 8 (10.6%) patients in the study group and 22 (29.3%) in the control group (p=0.037). At 18 months follow-up, no difference in patient satisfaction (p=0.95) and discomfort (p=0.89) was noted; however, the rate of hemorrhoidal prolapse was significantly higher in the study group (16.3%) than in the control group (13.5%) (p=0.045), and bleeding was reported in 10.2% and 15.4% of the patients in these groups, respectively (p=0.86). Open hemorrhoidectomy for relapse of hemorrhoidal prolapse was performed in 2 (2.6%) patients in the study group and 4 (5.3%) patients in the control group (p=0.68). CONCLUSION:Ligation of hemorrhoidal arteries in combination with mucopexy without ultrasound guidance is a safe, easy, and reproducible technique, with comparable effectiveness, and long-term results to HAL-RAR. This procedure can be recommended for the surgical treatment of stage II–III hemorrhoids.

Hemorrhoidal artery ligation (HAL) has become universally accepted minimally invasive treatment of hemorrhoids disease. HAL involves precise identification of the superior rectal arteries supplying hemorrhoidal tissues using ultrasonic Doppler principles. During this process, at least there are three distinct sounds may be encountered by the surgeon. Only the pulsing Doppler sound is useful as it indicates the presence of hemorrhoidal artery. The accuracy based on traditional auscultation is commonly affected by surgeon’s hearing sensitivity and clinical experience. Therefore, automatic Doppler blood flow sound will be a great help in locating hemorrhoidal arteries. In this paper, a method based on the center frequency and kurtosis features extracted from Burg’s power spectral density (PSD) to distinguish three different types of Doppler blood flow sound signal during HAL procedure is proposed. Separability measurement was carried out using K– means clustering with the city block distance and three clusters corresponding to different sound types are successfully formed. In terms of arterial sound detection, an accuracy of 94.11% can be achieved. This result suggests that centre frequency, kurtosis, and maybe some other statistical features extracted from Burg PSD have the potential to be utilized as a means in automatic Doppler blood flow sound recognition.

SHORT TERM OUTCOME OF DOPPLER GUIDED HEMORRHOIDAL ARTERY LIGATION AND RECTO-ANAL REPAIR IN COMPARISON WITH CONVENTIONAL OPEN HEMORRHOIDECTOMY AS A TREATMENT METHOD FOR PROLAPSED HEMORRHOIDS. Sadq Ghaleb Kadem MB, ChB, FICMS, General Surgeon, Al-Shiffa General Hospital, Basrah, IRAQ. Abstract Conventional hemorrhoidectomy is the most common surgical procedure used to treat hemorrhoids, but it is associated with significant side effects and complications. Doppler-guided hemorrhoidal artery ligation and recto-anal repair is a new minimally invasive treatment option to avoid the complications of conventional hemorrhoidectomy. This study aimed to evaluate the short term outcome of doppler-guided hemorrhoidal artery ligation and recto-anal repair in comparison with conventional open hemorrhoidectomy as a method for treating patients with prolapsed hemorrhoids. This study was conducted at Al-Shiffa General Hospital in Basrah, Iraq, during the period from January 2015 to December 2016. One hundred patients with symptomatic hemorrhoids who are candidates for surgery were included in the study and were divided into two equal groups; the first group operated upon with conventional open hemorrhoidectomy and the second group operated upon with doppler guided hemorrhoidal artery ligation and recto anal repair technique which utilizes a special doppler ultrasound proctoscope to identify and ligate the hemorrhoidal arteries and to gather up and lift back into position. Both groups were similar in patients characteristics, all operations have been done under general or spinal anesthesia and in lithotomy position by the same surgeon. During intra and postoperative periods of follow-up, the outcome and the complications of both procedures were analyzed statistically and compared. Doppler guided hemorrhoidal artery ligation and recto-anal repair technique significantly reduce postoperative pain and according to the Visual Analogue Scale; the majority of patients (64%) in doppler guided hemorrhoidal artery ligation and recto anal repair group have no pain at the night of the surgery while 82% of patients in conventional open hemorrhoidectomy group complained of moderate pain. It also significantly reduce the mean duration to return to normal daily activity to 5.44±2.02 days in comparison to 15.40±4.18 days for conventional open hemorrhoidectomy (p<0.001). The overall complications after conventional open hemorrhoidectomy were high; 14(28%) patients in comparison to 8(16%) patients after doppler guided hemorrhoidal artery ligation and recto-anal repair technique with significant statistical difference (p value<0.001). In conclusion, the doppler guided hemorrhoidal artery ligation and recto-anal repair technique is a valid alternative treatment for hemorrhoids in stages II, III and IV and its main benefits are to evolve with a little postoperative pain and to enable fast return of the patient to daily activities with low rate of postoperative complications

To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan-Morgan technique using either the CO(2) laser or cold scalpel. Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B). Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption. Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P =0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction. There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn’s disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2–70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14–77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3–16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5–16%) vs. 5% (0–13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.

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. The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids. A multicentre, parallel-group randomised controlled trial. UK NHS and Personal Social Services. 17 NHS Trusts. Patients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL. HAL with Doppler probe compared with RBL. 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. 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. 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. Blinding of participants and site staff was not possible. 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. Current Controlled Trials ISRCTN41394716. 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.

Doppler-guided ligation of the hemorrhoidal arteries was described as an alternative to hemorrhoidectomy. The authors report their experience with this procedure. From 2002 to 2004, 100 consecutive patients underwent hemorrhoidal artery ligation procedure for symptomatic hemorrhoids and were reviewed at one month and at three years. There were 54 females. Seventy-eight patients had Grade III hemorrhoids. Eighteen patients had previously been treated for the disease. The mean operative time was 28 minutes. On average, 8.4 ligatures were placed. Seventy-nine patients were discharged the same day. Six patients presented with early complication: isolated pain in one, pain and bleeding in three, isolated bleeding in one, and obstructed defecation in one. Late complications occurred in six patients: anal pain in one, fissure in two, and thrombosis of residual hemorrhoids in three. Twelve patients presented with a recurrence at a mean delay of 12.6 months, which was treated by repeat hemorrhoidal artery ligation (n = 1), hemorrhoidopexy (n = 7), and hemorrhoidectomy (n = 4). Hemorrhoidal artery ligation procedure is safe, easy to perform, and should be considered as an alternative for the treatment of symptomatic hemorrhoids, even with a recurrence rate of 12 percent, which can be treated by the same technique or another.

Aim. To evaluate the efficacy of haemorrhoidal artery ligation (HA) with a preliminary palpatory determination of its localization supplemented by mucopexy of haemorrhoids as a new surgical method in the treatment of haemorrhoidal disease (HD) and to compare it with HAL-RAR technology.Materials and methods. The randomized controlled clinical trial included patients over 18 years old with Goligher's grade II, III or IV symptomatic HD. We operated on patients in the study group (n = 75) using palpatory determination of the localization of HA and subsequent mucopexia. In the control group (n = 75) we used HAL-RAR. The primary endpoint (25-30 days after surgery): recurrence rate of HD symptoms. Secondary endpoints: postoperative complication rate, pain intensity on a visual-analogue scale from 1 to 10 points, patient satisfaction with the treatment results on a 10-point scale.Results. According to the initial characteristics (age, gender, body mass index, stage of HD, frequency of clinical symptoms), the groups did not differ. Anal bleeding relapse developed: study group - 11%, control group -14%; relapse of haemorrhoids prolapse: 3% and 5% respectively (p &gt; 0.05). Postoperative complications were noted in 6 (8%) in the study group and 4 (5%) in the control group (p &gt; 0.05). The intensity of pain on the 2nd and 25-30 days after surgery was 6.3 [4.8; 7.4] and 1.2 [0.6; 2.5] points in the study group and 6.5 [4.9; 7.3] and 2.1 [1.9; 4.1] in the control group, respectively (p &gt; 0.05). Patient satisfaction with the treatment results after 12 months was estimated at 8.7 [7.9; 9.2] and 9.4 [8.2; 9.6] in the study and control groups, respectively (p &gt; 0.05).Conclusion. HA ligation with a preliminary palpatory determination of its localization and supplemented with mucopexy of haemorrhoids is no less effective than HAL-RAR in preventing haemorrhoidal bleeding and prolapse of the nodes.

Meningioma is the most common intracranial tumor in adults. Often epilepsy is a major clinical manifestation of meningioma. Surgical treatment is a method of choice in patients with meningioma. The early results of the operation and the impact of operations on symptomatic epilepsy are well studied. However, long-term results are poorly investigated.Aim: We were interested in the evaluation of long-term results of surgical treatment of supratentorial meningiomas of the brain and their comparison with the early, as well as the dynamics of symptomatic epilepsy in these patients.Materials and methods: A retrospective analysis of the course of the disease was performed in 110 patients with totally removed supratentorial meningioma of the brain. The long-term results of the effectiveness of surgical treatment are evaluated. The average duration of observation was 48 months (13-83).Results: Neurological deficiency in the preoperative period was observed in 50 patients; at the time of discharge in 40, with an assessment in the distant period - in 12, out of 36 evaluated. Two patients had a hematoma in the removed tumor bed. Postoperative lethality was 1.8% - two patients with vascular complications. 30 of the 40 patients who had epilepsy before the operation became free of attacks after the intervention. In 10 of 40 patients, epilepsy remained. Including 2 patients due to continued growth of meningiomas. In 7 of the 70 patients who did not have attacks before surgery, there were early and / or late postoperative seizures for various reasons. 87 (79%) of tumors were highly differentiated, anaplastic meningioma was detected in 5 (4.5%) patientsConclusions: Total removal of meningiomas can achieve good long-term results. In our series of cases, only 12 (11%) of the neurological deficits with long-term observation were observed in 50 (45.4%) patients who had prior surgery. Symptomatic epilepsy was regressed in 75% of patients. There was an appearance of attacks in 7 patients with 70 patients who had not had an epinephrine before surgery. Histologically, 87 (79%) patients were diagnosed with grade I meningiomas

The OBJECTIVE was to compare the immediate and long-term results of surgical treatment of patients with De Bakey type I versus De Bakey type II acute aortic dissection.METHODS AND MATERIALS. We analyzed the immediate and long-term (5 years) results of surgical treatment of 136 patients with acute aortic dissection, operated on at the Samara Regional Clinical Cardiology Dispensary named after V. P. Poliakov from 2014 to 2022. Patients were divided into two groups: 1 (116 patients) – De Bakey type 1 dissection, 2 (20 patients) – De Bakey type 2 dissection.RESULTS. Hospital mortality was significantly higher in group 1 (24.1 % and 5 % in groups 1 and 2, respectively, p–0.05). Independent risk factors for hospital mortality in patients with acute aortic dissection were: De Bakey type I dissection, body mass index&gt;30.2 kg/m2, arterial hypertension, critical preoperative condition, acute renal failure, history of aortic surgery, duration of artificial circulation and circulatory arrest. The five-year survival rate of patients discharged from the hospital did not differ significantly (88 % and 74 % in groups 1 and 2, respectively, p-0.26). Five-year freedom from reoperations in group 1 – 89 %, in group 2 – 100 %, p = 0.3. Negative remodeling of the descending aorta in the long-term period occurred in 73 % of group 1; in group 2, remodeling of the descending aorta was positive or stable (p &lt; 0.001).CONCLUSIONS. De Bakey type 1 aortic dissection is associated with a higher risk of hospital mortality in patients after surgical treatment, compared with patients with De Bakey type 2 aortic dissection. Five-year survival rate, as well as freedom from reoperation on the aorta in patients discharged from the hospital, does not depend on the type of dissection.