Hemorrhoidal Dearterialization Research Articles

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization.

BackgroundArterial 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.MethodsPatients 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).ResultsOf 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).ConclusionTHD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial

Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure. Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis. Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation. The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed.

A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE.

The surgical procedure: three dearterializations and three mucopexies.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. 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. Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence. 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. 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.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020.

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Transanal hemorrhoidal dearterialization: Lessons learned from a personal series of 200 consecutive cases and a proposal for a tailor-made procedure

BackgroundTransanal 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 methodsBetween 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. Results200 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. ConclusionTHD-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.

The Management of Hemorrhoidal Disease by Dearterialization and Mucopexy.

Several minimally invasive surgical procedures have been recently developed to treat hemorrhoids without any excision. About 25 years ago, a non-excisional procedure providing doppler- guided ligation of the hemorrhoidal arteries has been proposed - named "hemorrhoidal dearterialization". The original technique has been modified over the years, and indications were expanded. In particular, a plication of the redundant and prolapsing mucosa/submucosa of the rectum (named "mucopexy") has been introduced to treat hemorrhoidal prolapse, without excision of the hemorrhoidal piles. At present, the THD® Doppler procedure is one of the most used techniques to treat hemorrhoids. Aim of this technique is to realize a target dearterialization, using a Doppler probe with the final purpose to reduce the arterial overflow to the hemorrhoidal piles. In the case of associated hemorrhoidal prolapse, a mucopexy is performed together with Doppler-guided dearterialization. The entity and circumferential extension of the hemorrhoidal prolapse guide the mucopexy, which can be considered tailored to a single patient; the dearterialization should be considered mandatory. Advantages of this surgical technique are the absence of serious and life-threatening postoperative events, chronic complications, and limited recurrence risks. The impact of the procedure on the anorectal physiology is negligible. However, careful postoperative management is mandatory to avoid complications and to guarantee an improved long-term outcome. Therefore, regular physiologic bowel movements, excessive strain at the defecation and strong physical activity are advisable.

A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD)

BackgroundAlthough conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. MethodsProspective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. ResultsOver this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. ConclusionsThese results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

Combined minimally invasive surgical treatment of chronic internal hemorrhoids

This article is devoted to the results of applying the original minimally invasive surgical technique for the treatment of chronic internal hemorrhoids. The purpose of the study is to improve the outcomes of treatment in patients with chronic internal hemorrhoids by the simultaneous use of pathogenically substantiated low-traumatic surgical methods: dearterialization of internal hemorrhoids with Doppler guidance and clamping with latex rings. Materials and methods. Study included 204 patients with chronic hemorrhoids of the II–III degree, divided into 3 groups depending on the technique of minimally invasive surgery. The standard research methods for coloproctology were used. Results. It was found that the best short-term and long-term results of the surgical treatment of chronic internal hemorrhoids were obtained using the combined surgical technique proposed by the authors. Conclusions. The proposed combination of minimally invasive surgery may be the method of choice in the surgical treatment of chronic hemorrhoids of the II–III degree.

Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam.

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. 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 12months following the procedure. 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 > 40years old. The mean duration of symptoms prior to treatment was 12.3years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40cm prior to treatment vs. 3.66 ± 0.48cm 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. The THD technique did not change the length of the anal sphincter 6months 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.

Hemorrhoid laser procedure with suture-pexy (HeLPexx): a novel effective procedure to treat hemorrhoidal disease

The hemorrhoid laser procedure with suture-pexy (HeLPexx), consisting of Doppler-guided hemorrhoidal dearterialization with laser and the addition of anal mucopexy, is a novel non-excisional procedure to treat hemorrhoids. The aim of the present study was to describe the technique and report the clinical and long-term results. A prospective study was conducted on patients with grade III hemorrhoids who had HeLPexx from January 2012 to February 2018. Pre- and postoperative assessment included a thorough clinical examination, constipation and incontinence scoring systems and a symptom questionnaire which was administered at all patients before surgery and at each follow-up visit to evaluate bleeding, prolapse, manual reduction, discomfort or pain, and impact on quality of life. Each symptom had a score between 0 and 4, (0 indicates no symptoms and 4 indicates daily symptoms). The sum of the score for each symptom constituted the Hemorrhoid Symptom Score. Resolution of symptoms, pain, morbidity, need for further medical and/or surgical therapy were also recorded. One hundred and seventy consecutive patients with grade III hemorrhoids [74 females; mean age 49.5years (range 22-79) years] were included. Median length of follow-up was 36 (range 12-72) months. Postoperative morbidity included urinary retention (7 patients, 4.1%), bleeding not requiring transfusion (1 patient, 0.6%) and thrombosis of hemorrhoidal piles (2 patients, 1.2%). The mean postoperative pain VAS score at 1week postoperatively was 1.8±1.1 (range 0-5) and 12 (7%) patients used pain medications for more than 1week postoperatively while none of the patients reported any pain by the end of the third week postoperatively. The Hemorrhoid Symptom Score significantly improved from 15.83±3.04 to 1.3±2.4 (p≤0.001) and showed a statistically significant improvement in all items. Recurrent symptoms were reported in 12 patients (7%) who required further treatment. Severe chronic constipation prior to surgery was found to be a predictive factor of failure (p = 0.04). HeLPexx appears to be safe and effective for treatment of symptomatic hemorrhoids. Further studies are needed to confirm our results.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY.

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.

The Surgical Management of Haemorrhoids – A Historical Perspective

SUMMARYHaemorrhoids have affected people since ancient time. First documented treatment for haemorrhoids reported from the Egyptian papyrus. Indeed, Ebers’ papyrus dated at 1550 BC, described the use of topical astringents to ease haemorrhoidal pain. More recently, the Milligan-Morgan haemorrhoidectomy and office procedures such as rubber-band ligation have been developed to improve patients’ symptoms. However, these treatments have accompanying problems, for example the haemorrhoidectomy is known to be a profoundly painful operation and office procedures have high recurrence rates and are only suitable for minor haemorrhoids. The development of stapled haemorrhoidopexy and Transanal Haemorrhoidal Dearterialisation (THD) procedures, present the opportunity to treat all grades of haemorrhoids, with improved post-operative pain, whilst maintaining a low recurrence rate. This article places these more modern techniques in the context of the long history of surgical treatments for haemorrhoids and reviews the latest literature comparing operative haemorrhoidectomy, stapled haemorrhoidopexy and THD. A systematic review was carried out to retrieve articles describing history of surgical management of haemorrhoids and studies comparing three modern treatments for haemorrhoids (Haemorrhoidectomy, Stapled haemorrhoidectomy, and THD) were reported.

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.

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. We compared transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy. This was a multicenter, randomized controlled trial. The study was conducted at 6 Spanish centers. Patients aged ≥18 years with grade III to IV hemorrhoids were included. Patients were randomly assigned to transanal hemorrhoidal dearterialization with mucopexy (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41). 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. 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. The main limitation of this study was that the 2 groups did not contain equal numbers of grade III and IV hemorrhoids. 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. clinicaltrials.gov identifier: NCT02654249.

Transanal Hemorrhoidal Dearterialization With Doppler Arterial Identification Versus Classic Hemorrhoidectomy: A Retrospective Analysis of 270 Patients.

PurposeDespite the minimally invasive nature of transanal hemorrhoidal dearterialization (THD) with Doppler arterial identification procedures, hemorrhoidectomy is still considered the gold standard procedure for hemorrhoidal disease. However, the classical techniques of hemorrhoidectomy have a high rate of postoperative complications. The main purpose of this study is to demonstrate the efficacy and complications of these techniques used for grades II and III hemorrhoids.MethodsA retrospective (case-control) study was carried out from January 2009 to May 2014, and all patients undergoing surgical procedures for hemorrhoidal disease in two French clinics were considered. Application of inclusion and exclusion criteria identified 270 eligible patients (163 undergoing Doppler THD and 107 treated with Milligan Morgan hemorrhoidectomy). Statistical analysis was calculated considering immediate postoperative complications, functional results, chronic complications, and recurrences.ResultsAnalysis of primary outcomes showed a significant difference between the 2 groups concerning postoperative pain, which had a lower rate in THD (P = 0.0001) and in postoperative bleeding (P = 0.02) than hemorrhoidectomy. However, long-term follow-up at three years showed a superior rate of recurrence in the THD group (P = 0.009).ConclusionThe THD technique is a safe and effective procedure for grades II and III hemorrhoids, has lower rates of post-operative pain and bleeding, and allows faster hospital discharge; however, it also shows a higher rate of recurrence at three years of follow-up.

Postoperative results of 407 patients submitted to Doppler-guided transanal hemorrhoidal dearterialization

IntroductionThe treatment of hemorrhoidal disease by conventional technique is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. A technique of hemorrhoidal dearterialization associated with rectal mucopexy is a minimal invasive surgical option that has been used to treat the hemorrhoidal disease and reduce its inconveniences. ObjectiveTo analyze the seven-year results of hemorrhoidal dearterialization associated with rectal mucopexy in the treatment of hemorrhoidal disease. MethodsThis study analyzed 407 patients with hemorrhoids grade II, III and IV, who underwent the technique of hemorrhoidal dearterialization in the Luzia de Pinho Melo Hospital, during the period between December 2010 and December 2017. Twenty-seven patients (6.6%) had hemorrhoidal disease of the grade II, 240 (59.0%) grade III, and 117 (28.8%) grade IV. In 23 patients (5.7%), the grade was not found. All patients were operated by the same surgeon under spinal anesthesia. The 407 patients underwent dearterialization, with a varying ligation of one to six arterial branches followed by rectal mucopexy by uninterrupted suture. Eighty-two (20.14%) required removal of concomitant perianal piles or external hemorrhoids and/or fibrosed. In the postoperative follow-up the following parameters were evaluated: pain, tenesmus, bleeding, prolapse, thrombosis, and recurrence. ResultsThe tenesmus was postoperative complaint reported by 93.6% of patients. Forty-three (10.5%) presented intense tenesmus and 44 (22%), moderate to intense pain. Four (0.98%) patients presented more intense bleeding in postoperative follow up; none of the patients required blood transfusions. The prolapse occurred in 18 (4.42%) patients, thrombosis in 11 (2.7%), and there were 19 (4.67%) recurrences that were reoperated in this period. ConclusionThe hemorrhoidal dearterialization technique presents good results, with light and easy-to-resolve complications and little postoperative pain.

PATIENTS' CONTENTMENT WITH TRANSANAL HEMORRHOIDAL DEARTERIALISATION

Hemorrhoidectomy was the method of choice for treating grade 3 and 4 hemorrhoids. Due to a large number of complications, a new surgical treatment called transanal hemorrhoidal dearterialization (THD) was introduced. The aim of the study was to evaluate the effect of treatment with THD in patients with hemorrhoids. This study included 70 patients, 48 males and 22 females, who were hospitalized at the Clinical Center Nis in the period from September 2016 to September 2018. Fifteen patients had grade 4 hemorrhoids, 54 were with grade 3, one patient with grade 2. The average duration of the operation was 33.33 minutes, and patients were hospitalized for 1-2 days. We recorded: sex, age, stage, type of anesthesia, duration of surgery, length of stay, patient satisfaction, combinations of THD with other procedures, and surgical complications. In 46 patients, surgery was performed under general anesthesia, in 18 patients in spinal and in 6 patients in local anesthesia with analgesia. In 37 subjects we used THD only, and in 33 we used THD in combination with other methods. We observed the development of complications in 9 patients. Bleeding occurred in 2 patients, pain in 2, and urinary retention in 4, and abscess in 1. The majority of the patients (62.9%) were satisfied with this method, 27.1% were partially satisfied and 10% were unsatisfied. This method provides a shorter stay in the hospital, low complications rate and is a safe, fast and simple initial surgical option.

Comparison of Doppler-Guided Transanal Hemorrhoidal Dearterialization for Grade III and IV Hemorrhoids in Vietnam.

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. 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 6months after surgery (long-term outcome). 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 18.2years of disease symptom duration, while grade III hemorrhoidal patients reported 11.2years. 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 6days 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. 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.

Doppler-guided hemorrhoidal dearterialization with laser (HeLP): a prospective analysis of data from a multicenter trial

Doppler-guided hemorrhoidal laser procedure (HeLP) is a new minimally invasive technique to treat symptomatic hemorrhoids. The aim of this multicenter study was to prospectively assess clinical results and patients' satisfaction in patients treated with HeLP. Indications for HeLP included patients with symptomatic hemorrhoids resistant to medical therapy, with low-grade prolapse. Clinical efficacy was evaluated assessing resolution of symptoms and patient satisfaction. Frequency of bleeding and frequency of acute hemorrhoid-related symptoms were given a score of 0 to 4 (where 4 = more than 3 episodes/week) and 0 to 3 (where 3 = more than 5 episodes/year), respectively. Quality of life, pain at rest, and pain with evacuation were scored using a visual analogue scale (VAS) of 0 to 10. Intra- and postoperative complications were recorded. Potential predictive factors for failure were assessed. Two hundred and eighty-four patients (183 males, 101 females) with a mean age of 47.5years were included in the study. At 6-month follow-up, symptoms had completely resolved in 257/284 (90.5%) and 275/284 (96.8%) patients were satisfied with the results. An analysis of a subgroup of 144 patients followed up for a minimum of 12months revealed a resolution of symptoms in 130/144 (90.3%) and satisfaction in 139/144 (96.5%). There was a statistically significant improvement of the bleeding score (from 2.4 ± 1.07 to 0.36 ± 0.49; p < 0.0001), acute symptoms score (from 2.03 ± 0.16 to 0.61 ± 0.59; p < 0.0001), quality of life (from 4.63 ± 1.32 to 8.96 ± 1.35; p < 0.0001), pain at rest (from 3.0 ± 2.05 to 1.1 ± 0.99; p < 0.0006), and pain with evacuation (from 4.8 ± 1.22 to 1.7 ± 1.15; p < 0.0001). No significant changes in continence and constipation were observed. Univariate analysis failed to show factors significantly associated with failure. The HeLP procedure seems to be safe and effective in patients with symptomatic hemorrhoids. It is simple, minimally invasive, and relatively pain free. It can be performed in an ambulatory setting without anesthesia, and it achieves high patient satisfaction. It may, therefore, be considered a "first-line treatment" in all patients without significant hemorrhoidal prolapse in whom medical therapy has failed.

Transanal hemorrhoidal dearterialization versus stapled hemorrhoidectomy in the treatment of hemorrhoids

Background and Objective:The aim of this study was to compare the outcomes of transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidectomy (SH) in the treatment of hemorrhoids by a meta-analysis.Methods:Randomized control trials (RCTs) comparing SH with THD were searched for in databases, including MEDLINE, PubMed, Web of science, Embase, and the Cochrane Library database. Data were independently extracted from each study, and a meta-analysis was performed using RevMan5.2 software.Results:Eight RCTs, including 977 patients, were included in this meta-analysis. No statistically significant differences were noted between THD and SH in terms of total complications (OR, 0.93; 95% CI, 0.69, 1.25), but a significant differences were noted in terms of bleeding (OR, 1.85; 95% CI, 1.10, 3.10). The total recurrence rate was higher in THD than in SH on short-term follow-up; however, the recurrence rate was equal in both the THD and SH groups on long-term follow-up. The present study showed that no significant difference between SH and THD in terms of postoperative pain (OR, 0.43; 95% CI, −0.43, 1.29), operative time (OR, −3.12; 95% CI, −7.01, 0.77), hospital time (OR, −0.00; 95% CI, −0.21, 0.20), time before returning to work (OR,-0.50; 95%CI, −4.42,3.43), and reoperation rate (OR, 1.81; 95% CI, 0.93, 3.54).Conclusion:Our meta-analysis indicated that THD and SH are equally effective techniques for the treatment of hemorrhoids. However, future studies addressing cost-effectiveness, satisfaction rate, and recurrence rate over a long follow-up period are needed to validate these results.

A comparison of surgical devices for grade II and III hemorrhoidal disease. Results from the LigaLongo Trial comparing transanal Doppler-guided hemorrhoidal artery ligation with mucopexy and circular stapled hemorrhoidopexy.

Little is presently known on the impact of device type for Doppler-guided hemorrhoidal artery ligation/mucopexy (DGHAL) or circular stapled hemorrhoidopexy (CSH) when a surgical treatment is considered for hemorrhoidal disease (HD). In this study, we aimed to compare the outcome in terms of adverse events and recurrence rate, of patients included in the multicenter LigaLongo RCT ( ClinicalTrials.gov NCT01240772) according to the type of devices used. In the DGHAL arm (N = 193), the procedure was done with transanal hemorrhoidal dearterialization (THD)™ (THD, Correggio, Italy) (104 patients) and with HAL-RAR™ (Agency for Medical Innovations (AMI) GmbH, Feldkirch, Austria) (89 patients). In the CSH arm (N = 184), procedure for prolapse and hemorrhoids (PPH)-03™ (Ethicon Endo-Surgery, Cincinnati OH) and hemorrhoidopexy and prolapse (HEM)™ (Covidien, Inc.) staplers were used in respectively 106 and 78 cases. Surgery-related morbidity at 90 postoperative days (POD) based on the Clavien-Dindo procedure-related complication score and clinical outcome in terms of recurrence and reoperation rate at 12 postoperative months (POM) was collected. Three hundred and seventy-seven patients were randomized according to HD grade. In the DGHAL arm, the number of ligations and mucopexies was higher in the AMI group (p < 0.0001); at 90 POD, the overall morbidity was similar between the two groups. In the CSH arm, donut sizes were similar; at 90 POD, the PPH group had a higher risk of postoperative grade 1 morbidity (anal urgency or incontinence) compared to the HEM group (p = 0.003). At 12 POM, no statistical difference was found between the two groups of each arm in terms of grade III recurrence or reoperation. Postoperative morbidity and outcome at 1year were similar regardless of the type of devices used. These findings suggest that device type has little impact on HD treatment results. clinicaltrials.gov -Identifier NCT01240772.