Doppler-guided Transanal Hemorrhoidal Dearterialization Research Articles

Early postoperative outcomes of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids.

PurposeAluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids.MethodsAM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial.ResultsThe pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6–5.5] vs. 7.6 tablets [range 3.3–11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery.ConclusionAM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

Selective Hemorrhoidal Dearterialization with High Mucopexy in the Surgical Treatment of Hemorrhoidal Disease

AbstractThe doppler-guided transanal hemorrhoidal dearterialization technique associated with mucopexy is a noninvasive surgical option used to treat hemorrhoidal disease (HD). Objective To compare and analyze the results using a variation of the doppler-guided transanal hemorrhoidal dearterialization technique with the technique of selective hemorrhoidal dearterialization with high mucopexy in the treatment of HD. Method A total of 292 patients who underwent surgical treatment for grade II, III and IV HD from March 2012 to December 2017 were studied. From this total, 110 (37.6%) patients underwent a conventional doppler-guided transanal hemorrhoidal dearterialization with mucopexy (CD), and 182 (62.3%) underwent selective hemorrhoidal dearterialization with high mucopexy (SHeLF). In the group of patients undergoing CD, 4 patients (3.64%) had grade II HD, 82 (74.55%) grade III, and 24 (21.82%) grade IV. In the group submitted to SHeLF, 18 (9.89%) patients had grade II HD, 86 (47.25%) had grade III, and 65 (35.71%) had grade IV. The same surgeon operated all patients under spinal anesthesia. In patients undergoing CD, six arterial branches have been dearterialized, while in patients undergoing SHeLF, the hemorrhoidary nipples submitted to a dearterialization were selected (from 1 to 5) by intraoperative evaluation followed by high rectal mucopexy. In the postoperative period, the following parameters were evaluated: pain, tenesmus, bleeding, and recurrence.Moderate results to severe pain was a postoperative complaint reported by 13 (11.82%) patients undergoing CD, and by 19 (10.44%) undergoing SHeLF. Intense tenesmus was reported by 26 (23.64%) patients undergoing CD and by 7 (3.85%) undergoing SHeLF. Three patients (2.73%) undergoing CD and 1 (0.55%) undergoing SHeLF evolved with postoperative bleeding. One patient (0.55%) in the group undergoing CD required surgical review of hemostasis. Six patients (5.45%) who underwent CD and 8 (4.39%) who underwent SHeLF were reoperated due to disease recurrence. Conclusion Comparing statistics, patients undergoing the SHeLF technique have less postoperative pain, tenesmus and postoperative bleeding when compared with CD.

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.

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.

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.

Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes

BackgroundDistal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy (Doppler-guided THD) seems to be associated with better short-term outcomes than conventional hemorrhoidectomy, but there are little data about long-term recurrence. The aim of this study was to compare Doppler-guided THD for grade III–IV hemorrhoids with conventional hemorrhoidectomy with regard to long-term postoperative morbidity and recurrence.MethodsThis was a single-center longitudinal and comparative study of a cohort of patients who underwent either distal Doppler-guided THD with low ligation of the hemorrhoidal artery and mucopexy or conventional excisional hemorrhoidectomy (Milligan and Morgan or Ferguson) for grade III and IV hemorrhoids. Short- and long-term postoperative morbidity was recorded. Severity of hemorrhoid symptoms (bleeding, prolapse, manual reduction, discomfort or pain and impact on quality of life) and fecal continence status (Vaizey score) were evaluated before surgery and at minimum of 1 year after surgery.ResultsEighty-three patients were included in the study. Forty-nine patients (59%) underwent Doppler-guided THD, and 34 (41%) patients underwent conventional hemorrhoidectomy. The 30-day postoperative surgical morbidity was 26.5% in the Doppler-guided THD group and 8.82% in the conventional hemorrhoidectomy group (p = 0.085). No significant differences between the groups were observed in terms of persistence of bleeding, prolapse, need for manual reduction in prolapse and pain. One (2%) patient in the THD group and 2 (5.4%) patients in the conventional hemorrhoidectomy group needed further surgical procedures. Minor fecal incontinence occurred only after conventional hemorrhoidectomy in 2 (5.4%) patients.ConclusionsOur results showed that Doppler-guided THD is not inferior to conventional excisional hemorrhoidectomy for advanced hemorrhoidal disease in terms of postoperative complications and long-term recurrence of symptoms.

Perianal abscess following doppler-guided transanal hemorrhoidal dearterialization.

The doppler-guided transanal hemorrhoidal dearterialization (DG-THD) is a well-established and validated minimally invasive procedure for the treatment of symptomatic hemorrhoids. As compared to the excisional technique, DG-THD has the advantage of being associated with less post-operative pain and do not compromise the anatomy or the physiology of the anal canal. Our objectif is to describe the first case of perianal abscess following DG-THD. We report perianal abscess in a previously healthy 32-year-old male patient, who underwent DG-THD for grade II hemorrhoids, as an outpatient procedure. One week later, the patient complained of persistent pain in the right iliac fossa and hypogastrium. CT-scan showed a peri-rectal fluid collection with gas bubbles and peripheral enhancement. MRI was obtained after first attempt of elective drainage, showing increase of the collection diameter without any fistula, which prompted a surgical exploration and drainage. Multi sensitive E. coli was found on culture. Post-operative recovery was slow but favourable. To the best of our knowledge, no previous report of perianal abscess following DG-THD has been described in the literature, which we believe in our case to be of haematogenous origin.

Doppler-Guided Transanal Hemorrhoidal Dearterialization (DG-THD) Versus Stapled Hemorrhoidopexy (SH) in the Treatment of Third-Degree Hemorrhoids: Clinical Results at Short and Long-Term Follow-Up

IntroductionThe stapled hemorrhoidopexy (SH) and the Doppler-guided transanal hemorrhoidal dearterialization (DG-THD) are minimally invasive procedures for the surgical treatment of hemorrhoids. This study aims to verify the efficacy of the DG-THD versus the SH in the treatment of third-degree hemorrhoids. MethodOne hundred consecutive patients were causally allocated to either procedure, obtaining two groups of 50 pts. A clinical examination was performed at 3, 7, 15, and 30 days after the operation. Quality of life, anal symptoms, recurrence of hemorrhoids, and reoperation were assessed by means of a questionnaire and of a clinical examination at long-term follow-up (7.0 year average). ResultsAt short-term follow-up, the median postoperative pain score was significantly lower in DG-THD group compared to SH group, (V.A.S 2 vs 6; t = 2.65, p < 0.01). The morbidity rate and the return to normal life and work were similar after the two procedures. At long-term follow-up, the incidence of piles was not statistically different between the two groups (DG-THD 10.0 %; SH 14.0 %). No differences were reported by patients in terms of satisfaction for surgery. ConclusionSH and DG-THD procedures do not show significantly different results with regard to the patients outcome. However, considering the lower p. o. pain, the DG-THD might be proposed as the first line treatment in third-degree hemorrhoids.

Comparison of the early results of transanal hemorrhoidal dearterialization and hemorrhoidectomy using an ultrasonic scalpel

Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery) is a new approach for treating hemorrhoids. The early results of the procedure are presented and compared with those of hemorrhoidectomy using an ultrasonic scalpel (US surgery). Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial. The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation. The number of analgesic tablets consumed during the first postoperative week in the THD patients was significantly lower than that in the US patients. The blood loss was significantly greater in the THD patients. The hospital stay and length of time until the first defecation after surgery were both significantly shorter in the THD patients. The postoperative complications were comparable between the two groups of patients. The THD surgery was as effective as the US surgery for the treatment of hemorrhoids in the short term. THD surgery might be a preferred treatment because it is associated with a similar complication rate and short-term results, but results in lower postoperative pain and analgesic requirements compared with the US surgery.

Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings

Transanal hemorrhoidal dearterialization (THD) is a recently developed procedure to minimize postoperative pain from hemorrhoidectomy. This technique utilizes Doppler signals to aid ligation of hemorrhoidal arteries followed by mucopexy of redundant mucosa if needed. The aim of the present study was to assess patient satisfaction after THD. This is a retrospective cohort study of patients who underwent THD at three different sites from April 2007 through October 2010. All procedures were performed in ambulatory settings according to protocol. Telephone surveys were conducted after a minimum of 1-month follow-up to assess patients' satisfaction on a scale of 1-10. Patients were asked whether the procedure had alleviated their symptoms. Patients were asked to recall duration of pain and time from surgery to return to work. Between April 2007 and October 2010, 216 patients with grade III-IV hemorrhoids underwent THD. There were 165 males and 61 females. Average age was 52.2±14.2years. All patients were discharged the same day after meeting ambulatory surgery center discharge criteria. Postoperative difficulty urinating occurred in 37 (17%) patients, and six of them required temporary urinary catheterization. Transitory postoperative bleeding was reported by 38 (18%) patients. Transitory incontinence to stool and flatus occurred in 18 (9%) and 16 patients (8%), respectively. Pelvic muscle spasms occurred in 21 (10%) patients. Median follow-up was 23months (range 1-42months) with 143 (66%) having at least 9months between procedure and interview. Mean patient satisfaction was 8.5±0.7 (on a scale of 1-10 with 10 being the best), and 91.5% of patients felt the procedure had "helped" them. Average number of days with discomfort was 6.7±2.1. Patients returned to work after an average of 10.3±3.2days. Our study is limited by lack of long-term follow-up and by retrospective complication assessment. Patient satisfaction with THD performed in ambulatory settings is high. Our data support performance of this procedure in an ambulatory setting.

To improve the “target” of transanal hemorrhoidal dearterialization

Sir, We read with interest the paper by Toh et al. [1]. This study was carried out with the critical attitude of those who want to improve a surgical treatment that is very effective but can still be improved. Our comments about the study results concern the ‘‘functional anatomy’’ of the lower rectum. Actually, in addition to the exact number of terminal branches of the higher rectal arteries, a fundamental factor in this surgical approach is the correct understanding of the topography of these branches and their relationship with the rectal wall. Hemorrhoidal dearterialization with transanal hemorrhoidal dearterialization (THD) ensures an excellent control of rectal bleeding, and in most cases, the resolution of prolapse thanks to a ‘‘tailored mucopexy’’. The complex vascular network of the ‘‘corpus cavernosum recti’’ is the key to perfecting this therapeutic approach. According to our experience, there are always more than three (usually six) terminal branches of hemorrhoidal arteries to be ligated [2]. The target of therapy should be the point at which the arteries enter the submucosa of the low rectum, just before supplying blood to the ‘‘corpus cavernosum recti’’ [3]. In this way, an extraparietal arterial ligation can be avoided, and action can be taken right where the arterial hyperflow could have the greatest effect on the hemorrhoids. Use of Doppler-guided THD allows a detailed identification of the arteries and a rigorous and effective ligation of them. Moreover, the surgeon avoids taking big bites when suturing and making a ‘‘blind dearterialization’’ that would be at greater risk of bleeding and might partially alter both the anatomy and dynamics of the rectal wall, thus affecting rectal compliance and causing postoperative functional disturbances.