Hemorrhoidal Artery Research Articles

Does hemorrhoidal artery embolization really benefit patients with hemorrhoids?

This letter offers commentary on an article published in a recent issue of the World Journal of Gastroenterology . Hemorrhoidal artery embolization is a promising approach to severe hemorrhoidal bleeding treatment, but inappropriate patient selection and the use of different embolization procedures may affect the clinical efficacy and cause serious complications. In this article, the most appropriate candidate patients, embolization materials, embolization methods, and clinical evaluation methods are discussed to improve the safety and effectiveness of the procedure.

Haemorrhoid artery ligation - recto anal repair (HAL-RAR) blind versus Doppler: a systematic review and meta-analysis.

Haemorrhoids remain a highly prevalent condition in Australia, affecting 39% of the adult Australian population. While haemorrhoidectomy remains the gold standard in the management of haemorrhoids, newer techniques such as haemorrhoid artery ligation-recto anal repair (HAL-RAR) are emerging as promising management modalities. We compare the efficacy of non-Doppler guided (non-DG) HAL-RAR versus Doppler-guided (DG) HAL-RAR in the management of haemorrhoids. This study was registered with PROSPERO (CRD42022353806) and adhered to PRISMA 2020 guidelines. We conducted a systematic review using Medline, Embase and Cochrane database for comparative studies between Doppler-guided HAL-RAR and non-Doppler-guided HAL-RAR in accordance with the PRISMA 2020 statement for reporting systematic reviews. Five studies were included in our systematic review and meta-analysis. There was no clinically significant difference in operative times (SMD 0.46, 9% CI -3.16 0 4.08, P = 0.804) or post-operative bleeding (P = 0.142) between the two groups. DG HAL-RAR patients were more likely to have post-operative urinary retention (P < 0.001). Non-DG patients were less likely to experience recurrence (OR 5.12, P < 0.001). Our review of non-DG HAL-RAR compared to DG HAL-RAR reflects the non-inferiority of the non-DG HALRAR procedure. We hope that these results would provide a guide to clinicians performing HAL-RAR, and would provide some cost savings for institutions who are unable to procure the necessary equipment for DG HAL-RAR.

Comparison of open haemoridectomy (Milligan-Morgan) and HAL-RAR in the treatment of grade III and IV haemorrhoids

Background &amp; Objective: Hemorrhoidectomy (HD), either open (Milligan-Morgan) or closed (Ferguson), is the conventional treatment for stages 3 and 4 of the condition. HAL-RAR therapy, a minimally invasive treatment for high-grade hemorrhoids, involves the integration of HAL (hemorrhoidal artery ligation) with a procedure known as mucopexy, which lifts the hemorrhoidal prolapses. The study objective was to compare the efficacy of open hemorrhoidectomy against haemorrhoid artery ligation with recto-anal repair (HAL-RAR). Methods: A comparative randomized controlled trial was conducted at general surgery department of Pakistan Aeronautical Complex Hospital Kamra and Pakistan Air Force Hospital Islamabad between June 2021 and December 2022. Total 30 patients diagnosed with hemorrhoids of grades III–IV were assigned randomly to either HAL-RAR (n=15) or hemorrhoidectomy (n=15). Every procedure was a day surgery performed under spinal anesthesia. After 15 days, 30 days, and 6 months patients were re-evaluated. Patients rated their own pain on a visual analog scale. All the data was analyzed by SPSS v 26. Results: Mean age of the participants was 51.3±6.67 years. HAL-RAR group addressed a greater number of prolapsed hemorrhoidal cushions compared to the hemorrhoidectomy group (2.9 vs 2.02, p = 0.001), and the operation took longer in HAL-RAR group (40 min vs 24 min, p = 0.001). HAL-RAR group had less discomfort in the first 30 days after surgery (p = 0.001). In addition, higher number of patients in HAL-RAR group reported experiencing relief from pain (VAS = 0) after day 7. By day 15, HAL-RAR group had substantially better symptom resolution than the hemorrhoidectomy group. Resolution of bleeding, prolapse, itching, and soiling occurred sooner in HAL-RAR group than in hemorrhoidectomy group during the 30-day follow-up. Conclusion: The symptoms of haemorrhoids are resolved with less discomfort with HAL-RAR than after hemorrhoidectomy, and recovery time is shorter.

SUS 2 - Routine histological examination of haemorrhoidal tissue – an unnecessary environmental and economic expense?

Abstract Background Modern, less invasive methods of haemorrhoid treatment, such as haemorrhoid artery ligation and radiofrequency ablation, are increasingly employed. These do not yield specimens for histological analysis. However, when open haemorrhoidectomy is performed, even in the absence of suspicious operative features and in low-risk patients, the haemorrhoid specimen is routinely sent. This has both environmental and financial costs in an increasingly pressured NHS, and negatively impacts sustainability with no clinical advantage. Methods We retrospectively studied 112 open haemorrhoidectomies performed at our UK hospital from February 2018 to June 2023, reviewing clinic letters, operation notes and post-operative histology. Aims To assess the frequency of incidental pathology identified during routine histological assessment, and the associated financial costs and carbon footprint generated. Results 112 open haemorrhoidectomies were performed in the 5-year study period. In total, two patients with risk factors for AIN/Anal cancer were identified. There were no documented concerns of abnormal intra-operative findings. Histology mainly revealed haemorrhoid tissue alone (103) and benign polyps (8). AIN3 was detected in one of the high-risk patients. The cost per histology specimen was £93.32 (Total cost £10,451.84). Each specimen is estimated to generate 0.29kg of Carbon Dioxide equivalents (Total 32.48kg CO2e). Conclusion Routine histological assessment of haemorrhoidectomy specimens is time-consuming, expensive and has an avoidable carbon footprint for a low detection of incidental pathology. Our study suggests that histology should be reserved for patients with risk factors for AIN/Anal cancer, or concerning intra-operative findings. Larger scale studies, and development of national guidelines would aid clinician decision-making.

Comparison of Non-Surgical Methods for Treating Hemorrhoids

Introduction and purpose Hemorrhoidal disease is one of the most common proctological problems worldwide. The etiology of hemorrhoidal disease has not been fully explained. Authors note that lifestyle factors and dietary habits are primarily responsible for hemorrhoidal disease. These include: a low-fiber diet, constipation, a sedentary lifestyle, and suboptimal body position during defecation commonly observed in Western societies. Due to the high prevalence of the disease in the population and the associated decrease in quality of life, outpatient procedural treatments that are highly effective and allow for a quick return to normal activity are very popular among patients. The aim of this study is to discuss non-surgical methods of hemorrhoid treatment. Material and methods This paper was based on a review of materials available on PubMed, searched using the following keywords: “hemorrhoids”, “sclerotherapy”, “rubber band ligation”, „infrared coagulation”, „laser hemorrhoidoplasty”, „Doppler guides hemorrhoidal artery ligation”. Results In recent years, there has been a significant development in non-surgical techniques for treating hemorrhoids, which are widely used in patients with grade I-III hemorrhoids and can be performed in an outpatient setting or during short hospital stays with the use of regional anesthesia, such as: Sclerotherapy, rubber band ligation, Infrared coagulation, Laser hemorrhoidoplasty, Doppler Guides Hemorrhoidal Artery Ligation. Conclusion In conclusion, non-surgical methods for the treatment of hemorrhoids offer a range of effective alternatives to conventional surgery. The choice of treatment should be individualized, taking into account the severity of the hemorrhoidal disease, patient preferences, and the potential for complications.

Laser Hemorrhoidoplasty and Lateral sphincterotomy Procedures vs Conservative Treatment for Hemorrhoids and Fissure in Ano: A Trial Comparing Laser and Conservative treatments

Objective: According to the ‘‘vascular’’ theory, arterial overflow in the superior hemorrhoidal arteries would lead to dilatation of the hemorrhoidal venous plexus. Hemorrhoid laser procedure (LHP) is a new laser procedure for outpatient treatment of hemorrhoids in which hemorrhoidal arterial flow feeding the hemorrhoidal plexus is stopped by laser coagulation. Aim: Our aim was to compare the hemorrhoid laser procedure and laser aided lateral sphincterotomy vs conservative treatment of symptomatic hemorrhoids and fissure in ano. Material and Method: A comparison trial between hemorrhoid laser procedure, lateral sphincterotomy and conservative treatment for hemorrhoids and fissure in ano was made. This study was conducted at Vels Medical College and Hospital, Manjankaranai, Tamil Nadu. Patients with symptomatic grade III or grade IV hemorrhoids with minimal or complete mucosal prolapse were eligible for the study: 30 patients treated with the laser hemorrhoidoplasty, 30 patients–with laser aided lateral sphincterotomy and 40 patients treated with conservative methods. Operative time, postoperative pain, post-op healing time were evaluated. Results: A total number of 100 patients ( 65 men and 35 women, mean age, 46 years) entered the trial. Significant differences between laser hemorrhoidoplasty, laser sphincterotomy and conservative treatments were observed in operative time and early postoperative pain. The procedure time for LHP was 15.49 min laser aided lateral sphincterotomy was 10.19 min. Conclusion: The laser hemorrhoidoplasty and laser guided sphincterotomy procedures were more effective than conservative methods. Postoperative pain and healing time were drastically less in the early and late post op period.

Exploring factors impacting patient decisions in hemorrhoid surgery: A questionnaire survey in Taiwan

BackgroundMinimally invasive hemorrhoid surgeries like Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL) and Stapled Hemorrhoidopexy (PPH) offer benefits over traditional methods. This study investigated public perceptions and attitudes towards these surgeries, exploring awareness, preferences, and influencing factors. MethodsA detailed questionnaire was disseminated to 2011 participants from various regions of Taiwan in December 2023, gathering data on demographics, understanding of minimally invasive surgery, and attitudes towards hemorrhoid surgery. Chi-square tests were used for analysis (p < 0.05). ResultsHemorrhoid prevalence was similar across sexes and age groups. About 70 % preferred medical centers or district hospitals for surgery. Postoperative complications were a primary concern, with significant sex differences. Approximately 70 % preferred minimally invasive surgery if costs were below NT$50,000. Medical personnel showed higher awareness of minimally invasive surgery benefits. Most participants relied on personal networks and medical social media for information. ConclusionsThe study revealed generally positive perceptions of minimally invasive hemorrhoid surgery, with cost being a significant factor. Knowledge gaps exist, particularly among non-medical personnel. Future initiatives should aim to enhance public awareness of minimally invasive surgery benefits, and policy considerations should address financial aspects of healthcare decisions.

Doppler-guided hemorrhoidal artery ligation with mucopexy versus stapled hemorrhoidopexy in the management of grades 3 and 4 prolapsed hemorrhoids: A prospective randomized clinical study

Doppler-guided hemorrhoidal artery ligation with mucopexy versus stapled hemorrhoidopexy in the management of grades 3 and 4 prolapsed hemorrhoids: A prospective randomized clinical study

Imaging for Hemorrhoidal Disease: Navigating Rectal Artery Embolization from Planning to Follow-up.

Hemorrhoid disease is very common, affecting greater than one-third of adults. Conservative management and several office-based procedures are useful in the treatment of internal hemorrhoids. Patients with refractory hemorrhoid disease have traditionally been treated with surgical hemorrhoidectomy. Rectal artery embolization has emerged as an alternative to surgical hemorrhoidectomy and has been shown to be safe and effective in case series and clinical trials completed over the past decade. Embolization has significantly less postprocedure pain when compared with surgical hemorrhoidectomy with similar outcomes. Pre- and postprocedure imaging are not routinely performed. Intraprocedural imaging consists of selective catheterization of the superior rectal arteries from the inferior mesenteric artery, and the middle rectal arteries from the internal iliac artery. The inferior rectal artery is seldom embolized due to the supply of the levator ani muscle and skin. To date, intermediate and large particles and fibered and nonfibered coils have been used successfully.

Transanal eco-Doppler evaluation after hemorrhoidal artery embolization.

Hemorrhoidal artery embolization (Emborrhoid) is a novel method for the treatment of severe hemorrhoidal bleeding. Despite having a technical success rate of 93%-100%, the clinical success ranges between 63% and 94%, with a rebleeding rate of 13.6%. To evaluate the effectiveness of this procedure in reducing hemorrhoidal flow and hemorrhoidal bleeding. This prospective observational pilot study was conducted at Division of General Surgery 1 and Tertiary Referral Pelvic Floor Center, Treviso Regional Hospital, Italy. In a 2 months period (February-March 2022), consecutive patients with hemorrhoidal bleeding scores (HBSs) ≥ 4, Goligher scores of II or III, failure of non-operative management, and a candidate for Emborrhoid were included. Endoanal ultrasound with eco-Doppler was performed preoperatively and 1 month after the procedure. The primary endpoint was to quantify the changes in arterial hemorrhoidal flow after treatment. The secondary endpoint was to evaluate the correlation between the flow changes and the HBS. Eleven patients underwent Emborrhoid. The overall pretreatment mean systolic peak (MSP) was 14.66 cm/s. The highest MSP values were found in the anterior left lateral (17.82 cm/s at 1 o'clock and 15.88 cm/s at 3 o'clock) and in the posterior right lateral (14.62 cm/s at 7 o'clock and 16.71 cm/s at 9 o'clock) quadrants of the anal canal. After treatment, the overall MSP values were significantly reduced (P = 0.008) although the correlation between MSP and HBS changes was weak (P = 0.570). A statistical difference was found between distal embolization compared with proximal embolization (P = 0.047). However, the coil landing zone was not related to symptoms improvement (P = 1.000). A significant difference in MSP changes was also reported between patients with type 1 and type 2 superior rectal artery (SRA) anatomy (P = 0.040). No relationship between hemorrhoidal grades (P = 1.000), SRA anatomy (P = 1.000) and treatment outcomes was found. The preliminary findings of this pilot study confirm that Emborrhoid was effective in reducing the arterial hemorrhoidal flow in hemorrhoidal disease. However, the correlation between the post-operative MSP and HBS changes was weak. Hemorrhoidal grade, SRA anatomy and type of embolization were not related to treatment outcomes.

Arterial Embolization as a Prominent Option in the Treatment of Hemorrhoid Diseases

Hemorrhoidal disease (HD) is the most common anorectal disease, affecting millions of people worldwide. The most common clinical picture is rectal bleeding, which significantly impairs the quality of life of patients. Treatment of HD varies from diet and lifestyle changes to radical surgery, depending on the degree and severity of symptoms. Endovascular embolization of superior rectal artery (SRA), known as emborrhoid technique, has recently emerged as a promising minimally invasive approach. Because hemorrhoidal plexuses are almost entirely fed through the SRA. They are also fed less by middle rectal artery (MRA) and rarely inferior rectal artery (IRA). Due to some anastomoses and unpredictable variations, vascular structures must be examined before the procedure. So far, there have been reports of studies involving a small number of patients regarding the use of coils and particles as embolization agents. Some of these used particles and coils alone, while others used a combination of particles and/or coils. The studies demonstrated similar clinical efficacy with satisfactory results, and no significant complications such as ischemic necrosis were observed. The use of liquid embolic agents such as N-butyl-cyanoacrylate (NBCA) and ethylene vinyl alcohol copolymer (EVOH) has also recently been suggested to be effective. In conclusion, the current data support the feasibility, effectiveness, and safety of rectal artery embolization for hemorrhoidal disease. However, there is no guideline or consensus in the selection of embolic materials. More randomized controlled studies are needed. This review aims to evaluate the effectiveness and feasibility of embolization applications in hemorrhoidal diseases.

Real-time ultrasound-guided sacral plexus block combined with mild sedation for hemorrhoidectomy and hemorrhoidal artery ligation in a patient with amyotrophic lateral sclerosis: a case report

BackgroundPatients with amyotrophic lateral sclerosis present perioperative challenges for clinical anesthesiologists for anesthesia-associated complications.Case presentationA 54-year-old Han woman with a 2-year history of amyotrophic lateral sclerosis was scheduled for hemorrhoidectomy and hemorrhoidal artery ligation. We performed real-time ultrasound-guided sacral plexus block with dexmedetomidine under standard monitoring. The anesthesia method met the surgical demands and avoided respiratory complications during the procedures. There was no neurological deterioration after the surgery and 3 months after, the patient was discharged.ConclusionsReal-time ultrasound-guided sacral plexus block combined with mild sedation may be an effective and safe technique in patients with amyotrophic lateral sclerosis undergoing hemorrhoidectomy and hemorrhoidal artery ligation.

Long-term results and quality of life after stapled hemorrhoidopexy vs Doppler-guided HAL-RAR: a propensity score matching analysis.

The study aimed to evaluate and compare the short and long-term outcomes of doppler-guided (DG) hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) using a wireless-doppler-guided probe and stapled hemorrhoidopexy (SH) for treatment of II-III hemorrhoids. This cohort study included patients who underwent HAL-RAR (n = 89) or SH (n = 174) for grade II-III hemorrhoids between January 2020 and December 2021. After propensity score matching at a 1:1 ratio, 76 patients for each group were analyzed. Short and long-term outcomes were collected. Pain was measured using a Visual Analogue Scale (VAS) at POD1, POD 10, 1month, and 6months after surgery. The enrolled patients completed the Hemorrhoidal Disease Symptom Score and Short Health ScaleHDquality of life (HDSS/SHS QoL) questionnaire preoperatively and during a regular follow-up visit at 24months after surgery. Groups exhibited comparable overall postoperative complication rates (23% HAL-RAR/ 21% SH; p = 0.295). Postoperative pain via VAS showed median scores of 4, 3, 1, 1 for HAL-RAR and 6, 4, 2, 1 for SH at POD1, POD10, 1month, and 6months, respectively (p = < 0.001, 0.004, 0.025, 0.019). At a median follow-up of 12months, the recurrence rate was 10.5% in the HAL-RAR group and 9.2% in the SH group (p = 0.785), respectively. At 24months, 15.7% of HAL-RAR patients and 19.7% of SH patients remained symptomatic (p = 0.223). Median post-op QoL index was 1 (HAL-RAR) and 0.92 (SH), p = 0.036. HAL-RAR is a safe and feasible technique in treating grade II-III hemorrhoids showing better outcomes in terms of postoperative pain and QoL. This paper adds a new perspective in comparing the HAL-RAR and SH, focusing the attention on the patients and not surgical techniques. A long and difficult follow-up was completed to fully understand the long-term results and the impact on the QoL of the patients who underwent these procedures.

A comparative study between laser hemorrhoidoplasty with digital-guided hemorrhoidal artery ligation and conventional (Milligan-Morgan) hemorrhoidectomy

Background: Hemorrhoids have a much higher incidence than rectum and colon diseases worldwide. The prevalence was estimated to be between 2.9% and 27.9% among the worldwide population, of which 4% are symptomatic. Based on the Gauss method, the highest incidence was present in patients aged between 45 and 65 years. Aims and Objectives: To compare laser hemorrhoidoplasty with digital-guided hemorrhoidal artery ligation (DGHAL) and conventional (Milligan-Morgan) open hemorrhoidectomy procedures. Materials and Methods: A prospective follow-up study was undertaken in the Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, from January 2020 to June 2021. In this comparative and prospective study, 60 patients were included, of whom 30 were treated with open surgical hemorrrhoidectomy (Milligan-Morgan) and 30 were treated with laser hemorrhoidoplasty with the DGHAL method. Results: Male patients numbered 41 and female patients numbered 19. Between laser hemorrhoidoplasty with DGHAL and the open surgical hemorrrhoidectomy (Milligan-Morgan) approach, there were significant differences in operating time, blood loss, bleeding; and early postoperative pain. In terms of early postoperative pain, there were statistically significant differences between the two groups (P&lt;0.001). The mean operational time for laser hemorrhoidoplasty with DGHAL was 22.57±1.794 min, compared to 29.43±3.664 min for the open surgical hemorrrhoidectomy (Milligan-Morgan) method (P&lt;0.002). Conclusion: Laser hemorrhoidoplasty with Doppler-guided hemorrhoidal artery ligation (DGHAL) is safe and effective in cases of all grades of hemorrhoids as compared to open surgical (Milligan-Morgan) hemorrhoidectomy.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance

IntroductionWhile 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. MethodsThe 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. ResultsIn 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. ConclusionsWhile 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.

Haemorrhoidal artery ligation with mucopexy vs haemorrhoidectomy according to Ferguson

Haemorrhoidal artery ligation with mucopexy vs haemorrhoidectomy according to Ferguson

Desarterization of hemorrhoidal arteries in outpatient treatment of chronic hemorrhoids

Introduction. Desarterization of hemorrhoidal arteries with mucopexia, a pathogenetically caused minimally invasive operation, is more often performed in stationary conditions under regional or general anesthesia. Aim. To study the results of desarterization of hemorrhoidal arteries in patients with hemorrhoids operated on an outpatient basis under local anesthesia.Materials and methods. 459 patients with chronic hemorrhoids of stage 2–4 with varying degrees of node prolapse under local infiltration anesthesia with Ultracaine were operated on by one surgeon. The duration of the intervention, the intensity of the pain syndrome, and the complications of treatment were studied. Results. The median duration of the operation is 25 minutes, the intensity of pain during the operation on a 10-point scale is 2 points, on the 3rd day of the postoperative period-2 points. Complications occurred in 6 (1.3%) people, in the 1st urinary retention, paraproctitis, and in the 4th – bleeding. Discussion. The obtained results of a longer procedure in patients with stage II hemorrhoids are associated with the training period. The intensity of pain during the HAL-RAR procedure performed under local anesthesia, including in patients of stage III-IV and IV, was acceptable and was tolerated by patients satisfactorily. The structure of the complications that have arisen is limited by a narrow range of pathology: bleeding, acute urinary retention, paraproctitis. Conclusion. Hemorrhoidal artery desarterization is an effective method of treating patients with chronic hemorrhoids on an outpatient basis: low duration ofsurgery, low frequency of complications. Local anesthesia during the ligation of hemorrhoidal arteries with mucopexia provides adequate anesthesia, patients tolerate the procedure and pain in the postoperative period, regardless of the stage of the disease, therefore, this method of treatment is advisable to use in outpatient practice.

Clinical efficacy of ultrasound doppler-guided hemorrhoidal artery ligation combined with procedure for prolapse and hemorrhoids in treatment of severe hemorrhoids.

Hemorrhoids are a prevalent anorectal condition that affects a wide range of adult populations. The severity of this condition was graded using a validated hemorrhoidal grading system, specifically focusing on grade III and IV cases. This retrospective study aimed to compare the clinical efficacy of a standard Procedure for Prolapse and Hemorrhoids (PPH) with a combined Doppler-guided Hemorrhoidal Artery Ligation (DG-HAL) and a PPH approach in patients with severe hemorrhoids. Conducted from May 2021 to January 2023, the study included patients aged 18-65 with confirmed diagnosis of Grade III or Grade IV hemorrhoids. Patients with a history of anorectal surgery and significant comorbidities were excluded. The control group underwent standard PPH, whereas the observation group received DG-HAL followed by PPH. Clinical outcomes were measured using variables such as the operative duration, intraoperative blood loss, postoperative wound healing time, and length of hospital stay. Efficacy was evaluated using a hierarchical scale and a visual analog scale (VAS) for postoperative pain. The complication rates were also assessed. baseline characteristics were homogeneous between the 2 groups. The observation group demonstrated significantly faster postoperative wound healing and shorter hospital stay (P < .01). The overall therapeutic efficacy in the observation group was 90.0%, which was higher than that of the control group (75.0%; P = .025). The VAS pain scores were also significantly lower in the observation group (P = .002). A marked decrease in complication rates was observed in the observation group (3.3%) compared with that in the control group (17.9%) (P < .05). The combined DG-HAL and PPH surgical approach exhibited superior clinical efficacy in treating severe hemorrhoids. This technique offers high effectiveness, reduced postoperative VAS pain scores, and lower complication rates. The long-term efficacy requires further observation.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance

IntroductionWhile 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. MethodsThe 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. ResultsIn 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. ConclusionsWhile 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.

Applied anatomy of female pelvic plexus for nerve-sparing radical hysterectomy(NSRH)

BackgroundNerve-sparing radical hysterectomy(NSRH)has the advantage of reducing postoperative complications and improving postoperative quality of life. The separation and protection of the pelvic plexus in NSRH is extremely important and challenging.Methods24 female cadaveric hemipelves were dissected. Morphologic patterns and compositions of pelvic plexus as well as relationship of pelvic plexus to the surrounding structures were observed and documented.ResultsTwo patterns of superior hypogastric plexus were observed, including fenestrated and cord-like shape. The origin of bilateral hypogastric nerves were inferiorly to upper margin of promontory about 1.6 ± 0.1 cm and parallel to the ureter in front of the sacrum. Pelvic splanchnic nerves(PSN)from the second sacral nerve, the third sacral nerve and the forth sacral nerve were observed combing with the hypogastric nerves within the lateral rectal ligament. The sacral sympathetic trunk can be identified anteriorly or medially to the anterior sacral foramen. We identified the boundaries of pelvic plexus as following: the upper margin is formed by the PSNs from the third sacral nerve, posterior margin by inferior rectal artery, and anteriorly by vesical venous plexus. The uterine branches from pelvic plexus were observed accompanying with uterine artery, while other branches were inferiorly to the artery. The PSNs were located beneath the deep uterine veins within the cardinal ligament. The upper margin of pelvic plexus was observed directly approach to urinary bladder within the vesico-vaginal ligament as a single trunk accompanying with ureter, between the middle and inferior vesical veins.ConclusionsOur study clarified the intricate arrangement, distribution and relationship of female pelvic plexus and the related structures to provide reference index for NSRH application. The innervation patterns of bladder and uterine were clarified, and by tracing these visceral branches of pelvic plexus, we suggest several new important land markers for NSRH.