Recto-anal Repair Research Articles

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

Background & 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.

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.

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 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.

Outcome of Haemorrhoidal Artery Ligation and Recto Anal Repair (HAL-RAR) with Doppler Guidance for Symptomatic Grade-II, III and IV Internal Haemorrhoids

Background: Internal haemorrhoids are very common all around the world and the classical surgical treatment is open haemorrhoidectomy for a long time. This procedure has a lot of complications and is very painful for the patient. Doppler guided HAL-RAR has shown satisfactory results in the literature with minimal pain and a significantly lower rate of complications compared to open haemorrhoidectomy .&#x0D; Objective: To assess the outcome of a relatively new surgical procedure (HAL-RAR) using doppler guidance for the treatment of grade-II, III and IV internal haemorrhoids.&#x0D; Methods: This case series was conducted at Surgimed hospital, Lahore, Pakistan, between May 2015 to December 2021. One hundred patients who attended the outpatient department of the hospital were recruited for this study. These patients presented with grade-II, III or IV symptomatic internal haemorrhoids. Surgical intervention in the form of HAL-RAR was performed in all patients and outcome was measured in terms of mean operating time, length of hospital stays, post-operative pain, recurrence of prolapse and bleeding, and early and late post-operative complications with one year follow up for all patients. &#x0D; Results: Out of these 100 patients, 72 were males and 28 were females. On average, seven haemorrhoidal artery ligations and three recto anal repairs were performed in each patient. The average hospital stay was 31 hours with a range between 24 hours to 72 hours. Early post-operative pain was minimum and only twelve patients required narcotic analgesics. Three patients complained of excessive pain lasting for five days. Seven patients had self-limiting bleeding, two patients had post-operative bleeding which was controlled by re-ligation of the bleeding point and one patient developed a perianal fistula. In the long term follow up, one patient had recurrence of prolapse six months after the surgery. &#x0D; Conclusion: HAL-RAR with doppler was a safe and efficient method for treatment of grade-II, III and IV internal haemorrhoids, with very low post-operative pain scores, satisfactory relief of symptoms, and low recurrence rates.&#x0D;

COMPARISON OF OUTCOME BETWEEN OPEN HAEMORRHOIDECTOMY VERSUS TRANS-ANAL DOPPLER GUIDED HEMORRHOIDAL ARTERY LIGATION WITH RECTO-ANAL REPAIR IN 3RD AND 4TH DEGREE HAEMORRHOIDS

Background: Haemorrhoids are very common but their exact prevalence is not known as most of the people suffering from them do not seek medical or surgical advice. The literature states their prevalence to be about 39% and commonly affect people aged between 45–65 years of age. Objective of the study was to compare the outcomes of open haemorrhoidectomy Vs Trans anal Doppler ultrasound guided hemorrhoidal artery ligation with recto-anal repair in 3rd and 4th degree haemorrhoids. It was a Randomized control trial, conducted at the Department of Surgery, King Edward Medical University, Lahore; from October 2019 to March 2021. Methods: This was a randomized control trial study where the results of 70 patients of haemorrhoids including 3rd and 4th degree disease fulfilling the selection criteria, who underwent open haemorrhoidectomy (OH) and Doppler guided haemorrhoidal artery ligation with rectoanal repair (HAL RAR) procedure on elective and emergency operating lists, were analyzed with regards to post-operative pain, bleeding and hospital stay. Results: From our seventy patients the minimum age was 23 and maximum age limit was 55 years (mean: 35.09±7.47). There were 49 (70%) males and 21(30%) females. Mean post-op pain on day 7 for OH was 1.12±0.72 and for HAL RAR it was 1.06±0.52. Post-op bleeding (POB) occurred in 4(10%) patients in OH group and 2(6.66%) patients in HAL RAR group. Mean hospital stay for OH group was 2±0.45 and for HAL RAR it was 1.20±0.40, for POB, it was 1.9±0.30 in OH group and 1.86±0.34 in HAL-RAR group. Conclusion: There was no significant difference in mean post-op pain on day seven, and post-op bleeding, but there was significant difference in terms of mean hospital stay between the two groups.

Milligan–Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study

BackgroundSeveral surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan–Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL–RAR) technique.MethodsA retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL–RAR group. Primary end points were recurrence rates and patients’ satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables.ResultsA total of 124 patients were identified, submitted either to HAL–RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females–male / female ratio: 3.6) with a median age of 47 years old (range 18–69) were included in the HAL–RAR group while 47 patients (40 males and 7 females–male / female ratio: 5.7) with a median age of 52 years old (range 32–71) comprised the MM group. At a median follow up of 41 months (minimum 24 months–maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL–RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL–RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99—p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70—p 0.0013) in the HAL–RAR group.ConclusionsIn patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL–RAR. In patients with bleeding as the main presenting symptom of HD, HAL–RAR was associated with better patients’ satisfaction rates and similar recurrence rates compared to MM.

Comparison of Post Operative Pain Score between Doppler-Guided Hemorrhoidal Artery Ligation and Recto Anal Repair with Open Hemorrhoidectomy on Internal Hemorrhoid Grade III-IV at Siloam Hospitals Lippo Village

&lt;div class="WordSection1"&gt;&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Hemorrhoids are a common lesion affecting 5% of the general population. Open hemorrhoidectomy has been considered a gold standard. However, this method has a significant score of postoperative pain Because of this side effect, another alternative method to treat hemorrhoids has been invented which can reduce post-operative pain. One of these methods is doppler-guided hemorrhoidal artery ligation and rectoanal repair (DGHAL-RAR). This study aims to know the comparison of the postoperative pain score between doppler-guided hemorrhoidal artery ligation and rectoanal repair compared with open hemorrhoidectomy.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Method:&lt;/strong&gt; The sample population of this study is internal hemorrhoid grade III-IV patients at Siloam Hospitals Lippo Village from 2018-2020. Visual analog scale data are taken from medical records. Sample data is obtained using a consecutive sampling method until 64 samples are met. The data obtained will be processed with the Mann U-Whitney test.&lt;/p&gt;&lt;/div&gt;&lt;div class="WordSection2"&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Incidence of postoperative pain more than VAS 3 occurred in DGHAL- RAR and open hemorrhoidectomy is 81,3% and 96,9% with a p-value of 0,104. The average score of Visual Analogue Scale score in DGHAL-RAR and open hemorrhoidectomy are 1,97 and 3,13 with a p-value of 0,001.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; This study shows that the comparison of pain scores in DGHAL-RAR and open hemorrhoidectomy is not statistically significant. The mean score of the Visual Analogue Scale Score in the DGHAL-RAR group is statistically significantly lower than the mean score in the open hemorrhoidectomy group.&lt;/p&gt;&lt;/div&gt;&lt;strong&gt;&lt;br clear="all" /&gt;&lt;/strong&gt;

Life-Threatening Abdominal Bleed after DGHAL – A Case Report

Doppler guided haemorrhoidal artery ligation with recto-anal repair (DGHAL RAR) has been reported to be an effective, reliable and safe procedure for symptomatic haemorrhoidal disease with less postoperative pain and hence, good patient acceptance [1]. The reported complications are minor and include recurrence of anal bleed, prolapse, anal fissure, tenesmus to name few [2]. We report a case of life threatening intra-abdominal bleed following DGHAL RAR.

P443 Haemorrhoidal Artery Ligation – Recto-Anal Repair (HAL-RAR) with mucopexy for grade III hemorrhoids in IBD patients

Abstract Background Symptomatic hemorrhoids represent an important and sometimes underestimate chapter of perianal Inflammatory Bowel Diseases (IBD), with an incidence reported up to 20.7%. At present, there is still no consensus in the scientific community on the exact indications of surgery in IBD patients presenting with symptomatic haemorrhoids, due to the reported high risk of postoperative complications. We describe our experience with Haemorrhoidal Artery Ligation – Recto-Anal Repair (HAL-RAR) hemorrhoidopexy in highly selected patients with IBD. Methods This was a single-center longitudinal study of a cohort of patients with both Ulcerative Colitis (UC) and Crohn’s Disease (CD) who underwent HAL-RAR using a dedicated doppler-guided probe (Trilogy™) for symptomatic grade III hemorrhoids not responding to medical therapy. Short and long-term postoperative morbidity were recorded. Severity of hemorrhoid symptoms, specifically bleeding, prolapse, manual reduction, discomfort or pain and impact on quality of life (Giordano score) and fecal continence status (Vaizey score) were evaluated before surgery and at minimum of 6 months after surgery. Results Sixteen patients with symptomatic grade III haemorrhoids underwent HAL-RAR (12 female). The mean age was 49 yrs old (37–66). Twelve had CD and 4 UC; none presented with anorectal or perianal involvement. All patients were taking optimal medical treatment for IBD. Only the patients with CDAI&amp;lt;150 and Full Mayo score of 1 (with endoscopic sub-score of 0) were included. Mean follow-up was 27.8 months (9–76). The mean operating time was 46 minutes. Short-term complications included one patient requiring prolonged analgesia with NSAIDs for two weeks, one patients needing hospitalization for bleeding after 10 days, treated conservatively and one patient with acute urinary retention, resolved after catheterization. The was no abscess or fistula formation. During the follow-up period, no patients suffered from recurrent haemorrhoidal bleeding and none had recurrent prolapse. A 66 yrs old female reported at 6 months post-operatively the worsening of Vaizey score from 4 to 6 due to the need of taking costipating medicines. All patients report significant amelioration of quality of life. Conclusion Our results show that HAL-RAR Hemorrhoidopexy is a safe and effective technique for treating grade III symptomatic hemorrhoids in highly selected IBD patients without anorectal involvement. These results need to be validated in large and multicenter trials.

Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease.

A wide variety of methods has been proposed for treating hemorrhoidal disease. The aim of the study is to assess the safety and effectiveness of hemorrhoidal artery ligation with rectoanal repair (HAL-RAR). Retrospective study from January 2010 to November 2019 of patients who underwent HAL-RAR for grade II, resistant to conservative treatment, and grades III and IV hemorrhoidal disease. Demographics, degree of disease, hospital stay, postoperative pain, complications, and recurrence were recorded. Patients were followed up at postoperative days 1 and 8 and at 1, 6, and 12 months. A total of 105 patients (60 men, 45 women) underwent HAL-RAR. Median age was 49 (range, 20-86) years. Two patients with hemorrhoidal thrombosis underwent emergent excision of the hemorrhoid. Median length of hospital stay was 2 (range, 1-13) days. Patients reported median visual analog scale pain score 3 (range, 1-5) on the 1st postoperative day. At 1 month, no patient reported pain, 84.76% of patients confirmed complete resolution of symptoms, while complication rate was 7.61%: 2 patients presented urinary retention, 3 dyschezia, 2 bleeding, and 1 hemorrhoidal necrosis. At 6 months, 2 patients presented mild symptoms and 7 recurrence. At 12 months, 92.4% of patients experienced complete resolution of symptoms, 2 patients intermittent bleeding, and 2 recurrence. Overall recurrence and re-intervention rate were 8.57% rate and 10.5%, respectively. HAL-RAR is a safe and effective minimal invasive operative technique related to a high percentage of success, low complication, and recurrence rates. Long-term follow-up is lacking and would better establish the results of this technique. Trial registration number NCT04778124 Date of registration 26/02/2021 "retrospectively registered".

Doppler-Guided Hemorrhoid Artery Ligation with Recto-Anal Repair Outcome on Female Patients in Basra: Assessment Study

Background: Hemorrhoidal disease is a common morbidity seen by general surgery clinics. Transanal Doppler guided (DG) hemorrhoidal artery ligation (HAL) with rectoanal repair (RAR) has been invented as a new treatment option. HAL-RAR was associated with mild to moderate postoperative complications in the literatures; and considered easy, safe, mostly painless procedure with very good results in treating hemorrhoids. Objective: This study was conducted to evaluate the outcome of using DG-HAL-RAR procedure through documenting postoperative complications during a median follow-up period of 18 months. Method: The study included 151 women presented with hemorrhoids in Basra, operated upon using the DG-HALRAR and complications assessed. Results: The patients’ mean age was 40–99 years. Most of the hemorrhoids were internal plus external (86.1%), of third degree (68.2%) and non-recurrent (90.1%). The surgical management needed an average of 6 ligations and 3 mucopexies. During the follow up periods, the most frequent complication was early bleeding, while the least was hemorrhoids recurrence. Discussion: During the follow up period, the postoperative complications were early bleeding, early pain, urine retention, late bleeding, anal stenosis, and hemorrhoids recurrence, the incidence of which were similar or close to the incidence of documented by other studies, except for early bleeding which was much higher than in our study. Some complications, reported by other studies,were not reported in this study. Conclusions: DG-HAL-RAR procedure can be used effectively and safely in second or third degree hemorrhoids. Keywords: Hemorrhoidectomy, Anal surgery, DG-HAL-RAR, Basra

Safety and Effectiveness of HAL-RAR (Haemorrhoid Arteri Ligation with Recto Anal Repair) With No Doppler Guided Technique on Stage III Internal Haemorrhoid: A Single Operator Experience

Safety and Effectiveness of HAL-RAR (Haemorrhoid Arteri Ligation with Recto Anal Repair) With No Doppler Guided Technique on Stage III Internal Haemorrhoid: A Single Operator Experience

Hemorrhoidal Artery Ligation Operations-Recto-Anal Repair (HALO-RAR) Procedure for Recurrent Haemorrhoids: Excellent Patient Satisfaction.

BackgroundHaemorrhoid is the most common anal canal disease. Treatments may vary from non-invasive to invasive depending on the symptoms. Haemorrhoidectomy has been widely used. However, it has some drawbacks like severe postoperative pain, longer time to return to daily activities and complications such as anal stenosis. To overcome these, various new treatment methods have been introduced. Doppler-guided hemorrhoidal artery ligation operations (HALO) are becoming popular among surgeons. HALO has been reported to have a lower recurrence rate of less than 10% and higher patient satisfaction of approximately 90% with minimal postoperative pain. It achieves very good postoperative outcomes in the treatment of early haemorrhoids where per rectal bleeding and/or perianal discomfort are main symptoms. Nevertheless, it has a limitation in the treatment of prolapsing haemorrhoids. To tackle this, simultaneous recto-anal repair (RAR) has been recently introduced. HALO, in combination with RAR, has been reported to achieve good postoperative outcomes and excellent patient satisfaction.This is a two-stage open operation. The stages are: - Doppler-guided HALO and - RAR (recto-anal repair)MethodsWe are presenting a single-centre one-year experience of Doppler-guided haemorrhoidal artery ligation operation and recto-anal repair (DG-HALO and RAR) conducted on haemorrhoidal patients to evaluate the outcomes and effectiveness of the procedure. Retrospective data were collected for the patients who underwent HALO over one year period from June 2018 to August 2019. A total of 10 patients were treated with the HALO-RAR procedure.ResultsThe male to female ratio was 7:3, median age was 47.98 (28.38 - 61.7) years, median body mass index (BMI) was 30.23 (23.8 - 39.1). Eight patients were American Society of Anesthesiologists (ASA) Grade II, one patient was ASA I and one was ASA III. Time from initial consultation to the HALO procedure was 9.90 (3.5 - 19.8) months. All patients complained of preoperative bleeding and six of them complained of pain or discomfort. Nine patients underwent previous bandings in the clinic and one patient declined banding. The average time of the procedure was 57 mins. The average number of ligations was 10 (0-21). In one case, the proctoscope did not pair with the speaker. The average number of plications was three (2-4). Postoperatively, nine patients had no immediate complications; one patient had acute urinary retention. Seven patients were discharged on the same day. One patient had to stay overnight for monitoring prior to restarting apixaban, one patient for his learning difficulties and one patient had an unplanned overnight stay due to acute urinary retention requiring catheterization. Eight patients had their first follow-up; improvement of symptoms was found in 100% patients on the first follow-up.ConclusionHALO-RAR should be considered as a treatment option for recurrent symptoms after banding for haemorrhoids. The study showed good overall results with no immediate surgical complications. Excellent patient satisfaction was found even in long-term follow-up.

Experience with Haemorrhoidal artery ligation under direct vision at a tertiary care hospital: A case series.

This study aims to share the results of haemorrhoidal artery ligation under direct vision in the management of symptomatic haemorrhoids. We conducted a case series of 70 patients at Combined Military Hospital Rawalpindi & Quetta, from January 2015 to October 2017. All patients underwent Haemorrhoidal Artery Ligation (HAL) and Recto Anal Repair (RAR). Ligation of superior haemorrhoidal artery was done under direct vision following manual palpation. Patients were followed up postoperatively at 1, 3 and 6 months. At 1 month follow up, all 70 (100%) patients were pain free. Post operative bleeding was observed in 7 (10%) patients but did not require surgical intervention. Sixty two (89%) patients were able to return to their daily activities 1 week after surgery and 57 (81%) resumed military duties or joined their work place at 2 weeks. 70 (100%) patients were asymptomatic and 45 (64%) highly satisfied with their surgery at 3 months. This increased to 53 (75%) at 6 months. 48 (69%) said that they would recommend this procedure to someone else. Prolapse recurrence was observed in 1(1.42%) patient 6 months post operatively which was dealt by band ligation. All patients completed follow-up at 1, 3 and 6 months. HAL is a simple yet safe technique with few complications, acceptable patient satisfaction and early return to work.

SURGICAL TREATMENT OF HEMORRHOIDAL BLEEDING IN PATIENTS WITH CARDIOVASCULAR DISEASES UNDER ANTICOAGULANT AND ANTIPLATELET THERAPY

The OBJECTIVE was to build an algorithm for medical and surgical treatment of hemorrhoidal bleedings in patients with cardiovascular diseases under anticoagulant and antiplatelet therapy.MATERIAL AND METHODS. The research was based on the analysis of results of treatment of hemorrhoidal bleedings in 86 patients with comorbidity (chronic combined hemorrhoids (2–4 stages) and cardiovascular diseases) under antiplatelet and antithrombotic therapy. Doppler-guided hemorrhoid artery ligation (with or without recto-anal repair) was used for the patients from the study group with no interrupting regular antiplatelet and anticoagulant therapy, whereas, in control group of patients, antithrombotic therapy was rejected for three to seven days in order to implementation of hemorrhoidectomy by Milligan – Morgan.RESULTS. The doppler-guided hemorrhoid artery ligation with recto-anal repair was a minimally invasive method without intra-operative blood loss with lowest pain syndrome at the short in hospital staying in comparison to hemorrhoidectomy by Milligan – Morgan. This fact determined the great clinical and economic effectiveness of the research method for the treatment of hemorrhoidal bleedings in patients with comorbidity.CONCLUSION. The minimal invasive surgical method of treatment hemorrhoidal bleedings – doppler-guided hemorrhoid artery ligation – could be used for patients with cardiovascular diseases and did not require interrupting anticoagulant and antiplatelet therapy.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

HAL-RAR for the treatment of hemorrhoids - a new, non invasive method

Introduction: HAL-RAR is a new, minimally invasive technique for the treatment of haemorrhoids, whereby Doppler-guided ligation of the haemorrhoidal arteries (HAL) is combined with a mucopexy of the prolapsed haemorrhoidal tissue (RAR = Recto Anal Repair). Methods: We did these operations as an alternative to the conventional haemorrhoidectomies in the cases of grade III or - in some cases - grade II haemorrhoids. Between August 2017 and April 2019 a total of 45 patients were operated on with the HAL-RAR procedure. All operations were done under general or spinal anaesthesia. Results: Complications were seen in three patients within 30 days of surgery. One patient had proctitis, one patient suffered from a thrombosed haemorrhoid, while one patient had bleeding, which occurred on the 16th postoperative day. Two of them needed re-operation. Except one patient, all of them was treated in one-day surgery. HAL-RAR seems to be less painful than conventional procedures and causes more patient satisfaction in the early postoperative period. Neither the bleeding, nor the pain did not re-appear after 1 year, but one patient mentioned recurrence of the prolapse. Conclusion: Doppler-guided suturing is an effective, minimally invasive treatment option for even advanced haemorrhoidal diseases and seems to be ideal for one-day surgery.

Hemorrhoid artery ligation and recto-anal repair treatment for hemorrhoid: a case series

Introduction: Hemorrhoidal artery ligation (HAL) combined with recto-anal repair (RAR), is an alternative technique for the treatment of hemorrhoid disease from grade I to IV. HAL-RAR involves anoscope with a Doppler to identify the position and depth of rectal arterial, which can be selectively ligated 3-4 cm above the dentate line. This technique has been proposed as a practical, easy to learn, minimally invasive, and safe.Case: 5 cases in Husada Hospital Central of Jakarta with hemorrhoid grade IV underwent HAL-RAR. The initial result, 14th day post-operative follow up, early benefits, and postoperative complications that most affected by HAL-RAR technique will be analyzed. Treatment confirmed 5 cases showed less postoperative pain measured by visual analog scale (VAS), fewer complications, on the 14th day follow up the main complication there was only one case with residual protrusion in initial follow up resolved four weeks later, and well-controlled of manifestation. All patients were satisfied with the result.Conclusion: HAL-RAR is an easy to learn technique, useful to perform, less post-operative pain, and gives fewer complications as treatment of advanced hemorrhoid disease. But, needed more cases and a longer follows up to analyze the late complications and recurrence.

Latest Innovation in Surgical Management of Haemorrhoids

Haemorrhoids are one of the commonest ano rectal problems. Numerous techniques of surgical treatment from old standard Milligan Morgan Haemorrhoidectomy to Non-invasive modalities including IRC, DGHAL RAR(Doppler guided haemorrhoidal arterial ligation and Recto anal repair), MIPH, Radiofrequency to Laser haemorrhoidoplasty. DGHAL was safest but involves substantial basic investment and per case recurring cost of Single use Doppler probes. Thus it was becoming unapproachable to lower middle class and poor patients. Rest other modalities also involve substantial investment and also per case expenditure. Over the experience of over 4,520 procedures by DGHAL equipment we describe same results by DIGITALLY GUIDED HAEMORRHOIDAL ARTERIAL LIGATION (DGHAL) evidenced by use of vascular Doppler confirming artery and stoppage of sound after ligation with hardly any expenditure. This was planned with special reference to Diabetic patients where excisional surgery or even RAR also needed more invasive approach, thus LASER Haemorrhoidoplasty was preferable.

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Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years by Altomare et al. 1 The authors present one of the largest series of prospectively maintained data from 32 458 patients treated for haemorrhoids during a 17-year period (2000–2016) in several Italian referral centers. It included the era of PPH at the beginning of the 2000's and the rise of the novel non-resection haemorrhoidal treatments at the turn of the 2010′s. The Doppler-guided haemorrhoidal artery ligation alone procedure had unacceptably high recurrence rates for high grade haemorrhoids of up to 30% 2. With the addition of the mucopexy component (rectoanal repair) it replaced stapled haemorrhoidopexy as the number two technique in the treatment of grade III haemorrhoids. The authors report that non DG-HAL techniques have gained in popularity which make the procedure less costly. Abandoning the Doppler proctoscope which had a questionable benefit for the success of this technique was already demonstrated by our own group and others 3. The return to a conventional haemorrhoidectomy technique confirmed in the eTHOS trial for higher grade haemorrhoids (grade III and IV) parallels European strategies in the treatment of the most common proctological disorder in our daily practices and fits into recent guideline developments by the ESCP (https://www.escp.eu.com/guidelines#haemorrhoids).