Transanal Hemorrhoidal Dearterialization Research Articles

Conventional excisional haemorrhoidectomy versus transanal haemorrhoidal dearterialization for haemorrhoids - a systematic review and meta-analysis.

Introduction Although effective, conventional excisional haemorrhoidectomy (CEH) may be associated with significant postoperative pain. Novel techniques such as transanal haemorrhoidal dearterialization (THD) are suggested to reduce pain, but may result in higher recurrence rates. We aimed to compare short and long-term outcomes of CEH and THD in the present meta-analysis. Methods A PRISMA-compliant meta-analysis was performed, searching PubMed, EMBASE and CENTRAL databases for randomized controlled trials (RCTs) from 1995 until December 2022. The primary objective was recurrence. Secondary objectives included complication rates, length of stay (LOS), operative time and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. Subgroup analysis was also performed. Results 6 RCTs encompassing 465 patients were captured. There were 142 (59%) males in the CEH group and 129 (54%) in the THD group.. On random effects analysis, THD had a higher recurrence rate (OR = 2.76, 95% CI = 1.03 to 7.38, p = 0.04) albeit a shorter return to baseline comparative to CEH (MD = -14.05 days, 95% CI = -20.38 to -7.72, p < 0.0001). There were no differences in bleeding (p = 0.12), urinary retention (p = 0.97), incontinence (p = 0.41), anal stenosis (p = 0.19), thrombosed residual haemorrhoids (p = 0.16), operating time (p = 0.19) or LOS (p = 0.22). Results remained similar on subgroup analysis. Conclusions CEH is associated with lower recurrence rates and no difference in complication rate to THD, although patients take longer to return to baseline function postoperatively.

The learning curve for transanal hemorrhoidal dearterialization with mucopexy. Experience of 459 cases

Aim: to evaluate learning curve for transanal hemorrhoidal dearterialization (THD) with mucopexy for chronic hemorrhoids II-IV stage.Patients and Methods: the THD was performed by one surgeon in 459 patients under local anesthesia in 2013- 2021. Patients were aged 45 (37;54) years, 355 (77.3%) — males. Stage II was diagnosed in 85 (18.5%) cases, stage II-III — in 47 (10.2%), stage III — in 296 (64.5%), stage III-IV and IV — in 27 (5.9%) and 4 (0.9%) cases. Regression and CUSUM analysis were used to construct the learning curve. The operation time, postoperative morbidity and recurrence rate were assessed.Results: the operation time was 25 (25;32.5) minutes, it was achieved on 210 cases. The postoperative complications occurred in 7 (1.5%) cases and were significantly often in stage III-IV and IV — 3 (9.7%) cases (p = 0.001). Recurrence was showed in 29 (6.3%) cases after 1 year of follow-up. The CUSUM function graph showed that with the experience level, a 2-fold decrease in the morbidity rate and recurrence rate was achieved after 24 and 28 procedures, respectively. When experience is achieved, the morbidity rate was low regardless of the disease stage. Despite the experience obtained, in patients operated in the 3rd and 4th quartiles, the recurrences occurred in 10 (7.7%) and 9 (8.8%) patients, respectively.Conclusion: the indicator of experience obtained is the decrease of operation time and post-op morbidity. The experience level dies not affect recurrence rate in stages III-IV due to limitations of the technique.

The evolution of hemorrhoids publications during 1980-2021: a global and medical view with bibliometric analysis

Aims: Hemorrhoids is a common anorectal disorder and significantly affects quality of life. Although the number of global studies on hemorrhoids has increased in recent years, there is still no bibliometric study in the literature. In this study, it aimed that analyzing the scientific articles published on hemorrhoids holistically. 
 Methods: The articles published between 1980 and 2021 were analyzed using bibliometric and statistical methods on hemorrhoids. Network visualization maps were used to identify trending topics and international collaborations. Spearman’s correlation coefficient was used for correlation studies. The Exponential Triple Smoothing estimator was used to estimate the number of articles expected to be published in the coming years. 
 Results: A total of 3203 publications were found. 1863 (58.1%) of these publications were articles. The most active author is Gupta PJ. (n=26). The first 2 journals that published the most articles were Diseases of the Colon & Rectum (n=228) and Colorectal Disease (n=82). Singapore General Hospital (n=35) and University of Rome La Sapienza (n=19) were the 2 most active institutions. According to the average number of citations per article, the top 2 most influential journals were British Journal of Surgery and American Journal of Gastroenterology. 
 Conclusion: In this comprehensive study on hemorrhoids, a statistical analysis of 1863 articles was shared. It was determined that the trend topics in hemorrhoid researches were THD, mucopexy, transanal hemorrhoidal dearterialization, colorectal surgery, embolization, constipation, risk factors, Milligan-Morgan, classification, recurrence and randomized controlled trial. This article can be a useful resource for scientists and clinicians in terms of the global output of hemorrhoids yesterday, today and tomorrow.

Simultaneous treatment for anal fissure and hemorrhoids

When using surgical approach to treatment for combined anal fissure and hemorrhoids doctor always faces the question of whether to divide the procedure into two sequential stages or to perform a simultaneous surgical intervention, and in which cases one or the other should be done. Purpose - to improve the results of treatment for patients with anal fissure in combination with chronic hemorrhoids by combining fissurectomy with transanal hemorrhoidal dearterialization (THD). Materials and methods. 177 patients with combination of anal fissure and hemorrhoids were studied. The Group I (GI) - fissure excision and hemorrhoidectomy, 60 patients. The Group II (GII) - anal fissure excision without surgery for hemorrhoids, 60 patients. The Group III (GIII) - proposed method used, 57 patients. Laser Doppler flowmetry was performed to assess blood flow intensity in fissure area. The assessment of treatment outcomes in patients was based on the following criteria: pain intensity, urinary retention in early postoperative period, postoperative wound suppuration, disease recurrence, iatrogenic incontinence, duration of postoperative hospital stay. Qualitative parameters are presented as the absolute number of cases (n) and their percentage (%). Comparison of these parameters between groups was performed using the Pearson’s χ2 test and the Fisher’s exact test. Statistical analysis was conducted by STATA 12.1 statistical package. Results. Pain intensity: GI - 8±1, GII - 6±2, GIII - 4±1. Urinary retention: GI - 19 (31.6%), GII - 8 (13%), GIII - 6 (10.5%). Wound suppuration: GI - 5 (8.3%), GII - 1 (1.7%), GIII - 1 (1.7%). Hospital stay (days): GI - 6±1.2, GII - 4±1.3, GIII - 3±1.1. Fissure recurrences: GI - 5 (8.3%), GII - 2 (3.3%), GIII - 1 (1.7%). Hemorrhoid recurrence: GI - 6 (10%), GIII - 2 (3.5%). Iatrogenic incontinence: GI - 4 (6.7%), GII - 1 (1.7%), GIII - 0. Significant decrease in relative risk of complications (by 88%) in GIII compared with GI - OR=0.12 (0.04-0.29), p=0.0001, and a tendency to reduction of complication risk by 15% compared with GII - OR=0.85 (0.29-2.4), p=0.734 was observed. Blood flow intensity (flowmetry results) in GII and GIII was comparable. Conclusions. Simultaneous anal fissure excision and THD can improve treatment outcomes. This method does not impair blood flow in the area of anal fissure. Proposed method is both radical and minimally invasive. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Minimally Invasive Treatment for Advanced Hemorrhoids.

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review.

Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2weeks, 1 month and 6 months after surgery. Forty-seven out of 75 patients were male, and the mean age was 50 (±17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.

Experience of transanal hemorrhoidal dearterialization in the surgical treatment of grades II-IV hemorrhoids that bleeding

The aim of the work was to analyze the use of Transanal Hemorrhoidal Dearterialization (THD) in the surgical treatment of hemorrhoids of various degrees. The use of THD for complicated hemorrhoids in 514 patients for the period 2008–2021 was analyzed on the clinical basis of the Department of Surgery No.3 of the Bogomolets National Medical University (Ukraine). The average age of the patients was 39.1 years. 159 (30.9%) patients had grade II hemorrhoid, 299 (58.2%) – grade III, 56 (10.9%) – grade IV. All patients had manifestations of rectal bleeding and periodic prolapse of hemorrhoidal nodes, 75 (14.6%) patients had a pain syndrome associated with anal fissures, 19 (3.7%) patients underwent THD for recurrent (after performing other operations) hemorrhoids. No severe postoperative complications were observed. The average length of stay in the hospital was 1.3 days. The working capacity of the patients was restored after 3–5 days. Since 2015, THD has been performed according to the method updated by the authors, which was called Distal Doppler-controlled Dearterialization (DDD). We compared the results of performed THD before and after supplementing her DDD. When comparing THD before and after supplementing its DDD, a significant (p=0.00007) increase in the specific gravity of surgical interventions in stage III hemorrhoids while preserving the quality and duration of the postoperative course was revealed. Also, the number of THD in combination with surgery for chronic anal fissure, the number of operations for recurrent hemorrhoids increased significantly (p<0.05), which indicates the validity and effectiveness of the technique as an operation of choice in the surgical treatment of stage II–IV hemorrhoids. Application of the updated technique using DDD facilitates the performance of mucopexy, allows performing operations at later stages of complicated hemorrhoids. Keywords: proctology, THD, DDD, Doppler-controlled dearterialization.

Long-Term Results with Hemorroidectomy THD in Disease Hemorrhoidal

1.1. Objective: To analyze prospectively a series of 300 cases of hemorrhoidal disease managed with transanal hemorrhoidal dearterialization guided by Doppler ultrasound (THD) 1.2. Material and Methods: During the months of May 2011 to June 2019 a total of 300 patients were included with an average age of 43 years, (3%) were diagnosed with hemorrhoidal disease grade II, grade III (15%), grade IV (10%) and mixed hemorrhoidal disease (72%), predominantly male (57%), which were treated with THD; surgical time, intensity of postoperative pain, recurrence, recovery time and time of return to work were analyzed. 1.3. Results: The average age was 43 years, with a predominance of 57% male, the predominant symptoms before surgery were 100% bleeding, 79% prolapse and 60% pruritus, 3% had Grade II hemorrhoids, 15% grade III, 10% Grade IV and 72% mixed hemorrhoids, the average surgical time of the surgery was 15.9min (range 15-20 min), 1 day hospital stay (100%), 2.3% presented urinary retention, in The VAS scale at day 1 patients presented a value of 4 (range 2-7), at day 7 a value of 2 and at day 30 a value of 0 in all patients, the recovery time on average was 10 days and return to work in 14 days (range 10-20 days), recurrence of 3%, 10 patients It is presented evidence of new external flaps. 1.4. Conclusion: This study shows that patients treated with THD hemorrhoidectomy adequately manage the disease with low recurrence rate and less postoperative pain as well as complications.

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.

Transanal Hemorrhoidal Dearterialization (THD) Anolift-Prospective Assessment of Safety and Efficacy.

The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2–32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.

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.

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview.

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.

An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis.

Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments. A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS. A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser. There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.

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.

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.

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.

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.

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.