Haemorrhoids is the most common rectal disease, accounting for almost half of all rectal disease. The term ‘haemorrhoid’ describes a vascular structure located between the mucosal muscular layer and anal sphincter muscle. This structure is supported by the elastic and muscular tissue of the anal canal and is divided by the dentate line into upper internal and lower external components. Physiologically, a haemorrhoid comprises part of the anal sphincter and, owing to the non-physiological distension and protrusion of this structure, accompanied by pain, should be considered a disease.1,2 Currently, haemorrhoids are viewed as a disease of civilization whose development is greatly affected by diet, hygiene and digestion.2
Grading of haemorrhoids based on morphology, which is widely accepted, is as follows:
grade 1: increased volume of haemorrhoid without prolapse but with bleeding;
grade 2: mucosal prolapse of haemorrhoid together with spontaneous reduction;
grade 3: haemorrhoid mucosal prolapse reduced only manually;
grade 4a: prolapse of mucosal haemorrhoid accompanied by acute distension and thrombosis;
grade 4b: mucosal haemorrhoid, which cannot be reduced, accompanied by the fibrosis of prolapse.3
Currently, other classifications, such as those according to symptoms, are less commonly used than the morphological classification.4
Treatments for haemorrhoids include dietary treatment, drug therapy, rubber band ligation, infrared photocoagulation, sclerotherapy and excision of thrombosed external haemorrhoids, and surgery. Surgical haemorrhoidectomy is undertaken through methods such as strangulated, prolapsed, Whitehead or stapled haemorrhoidectomy. Based on the studies by Bliasdell and Barron5,6 infrared coagulation, sclerotherapy and particularly rubber band ligation are among the methods producing the best outcomes and fewest complications in case of grade 2 and 3 haemorrhoids.4,7,8
The need for several treatment sessions to achieve a satisfactory outcome, incomplete feeling of recovery owing to the presence of an external object, pain, necrosis, or an allergic reaction to sclerosants are the chief complaints following these procedures. Laser therapy is an alternative method of resection of haemorrhoids. The success of protective treatment is directly linked to the grade of haemorrhoid, but several treatment sessions are required and the recurrence rate is relatively high. In 1995, Morinaga devised a new method for haemorrhoid treatment using a proctoscope with a specific design and a Doppler adaptor for haemorrhoid identification and haemorrhoid artery ligation (HAL).9 Ligation of the blood-carrying arteries results in a reduction in the internal pressure of the haemorrhoid plexus.4 A number of studies have shown that Doppler-guided haemorrhoid treatment is effective, pain-free and results in fewer complications than other methods. Thus, it could be a suitable alternative to traditional surgical methods. However, Doppler-guided haemorrhoidectomy has not been completely accepted by surgeons owing to a belief that there is no significant difference in terms of effectiveness and recurrence rate.
Patients and methods
This case–control clinical trial was carried out in Iran Mehr Clinic and Vali-Asr Educational Medical Center, Arak, Iran. After noticing the sample sizes in most of the previous studies (n = 300)8,10,11 and assessment criteria/observed cases, it was decided to include the same number of patients in both HAL and haemorrhoidectomy groups (n = 150). Sampling was achieved through non-randomized quota sampling. Patients were examined, and those with grade 2, 3 and 4 haemorrhoids were asked, following explanation of the procedures, to choose traditional haemorrhoidectomy or Doppler-guided haemorrhoidectomy. The HAL group comprised the patients undergoing Doppler-guided haemorrhoidectomy and the haemorrhoidectomy group consisted of the patients treated by the traditional method. Three surgeons performed open traditional surgery by the Ferguson method and patient monitoring in the control group, and another surgeon performed Doppler-guided HAL and patient monitoring in the case group. An attempt was made to match patients in each group in terms of haemorrhoid grade.
Initially, a checklist including information on age, sex, chief complaint, haemorrhoid grade (after examination by the surgeon), intraoperative ligator and type of anaesthesia was completed for each patient. The patients were followed up and assessed for postoperative complications 1 week, 1 month, 3 months and 6 months post surgery and the results were entered on each patient’s checklist. Postoperative pain was assessed by the requirement for analgesics. Indications for reoperation in patients with postoperative complications included prolapse, bleeding, thrombosis, fistula, proctitis and severe pain. The data obtained were analysed by central tendency indices and chi-squared test using SPSS Version 16 (SPSS Inc., Chicago, IL, USA). This study was conducted in compliance with the Helsinki Treaty and informed consent was obtained from each patient.
Of the patients in the HAL group, 93.3% were female and 6.7% were male. In the haemorrhoidectomy group, 40.9% of the patients were female and 59.1% were male. The mean age of the patients in the HAL group was 42.8 years and in the haemorrhoidectomy group was 45.3 years.
The frequency distribution of the patients’ symptoms in the HAL and haemorrhoidectomy groups is shown in Table 1.
The frequency distribution of haemorrhoid grade in the HAL and haemorrhoidectomy groups is shown in Table 2.
|Grade 2||50%||2.2%||< 0.001|
|Grade 3||22.7%||51.1%||< 0.001|
|Grade 4||25%||44.4%||< 0.001|
The analysis of the results using an independent t-test showed that there was no significant difference between the HAL and haemorrhoidectomy groups in terms of age (P = 0.312). However, the chi-squared test indicated a significant difference between the HAL and haemorrhoidectomy groups in sex distribution (P < 0.001). Hence, matching the HAL and haemorrhoidectomy groups in terms of age was accurate but not enough care was taken to match the two groups with regards to sex.
In terms of previous haemorrhoid surgery, there was no significant difference between the two groups (P = 0.219) and the distribution of the coexisting diseases was also the same in the two groups (P = 0.206). Pain was scored by determining the number of analgesics used as well as the patient's sensation of pain. However, the distribution of different grades of haemorrhoid was significantly different (P < 0.001). This indicates that the patients were not ideally matched, which can be attributed to giving the patients choice of the method of surgery.
Postoperative complications are shown in Table 3.
The comparison between pain scores in week 1, month 1, month 3 and month 6 revealed a significant difference between case and control groups in the first week and the first month postoperatively (P < 0.001). Pain was scored by determining the number of analgesics used as well as the patient's sensation of pain. However, the mean level of pain was not significantly different between the two groups during the third and sixth postoperative months (P = 0.597). Moreover, there was a significant difference between the HAL and haemorrhoidectomy groups in terms of the need for repeated surgery (P = 0.029). Thus, it appears that in terms of pain during the first postoperative month and the recurrence rate, Doppler-guided haemorrhoidectomy was more effective than the usual method of haemorrhoidectomy.
Complications such as prolapse, bleeding, pain during defecation, urinary distension and urinary infection were less likely following Doppler-guided haemorrhoidectomy than the usual method of haemorrhoid surgery. Thus, Doppler-guided haemorrhoidectomy could be a more appropriate method of treating patients with haemorrhoids.
Abdeldaim et al.10 followed 308 patients treated by Doppler-guided haemorrhoidectomy for up to 18 months postoperatively in 2007 and showed that Doppler-guided haemorrhoidectomy was an effective method with milder pain and fewer complications than traditional surgical methods. Wallis et al.11 surveyed 110 patients who underwent haemorrhoidectomy by proctoscopy, versus open traditional haemorrhoidectomy by the Ferguson method, and concluded that Doppler-guided haemorrhoidectomy is an effective method of treatment with no serious complications. The findings of the present study are in line with the results of these studies, which indicate the superiority of Doppler-guided haemorrhoidectomy.
In contrast, Faucheron and Gangner7 evaluated 1000 haemorrhoid patients who underwent Doppler-guided haemorrhoidectomy between 2002 and 2004 and reported a recurrence rate of 12% up to 3 years postoperatively. They suggested that this method should be used with caution.7 However, in the present study the recurrence rate was not significantly different between the two methods of haemorrhoidectomy. The discrepancy in the obtained results can be attributed to the postoperative follow-up period; in the study by Faucheron and Gangner,7 the patients were followed for up to 3 years postoperatively, while the follow-up period in the present study was 6 months.
Dal Monte et al.8 examined 300 patients undergoing Doppler-guided haemorrhoidectomy between 2000 and 2006 and concluded that the effectiveness and recurrence rate of this method equalled those of usual haemorrhoid surgery. They observed, however, that, as Doppler-guided haemorrhoidectomy is more expensive, it cannot be considered a direct alternative to traditional haemorrhoidectomy.8 Nevertheless, the findings of the present study demonstrate the superiority of Doppler-guided haemorrhoidectomy, and this is in line with the findings of previous studies in this area.
In summary, it can be concluded that Doppler-guided haemorrhoidectomy is a simple and minimally invasive method of surgery, resulting in milder pain and fewer complications than traditional surgical methods, and is a suitable treatment for patients with symptomatic haemorrhoids. This method is applicable to haemorrhoids of all grades and can enhance patient satisfaction and comfort; however, the recurrence rate cannot yet be determined with any certainty. Hence, similar case–control studies comprising larger samples of patients matched for haemorrhoid grade and with longer follow-up periods are required to achieve a more comprehensive evaluation of Doppler-guided haemorrhoidectomy.