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Al-Ozaibi, Hazim, Alani, Mazrouei, Badri, and Al-Jaziri: Transanal haemorrhoidal dearteralization – 1-year follow-up results, the Dubai experience

Introduction

In 1995, Morinaga et al.1 reported a new surgical technique for treating haemorrhoids, Doppler-guided haemorrhoidal dearteralization, or THD (transanal haemorrhoidal dearteralization), based on principles different from those of conventional haemorrhoidectomy. It addresses the issue of post-operative pain and treating the disease on an anatomophysiological basis without disturbing the anatomy and function of the anal canal. This non-excisional technique is based on the closure of the haemorrhoidal arterial flow that feeds the haemorrhoidal plexus through a Doppler-guided identification and ligation of the terminal branches of the superior rectal artery,1 sometimes coupled with mucopexy to treat the prolapse.

According to Aigner et al.,2 in patients suffering from haemorrhoidal disease both the diameter of the terminal branches of the superior rectal artery and the arterial blood flow velocity increases. THD aims to correct this physiological disturbance of the haemorrhoidal plexus by restoring the normal anatomy of the haemorrhoidal cushions.

The other important advantage of this technique is preserving and restoring the physiological role of the haemorrhoidal cushions in the continence mechanism. The deleterious effects of classic haemorrhoidectomy on the anal continence are well known. In a study by Bennett et al.,3 26% of haemorrhoidectomy patients had one or more defects in the anal canal 3 years postoperatively; therefore, THD may be the best option for patients who require an operative haemorrhoidectomy but in whom it is contraindicated because of incontinence.

Our goal was to compare the safety and efficacy of this method in reducing post-operative pain and complications compared with other methods in the literature.

Method

We carried out a retrospective study of 42 consecutive patients (36 men and six women) with symptomatic grade II and III haemorrhoids, aged between 18 and 65 years, who underwent THD during the period between September 2011 and October 2012. The patients underwent the surgical procedure under general or regional anaesthetic. Patients with concomitant anal pathology, thrombosed or prolapsed fourth-degree piles and patients with inflammatory bowel disease were excluded from the study. Patients were reviewed in the clinic after 1 week and 3 months, and were interviewed by telephone after 1 year. The patients were evaluated for pain during the first post-operative week using the 10-point visual analogue scale. During a follow-up period of 1 year, the development of complications and improvement of symptoms were assessed.

Results

After obtaining ethical committee approval, the records of 42 patients with grade II and III haemorrhoids who underwent THD were reviewed. Thirty-six patients were men and six were women. The overall mean age was 40.2 ± 12.6 years (range 17 to 65 years) with 33 patients under 50 years of age. Twenty-four patients (57%) had grade III haemorrhoids and 18 (43%) had grade II. Bleeding was the main pre-operative symptom in 41 patients (98%). The presenting symptoms are summarized in Table 1.

TABLE 1

Pre-operative symptoms

Presenting symptoms Frequency %
Bleeding 10 23.8
Discharge 1 2.4
Bleeding with pain 3 7.1
Bleeding with prolapse 22 52.4
Bleeding with prolapse and pain 5 11.9
Bleeding with discharge and pain 1 2.4
Total 42 100.0

Thirty-nine (93%) of the cases were carried out under general anaesthetic, while three (7%) were carried out under regional anaesthetic (pudendal block). All the cases were carried out as day-case surgeries. The overall mean operation time was 46.8 ± 9.4 minutes (range 25 to 65 minutes). Six sutures were applied in 26 patients, 10 patients had five sutures, two had four sutures and four had three sutures. Thirty-four patients had mucopexy, which ranged between one and six as shown in Table 2.

TABLE 2

Number of mucopexies

Mucopexy Frequency %
0 8 19.0
1 10 23.8
2 1 2.4
3 8 19.0
4 4 9.5
5 1 2.4
6 10 23.8
Total 42 100.0

The procedure was highly effective in reducing prolapse. Figure 1 shows the pre- and immediate post-operative results of the procedure in reducing prolapse.

FIGURE 1

(a) Before THD. (b) After THD. (c) Before THD. (d) After THD.

8-3-2-fig1a.jpg8-3-2-fig1b.jpg8-3-2-fig1c.jpg8-3-2-fig1d.jpg

Post-operative pain during the first week was analysed using the visual analogue scale. Twenty-six (62%) patients had post-operative pain; four had severe pain (score > 7) on the first day, which required analgesia, and 16 (38%) had no pain. The pain was experienced during and after defecation. Figure 2 summarizes the pain score during the first week of surgery.

FIGURE 2

Pain score in the first week.

8-3-2-fig2.jpg

During the follow-up period patients were observed for the development of complications. There were no significant complications. Thirty-three (79%) patients did not have any complications and nine (21%) had an immediate post-operative complication, which was not severe. Early complications are summarized in Table 3.

TABLE 3

Post-operative complications

Post-operative complications Frequency %
No 33 78.6
Fever 1 2.4
Abscess and fistula 1 2.4
Mild bleed 2 4.7
Haematoma 1 2.4
Tenesmus 2 4.7
Urine retention 2 4.7
Total 42 100.0

Patients were reviewed after 3 months, 38 (90%) patients showed improvement of their symptoms, while four felt only a temporary improvement for only 6–8 weeks before symptoms relapsed.

All the patients were followed 1 year after the operation for the recurrence of symptoms. The procedure was successful in 35 patients (83%) while seven (17%) patients had recurrence of their symptoms.

Discussion

Most of the studies reviewed report less post-operative pain. Giordano et al.,4 in a systemic review comprising 1996 patients, reported that post-operative pain was present in 18.5% of patients. Infantino et al.5 also reported that 72% of patients did not need analgesics and the other 28% used non-steroidal anti-inflammatory drugs one to three times a day for fewer than 2 days. In another study, carried out by Cavazzoni et al.,6 post-operative pain was also less intense; the mean pain score per verbal numerical scale was 3.6 and 1.4 on day 1 and day 3, respectively. In the current study, pain was much higher than that reported in the literature; 62% reported mild pain (score < 3), 27–46% had moderate pain (score 3–7) during the first 4 days and 15% of the patients reported severe pain during the first day only. There was no direct correlation between pain and mucopexy, but the four patients who had severe pain in the first 24 hours had mucopexy. Most patients’ pain was tolerable and could be easily managed with oral analgesics using non-steroidal anti-inflammatory medications, with most of the pain occurring in the first 24 hours.

Several comparative studies have been published comparing haemorrhoidal dearteralization with other techniques. In comparison with LigaSure® (Covidien, Jersey City, NJ, USA) haemorrhoidectomy the short- and medium-term results showed that THD patients had a higher rate of pain resolution than LigaSure® patients.7 Furthermore, when compared with stapler haemorrhoidectomy, THD patients had less post-operative pain.8 In a randomized trial comparing THD with conventional haemorrhoidectomy, post-operative pain was lower in the THD group during the first week.9 In the study by Norman et al.10 only 8% of patients had pain which resulted in > 2 days loss of work.

Causes of pain in the post-operative period could be oedema at the site of suture, a stitch that involves the sphincter muscles or a stitch taken below the dentate line, or it may be ischaemic in origin.

In a recent study, Talha et al.11 measured the early quality-of-life outcomes following Doppler-guided THD and concluded that symptoms had all significantly reduced and specific aspects of quality of life improved 1 month after surgery. In the current study, all the patients felt improvement of their symptoms after 1 month but by the third month 9% had relapse of their symptoms.

Transanal haemorrhoidal dearteralization was known to have fewer post-operative complications than other haemorrhoidectomy procedures. Bleeding was very rare after THD, and, most of the time, was not considered to be significant bleeding that required intervention. In this study, 79% of the patients did not have any post-operative complications, 5% had mild bleeding and 5% had urine retention. Other complications reported were tenesmus, fever, haematoma and abscess and anal fistula.

The recurrence rate was 17% during the first year, in other studies it was 10.5%.12 Giordano et al.4 reported that the overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding and 4.7% for pain during defecation; the recurrence rate was higher for grade IV haemorrhoids, and it is recommended that the procedure be repeated in the event of recurrence. The recurrences were more frequent during the learning curve. We did not find any statistical significance between the number of ligations or mucopexy and the recurrence of symptoms.

Several studies in different countries showed that THD is safe, not causing any trauma to the anal canal or rectum and effective with good results,13,14 and patient satisfaction from the procedure was 73.0%.15 Normal daily activities were restored, on average, 3 to 4 days postoperatively.

Conclusions

The THD technique has been shown to be safe and effective in the treatment of haemorrhoids compared with other procedures detailed in the literature. It can be carried out safely as a day-case surgery. It is not a painless procedure, but post-operative pain is mild and does not require analgesia. The main advantages are less bleeding, fast recovery and fewer complications. Long-term recurrence occurred in 7 out of 42 patients, which is very similar to other procedures.

References

1. 

Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol 1995; 90:610–13.

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Aigner F, Bodner G, Conrad F, Mbaka G, Kreczy A, Fritsch H. The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am J Surg 2004; 187:102–8. http://dx.doi.org/10.1016/j.amjsurg.2002.11.003

3. 

Bennett RC, Frieman MHW, Goligher JC. Late results of haemorrhoidectomy by ligature and excision. Br Med J 1963; 2:216–19. http://dx.doi.org/10.1136/bmj.2.5351.216

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Sohn N, Aronoff JS, Cohen FS, Weinstein MA. Transanal hemorrhoidal dearteralization is an alternative to operative hemorrhoidectomy. Am J Surg 2001; 182:515–19. http://dx.doi.org/10.1016/S0002-9610(01)00759-0

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Talha S, Burke JP, Waldron D, Coffey JC, Condon E. Early quality of life outcomes following Doppler guided transanal haemorrhoidal dearteralization: a prospective observational study. Acta Gastroenterol Belg 2013; 76:231–4.

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Nguyen V, Jarry J, Imperato M, et al. French experience in the management of hemorrhoids by HAL Doppler. J Visc Surg 2012; 149:412–16. http://dx.doi.org/10.1016/j.jviscsurg.2012.10.004

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Wałega P, Scheyer M, Kenig J, et al. Two-center experience in the treatment of hemorrhoidal disease using Doppler guided hemorrhoidal artery ligation: functional results after 1-year follow-up. Surg Endosc 2008; 22:2379–83. http://dx.doi.org/10.1007/s00464-008-0030-x

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Lucarelli P, Picchio M, Caporossi M, et al. Transanal hemorrhoidal dearteralization with mucopexy versus stapler haemorrhoidopexy: a randomized trial with long-term follow-up. Ann R Coll Surg Engl 2013; 95:246–51. http://dx.doi.org/10.1308/003588413X13511609958136




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