EGOGUIDED TRANSANAL HEMORRHOIDAL DEARTERIALIZATION. ONE YEAR OF EXPERIENCE IN A HOSPITAL IN URUGUAY.
The authors declare no conflict of interest
Financial support: not received
ABSTRACT
Introduction: There are multiple therapeutic options for symptomatic hemorrhoidal disease, from topical medical treatment to increasingly complex surgical treatment. Doppler-guided hemorrhoidal artery ligation (HAL), asociated or not to mucopexy (rectoanal repair-RAR), is a promising non-resective method.
Objective: To present our experience and evaluate the efficacy and safety of HAL-RAR.
Design: Prospective, observational, descriptive study.
Material and methods: Patients with grade III and grade IV hemorrhoids and patients with grade II hemorrhoids in whom rubber band ligation failed, who underwent HAL or HAL-RAR at the British Hospital of Uruguay between 2020 and 2021, were included. Data recorded was hospital stay, postoperative pain measured with the Visual Analog Scale (VAS 1 to 3 = mild), demand for analgesia, complications and recurrence at 6 months.
Results: Fifty patients were included, 56% men and 44% women, mean age 50 (range 25-75) years. Sixty-six percent had grade III hemorrhoids. Mucopexy (HAL-RAR) was added in 92%. After the learning curve, the average time of HAL-RAR was 35 ± 10 min.
In 1 patient the procedure was ambulatory and in 76% hospital stay was 24 h. In 4% of patients hospitalization was prolonged due to pain. The complication rate, including severe pain, was 10% and recurrence 2%. Seven days after the procedure, half of the patients had no pain, 2 patients had moderate pain (VAS 5 and 6), and the rest had mild pain.
Conclusions: In our center, hemorrhoidal dearterialization associated with mucopexy is reproducible, safe, and reliable, achieving surgical times similar to those reported in the international literature. Postoperative pain is mild in most patients, morbidity is low, and recurrence is minimal.
Keywords: hemorrhoids, hemorrhoidal artery ligation, transanal ultrasound-guided dearterialization
INTRODUCTION
Within the group of anal and perianal pathologies, hemorrhoidal pathology is the most frequent. Its high prevalence makes it a health problem, even more so if the social and labor repercussions it generates are taken into account (1,2).
The incidence of hemorrhoids increases with age. It is estimated that 50% of the population over 50 years of age presents some symptom linked to this pathology and it is estimated that 90% of the general population will have some degree of hemorrhoidal disease throughout their lives.
There are multiple therapeutic options for symptomatic hemorrhoidal disease, from topical medical treatments to increasingly complex surgical treatments. Although surgical resection is considered the gold standard in those classified as grade III and IV, new less invasive techniques have been incorporated into the therapeutic arsenal with the aim of reducing postoperative pain and functional alterations (1,2).
Stapled hemorrhoidectomy, known as PPH, is a procedure introduced by Longo that consists of resection of the rectal mucosa; it is not considered a less invasive method (3,4).
Doppler-guided ligation of hemorrhoidal arterial pedicles, also known as dearterialization associated or not with mucopexy, is a non-resective method, described by Morinaga et al. in 1995. This technique, focused on the selective ligation of the terminal branches of the superior rectal artery, thus reduces arterial flow to the hemorrhoidal plexuses(5) and is associated with less postoperative pain, shorter hospital stay, and prompt return to activity. . compared to classical resection methods such as Milligan-Morgan or Ferguson hemorrhoidectomies. For its realization, various types of anoscopes associated with a Doppler probe have been implemented. The terms “hemorrhoidal artery ligation” (HAL) and “transanal hemorrhoidal dearterialization” (THD) are used interchangeably to refer to this procedure (6-8).
The objective of this study is to present our experience and evaluate the efficacy and safety of hemorrhoidal dearterialization associated with mucopexy.
MATERIAL AND METHODS
This is a prospective, observational, and descriptive study conducted at the British Hospital of Uruguay between January 2020 and January 2021. It included all the patients who underwent guided dearterialization with a Doppler probe incorporated into a proctoscope (associated with mucopexy in cases of prolapse), using the A.M.I Trilogy™ equipment.
The inclusion criteria were:
• Patients over 18 years of age.
• Grade III and IV hemorrhoidal pathology.
• Grade II haemorrhoidal pathology with persistent bleeding or some degree of prolapse after failure of conservative treatment with rubber band ligation.
Patients with colorectal cancer (regardless of stage) found during the preoperative evaluation were excluded.
All patients underwent routine preoperative clinical and paraclinical evaluation.
No enemas or any other method of bowel preparation was performed before the operation.
Informed consent was given to each patient respecting her identity. The study was approved by the institutional ethics committee.
Surgical technique
Antibiotic prophylaxis with a single intraoperative dose of ampicillin sulbactam was used. All procedures were performed under general anesthesia, in the lithotomy position, and by the same surgical team. Prior to the start of the procedure, a bilateral internal pudendal block with 0.25% bupivacaine was performed. The proctoscope was introduced up to 6 to 7 cm from the anal verge, where the arterial flows guided by the Doppler auditory signal were identified. The pedicles located at hours 1, 3, 5, 7, 9 and 11 were systematically ligated, verifying the absence of distal signal after ligation. In patients with some degree of associated hemorrhoidal prolapse, mucopexy was performed by continuous suture in a distal direction, procedure known as rectoanal repair (RAR), from which the full acronym for this procedure (HAL-RAR) derives. When complementary signals arise during the revision, they are ligated with a similar technique, without associating mucopexy.
Postoperative evaluation
Postoperative pain was classified using the VAS scale from 1 to 10. Pain categorized as 1, 2, and 3 was considered mild. It was recorded at 2 hours, 24 hours, 7 days and 30 days after surgery, at final discharge. In the postoperative period, 1 g of intravenous paracetamol every 8 h was used in all cases, maintaining the same oral dose at discharge and gradually reducing it according to pain. In some cases of severe constipation, mild laxatives or low-dose oral petroleum jelly were used from the preoperative period. A high-fiber diet and more than 2 liters of fluids per day were indicated. Outpatient follow-up was scheduled at 7 days, 1 month, and 6 months, recording specific parameters such as hospital stay, analgesia demand, complications, and recurrence at 6 months. All patients completed the informed consent form.
RESULTS
Fifty patients, 28 (56%) men and 22 (44%) women, with a mean age of 50 (range 25-75) years were included. The technique was indicated mainly in patients classified as grade III (66%). Fifty-six percent of patients had previous rubber band ligation to control bleeding or prolapse. A 68-year-old male patient with grade III hemorrhoids had undergone a Milligan-Morgan hemorrhoidectomy 11 years earlier (Table 1).
Dearterialization was performed in all cases with 6 stitches. In 47 (94%) patients it was necessary to perform between 1 and 5 complementary stitches because additional Doppler signals were detected during the review.
In 46 (92%) patients with grade III and IV hemorrhoids, the procedure was completed with mucopexy up to 1 cm proximal to the dentate line. In the remaining 4 (8%) patients, only dearterialization was performed without pexy, since they were had grade II hemorrhoids with only bleeding, without prolapse, in whom banding had failed.
Throughout the year analyzed, surgical times decreased progressively. In the last 6 months, after overcoming the learning curve, the average was 35±10 minutes for the complete procedure (HAL-RAR) and 10 minutes less when mucopexy was not associated.
In 1 (25%) patient the procedure was ambulatory. The majority of patients (76%) were discharged after 24 h. In 2 (4%) women, hospitalization was prolonged. One presented acute infectious diarrhea with 6 to 8 liquid stools/day, which determined a greater demand for analgesia and control. Another young female patient with grade IV hemorrhoids presented intense pain with a high demand for analgesia. Both were discharged on the 5th postoperative day. In only one patient the procedure was ambulatory (Table 2).
A common symptom in the postoperative period was rectal tenesmus, present in all cases to a greater or lesser extent. The patient was instructed to differentiate tenesmus from pain, in order to be able to categorize postoperative pain objectively.
There were postoperative complications, including severe pain, in 5 (10%) patients. In two patients it was necessary to drain hemorrhoidal superficial thrombosis and one persisted with mild rectal bleeding that was controlled with two sessions of rubber band ligations (Table 2). There was only one recurrence (2%).
Half of the patients had no pain after 7 days and 78% after a month (Table 3). At that time, pain was mild (VAS 1, 2, and 3) in the rest of the patients, with the exception of the 2 (4%) patients mentioned above who had moderate pain (VAS 5 and 6, respectively) with delayed discharge (Table 2). At one month, 11 (22%) patients still had very mild pain (10 VAS 1 and 1 VAS 2) (Table 3).
At 6 months, consultation for sequelae anal plicomas is frequent, so patients were always warned of this possible outcome. Three patients opted for surgical resection, for functional or cosmetic reasons.
DISCUSSION
The therapeutic option for symptomatic hemorrhoids in mild cases focuses on medical treatment, leaving surgical treatment as the best option for severe cases or those in which initial treatment fails. Although conventional hemorrhoidectomy is considered the gold standard for grade III and IV hemorrhoids, there are other less morbid procedures.
Doppler-guided transanal hemorrhoidal dearterialization associated with mucopexy appears to be associated with less postoperative pain, shorter hospital stay, and earlier return to normal life, compared with conventional Milligan-Morgan or Ferguson hemorrhoidectomy. This has been reported by several studies, including a meta-analysis by Xu et al.(9) that proposes dearterialization as a technique as valid as the conventional one, but with a longer operating time. Similarly, Trenti et al. (10) show less postoperative morbidity, but with a longer surgical time, perhaps due to the learning curve of a new method.
Although postoperative bleeding and rectovaginal fistula are described as the most relevant complications of this method, they did not occur in our study.
In our series, the low postoperative morbidity (10% including severe pain), correct pain management, low recurrence (2%), and rapid return to routine stand out.
Regarding the operating time, it varied as the learning curve evolved, finally achieving an average time of 35 min. Ratto et al.(11) highlight operating times of 25 to 45 minutes in previous series by other authors, being 20 to 30 minutes in their study. The number of ligated arteries in his series was 6, as in ours.
A recent systematic review and meta-analysis by Aibuedefe et al.(12) that included 26 studies with 3137 participants and 14 surgical treatments for grade III and IV hemorrhoids, described the advantages of minimally invasive techniques in general. They conclude that multiple favorable techniques currently exist without a clear gold standard. Therefore, the technique must be adjusted to each patient.
One of the strengths of this study is that it was possible to standardize not only the surgical procedure but also the pre- and postoperative protocols, maintaining the same surgical team in all patients, a fact reflected in the results obtained.
CONCLUSIONS
In our center, hemorrhoidal dearterialization associated with mucopexy is reproducible, safe, and reliable, achieving surgical times similar to those reported in the international literature. Postoperative pain is mild in most patients, morbidity is low, and recurrence is minimal.
References
1. Johannsson H, Graf W, Pahlman L. Bowel habits in hemorrhoid patients and normal subjects. Am J Gastroenterol. 2005; 100: 401-6.
2. Agbo SP. Surgical management of hemorrhoids. J Surg Tech Case Rep. 2011; 3:68-75.
3. Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular stapler suturing device: A new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery. 1998. pp. 777-84.
4. Ripetti V, Caricato M, Arullani A. Rectal perforation, retropneumoperitoneum, and pneumomediastinum after stapling procedure for prolapsed hemorrhoids: Report of a case and subsequent considerations. Dis Colon Rectum. 2002; 45:268-70.
5. 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.
6. Giordano P, Overton J, Madeddu F, Zaman S, Gravante G. Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009; 52:1665-71.
7. Sohn N, Aronoff JS, Cohen FS, Weinstein MA. Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy. Am J Surg. 2001; 182:515-19.
8. Lienert M, Horstmann O. Transanale-Hämorrhoiden-Dearterialisation (THD) und Hämorrhoidal-Arterien-Ligatur (HAL): Evaluation der minimal-invasiven Therapie des Hämorrhoidalleidens. 34. Deutscher Koloproktologen-Kongress: Abstracts. Coloproctology. 2008; 30:77-96.
9. Xu L, Chen H, Lin G, Ge Q, Qi H, He X Transanal hemorrhoidal dearterialization with mucopexy versus open hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials. Tech Coloproctol. 2016; 20:825-33.
10. Trenti L, Biondo S, Galvez A, Bravo A, Cabrera J, Kreisler E. Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes. Tech Coloproctol. 2017; 21:337-44.
11. Ratto C, Campennì P, Papeo F, Donisi L, Litta F, Parello A. Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: a single-center study on 1000 consecutive cases and a review of the literature. Tech Coloproctol. 2017; 21:953-62.
12. Aibuedefe B, Kling SM, Philp MM, Ross HM, Poggio JL. An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int J Colorectal Dis. 2021; 36:2041-49.
Table 1. Classification of hemorrhoidal disease and previous treatment.
|
Hemorrhoidal disease Grade II Grade III Grade IV |
N (%) 6 (12) 33 (66) 11 (22) |
|
Previous treatment Rubber band ligation Milligan-Morgan hemorrhoidectomy |
N (%) 28 (56) 1 (2) |
Table 2. Length of stay and postoperative complications.
|
Length of stay (days) Ambulatory 1 2 5 |
N (%) 1 (2) 38 (76) 9 (18) 2 (4) |
|
Postoperative complications Superficial hemorrhoidal thrombosis Bleeding Moderate anal pain Recurrence |
N (%) 2 (4) 1 (2) 2 (4) 1 (2) |
Table 3. Pain (VAS Scale) reported by the 50 patients, according to postoperative time.
|
|
0/10 |
1/10 |
2/10 |
3/10 |
4/10 |
5/10 |
6/10 |
7/10 |
8/10 |
9/10 |
10/10 |
|
2 hours |
1(2%) |
14(28%) |
21(42%) |
6(12%) |
5(10%) |
1(2%) |
0 |
1(2%) |
1(2%) |
0 |
0 |
|
24 hours |
10(20%) |
19(38%) |
14(28%) |
2(4%) |
3(6%) |
0 |
0 |
0 |
2(4%) |
0 |
0 |
|
7 days |
25(50%) |
20(40%) |
3(6%) |
0 |
0 |
1(2%) |
1(2%) |
0 |
0 |
0 |
0 |
|
30 days |
39(78%) |
10(20%) |
1(2%) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |