Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease

Piotr Walega, Michal Romaniszyn, Jakub Kenig, Roman Herman, Wojciech Nowak, Piotr Walega, Michal Romaniszyn, Jakub Kenig, Roman Herman, Wojciech Nowak

Abstract

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD).

Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure.

Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR.

Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Figures

Figure 1
Figure 1
A.M.I. DGHAL-RAR Proctoscope.
Figure 2
Figure 2
A stitch ligating a haemorrhoidal artery.
Figure 3
Figure 3
Longitudinal suture, covering the whole mass of a prolapsed haemorrhoid.
Figure 4
Figure 4
Haemorrhoid lifted back into its anatomical position by tying the suture.

References

    1. Bernstein WC. What are hemorrhoids and what is their relationship to the portal venous system? Diseases of the Colon and Rectum. 1983;26(12):829–834.
    1. Thomson WH. The nature of haemorrhoids. British Journal of Surgery. 1975;62(7):542–552.
    1. Herold A, Kirsch JJ. Complications after circular stapled hemorrhoidectomy. Coloproctology. 2001;23(1):8–16.
    1. Jóhannsson HÖ, Påhlman L, Graf W. Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy. British Journal of Surgery. 2006;93(10):1208–1214.
    1. Holzheimer RG. Hemorrhoidectomy: indications and risks. European Journal of Medical Research. 2004;9(1):18–36.
    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. American Journal of Gastroenterology. 1995;90(4):610–613.
    1. Altomare DF, Roveran A, Pecorella G, Gaj F, Stortini E. The treatment of hemorrhoids: guidelines of the Italian Society of Colo-Rectal Surgery. Techniques in Coloproctology. 2006;10(3):181–186.
    1. Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S. Doppler-guided hemorrhoidal artery ligation. American Journal of Surgery. 2006;191(1):89–93.
    1. Barron J. Office ligation of internal hemorrhoids. The American Journal of Surgery. 1963;105(4):563–570.
    1. Russell YR, Donohue JH. Hemorrhoidal banding: a warning. Diseases of the Colon and Rectum. 1985;28(5):291–293.
    1. Alabiso ME, Grassi R, Fioroni C, Marano I. Iatrogenic rectal diverticulum in patients treated with transanal stapled techniques. Radiologia Medica. 2008;113(6):887–894.
    1. Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. British Journal of Surgery. 2001;88(5):669–674.
    1. Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy—cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Diseases of the Colon and Rectum. 2000;43(12):1666–1675.
    1. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database of Systematic Reviews. 2006;(4):p. CD005393.
    1. Ortiz H, Marzo J, Armendariz P. Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. The British Journal of Surgery. 2002;89(11):1376–1381.
    1. Oughriss M, Yver R, Faucheron JL. Complications of stapled hemorrhoidectomy: a French multicentric study. Gastroenterologie Clinique et Biologique. 2005;29(4):429–433.
    1. Forrest NP, Mullerat J, Evans C, Middleton SB. Doppler-guided haemorrhoidal artery ligation with recto anal repair: a new technique for the treatment of symptomatic haemorrhoids. International Journal of Colorectal Disease. 2010;25(10):1251–1256.
    1. Walega P, Krokowicz P, Romaniszyn M, et al. Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease. Colorectal Disease. 2010;12(10):e326–e329.
    1. Chauhan A, Thomas S, Bishnoi PK, Hadke NS. Randomized controlled trial to assess the role of raised anal pressures in the pathogenesis of symptomatic early hemorrhoids. Digestive Surgery. 2007;24(1):28–32.
    1. Chen HH. Anal manometric findings before and after hemorrhoidectomy: a preliminary report. Changgeng Yi Xue Za Zhi. 1999;22(1):25–30.
    1. Hiltunen KM, Matikainen M. Anal manometric findings in symptomatic hemorrhoids. Diseases of the Colon and Rectum. 1985;28(11):807–809.
    1. Weyand G, Webels F, Celebi H, Ommer A, Kohaus H. Anal pressures after stapler hemorrhoidectomy—a prospective analysis of 33 patients. Zentralblatt fur Chirurgie. 2002;127(1):22–24.
    1. Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V. Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. British Journal of Surgery. 2001;88(11):1487–1491.
    1. Patti R, Almasio PL, Arcara M, et al. Long-term manometric study of anal sphincter function after hemorrhoidectomy. International Journal of Colorectal Disease. 2007;22(3):253–257.
    1. Wałȩga 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. Surgical Endoscopy and Other Interventional Techniques. 2008;22(11):2379–2383.
    1. Arroyo A, Pérez-Vicente F, Miranda E, et al. Prospective randomized clinical trial comparing two different circular staplers for mucosectomy in the treatment of hemorrhoids. World Journal of Surgery. 2006;30(7):1305–1310.
    1. Ceci F, Picchio M, Palimento D, Calì B, Corelli S, Spaziani E. Long-term outcome of stapled hemorrhoidopexy for grade III and grade IV hemorrhoids. Diseases of the Colon and Rectum. 2008;51(7):1107–1112.
    1. Stamos MJ. Stapled hemorrhoidectomy. Journal of Gastrointestinal Surgery. 2006;10(5):627–628.
    1. Tjandra JJ, Chan MKY. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy) Diseases of the Colon and Rectum. 2007;50(6):878–892.

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