| ORIGINAL PAPERS |
Doppler-guided hemorrhoidal artery ligation in the management of symptomatic hemorrhoids
J. M. Ramírez, V. Aguilella, M. Elía, J. A. Gracia and M. Martínez
Section of Coloproctology. Service of Surgery "B". Hospital Clínico Universitario. Zaragoza, Spain
ABSTRACT
Objective: the aim of this study is to clinically test the efficacy of a new approach for patients having symptomatic grade III and IV hemorrhoids. ]]>
Material and method: 32 patients (17 females) complaining of grade III or IV hemorrhoids were included in the study. A specially designed proctoscope coupled with a Doppler transducer on its tip was used to identify the hemorrhoidal arteries, which were afterwards suture ligated. Operating time as well as per- and post-operative complications were anlyzed. Follow-up was planned following discharge after 1 week, 1 month, 6 months and 1 year.
Results: mean operation time was 27 (range 18-43) minutes, and 5 (range 4-7) arteries were located on average. No patient had severe or moderate postoperative pain, with anal discomfort being the main complaint. Rectal bleeding and tenesmus were the commonest post-operative complications. After one year of follow-up, 19 patients were free of symptoms and 6 of them had significant symptom relief. According to grade, the technique failed in just 3 grade III patients, but in as many as 4 grade IV hemorrhoid cases.
Conclusions: doppler-guided hemorrhoid artery ligation is an easy-to-perform technique that is well accepted by patients and has good results for grade III hemorrhoids.
Key words: Hemorrhoids. Hemorrhoid artery ligation. Doppler.
Ramírez JA, Aguilella V, Elía M, Gracia JA, Martínez M. Doppler-guided hemorrhoidal artery ligation in the management of symptomatic hemorrhoids. Rev Esp Enferm Dig 2005; 97: 97-103.
Recibido: 01-03-04.
Aceptado: 11-05-04.
Correspondencia: José Manuel Ramírez Rodríguez. Sección de Coloproctología. Servicio de Cirugía General y Digestiva B. Hospital Clinico Universitario. C/ San Juan Bosco, 15. 50009 Zaragoza. Tel.: 976 556 400. e-mail: jramirez@unizar.es
INTRODUCTION
]]> Hemorrhoidal disease remains the commonest pathology in any proctological outpatient clinic, and is an important problem of public health. Current knowledge accepts that hemorrhoids originate in the normal anal fibrovascular cushions (1) that in number of three are already present in the embryo, and play a complementary role in fecal continence by varying their size (2). It is when the submucosal attachment fibers break down that endoanal cushions lose their control properties, engorging and sliding out of the anal canal, and originating hemorrhoidal classical symptoms, mucosal prolapse and anal bleeding (3). According to this, once the local management has failed, current surgical treatments are intended to either correct or remove the sliding hemorrhoids.An innovative therapy for symptomatic internal hemorrhoids has been recently proposed (4) -it relies on the reduction of hemorrhoidal vascular flow by suturing hemorrhoidal arteries, which are previously located by means of an ultrasound transducer.
In the present paper we report the long-term results we have had using the Doppler-guided hemorrhoid artery ligation (DGHAL) technique for symptomatic hemorrhoidal disease.
MATERIAL AND METHOD
Thirty-two patients (17 women) with a mean age of 43 (range, 26-76) years were included in the study -27 (85%) complained of grade-III hemorrhoids (the prolapse needs manual reduction), and 5 (15%) were classified as grade IV (hemorrhoids are permanently prolapsed). Rectal bleeding was the main symptom in all cases. Most of them were continent and just three cases from the grade-IV group had to use a pad due to occasional soiling.
Patients were fully informed about the surgical technique and their written consent was required.
A Fleet 250 ml enema was the only preoperative preparation.
Even knowing that DGHAL is a procedure that may be performed under local anesthesia, we decided to operate under spinal anesthesia following our protocol for hemorrhoids. Patients were placed in the gynecological position.
To carry out the operation we used the KM-25 (Vaidan Medical Corp, Florida, USA) equipment especially designed for DGHAL. It consists of a 12 cm-long transparent proctoscope with a lateral window on its tip coupled with an ultrasound transducer. The proctoscope is linked to an amplifier and a light source (Fig. 1).
Patients were discharged on the same day, and all of them were advised to be on a high fiber diet and to use painkillers when necessary.
Patients were requested to complete a visual analog scale for pain (0 painless, 10 maximum bearable pain) to score pain every day for the first postoperative week and after the first motion. Follow-up was planned at one week, and then at six and twelve months.
RESULTS
Mean operation time, as measured since the insertion of the proctoscope until arterial sounds were no longer heard, was 27 min (range, 18-43). On average five arteries were located (range, 4-7), and six ligatures (range, 4-10) were used. No operative complications happened.
Regarding postoperative pain, results are shown in figure 2. No patient complained of either severe or mild pain, and all of them were totally painless one week after the operation.
In six cases, there was limited anal bleeding during the first postoperative week, and tenesmus disturbed four patients. There was also an episode of hemorrhoidal thrombosis and an acute anal fissure, and both of these cases were solved with conservative treatment.
The long-term results are shown in table I. In all, 19 patients were symptom-free, 6 had significant clinical relief, and just in 7 patients the operation did not solve any of the symptoms. When patients were grouped according to hemorrhoidal stage, 24 out of 27 with grade-III involvement had very good or good results; however only 1 out of 5 subjects with grade-IV disease was pleased with the operation.
DISCUSSION
It is important to point out that hemorrhoids are normal functional and anatomical structures that do not need treatment. In fact, when possible, they must be left in place due to their role in continence. Surgical management should only be considered when symptoms are present, particularly anal bleeding.
A huge number of treatments for symptomatic hemorrhoids have been proposed, and as the understanding of their etiology -as well as technology- improves, the number of therapies increases. In any case, it is important to bear in mind that the hemorrhoidal syndrome is a benign disease and its management should be as minimally aggressive as possible. According to this, local therapies should be selected as first-line treatments, and they suit nearly 90% of patients attended in outpatient clinics (5). For the rest, surgery is the option. Traditionally, hemorrhoidectomy has been the elective technique; however, it is related to serious postoperative complications such as severe anal pain, bleeding or even incontinence (6,7).
Recently a new approach has come to the arena, namely circular stapler anopexy (8), the idea of which is to preserve the vascular cushions and to reposition them into the anal canal. The reported results of this technique show it is significantly less painful that hemorrhoidectomy (9,10).
More recently, the work of Morinaga (4) on the use of a Doppler transducer to locate hemorrhoidal arteries and its effectiveness in the management of symptomatic piles is gaining consideration. In fact, the idea of decreasing the vascular supply to the hemorrhoidal plexus is far from being new, and even sclerotherapy is somehow based on this principle. Moreover, in the early 1970s the role of arteriovenous anastomoses in the pathogenesis of piles was recognized (11,12). The theoretical grounds of DGHAL have been sufficiently proven and served Galkin et al. (13) for treating symptomatic hemorrhoids with good results by endovascular embolization of the upper hemorrhoidal artery.
Apart from the already-mentioned innovative paper by Morinaga, a review of the literature shows few studies on DGHAL, none in our country. In a pioneering study on 60 patients (14), significant symptom relief was achieved in 90% of them, with a minimal rate of complications (the commonest was perirectal thrombosis); there were no cases of impacted feces, urinary retention, or incontinence disturbances. However, the study did not rely on a homogeneous series of patients, and the inclusion of patients complaining of grade-II hemorrhoids may explain the good overall results with a failure rate of just 3.3%.
]]> In our study, we decided to include only patients with permanent prolapsed piles or prolapsed piles that needed manual reduction, as in these cases the surgical indication deserves little discussion and DGHAL has to prove its benefits; there are much less aggressive techniques (banding, sclerotherapy, etc.) for grades I and II, and these should be the first-line treatment. Using this selection criteria, in our hands the procedure obtained good or very good results in 78% of cases. Considering only grade-III hemorrhoids, results were good or very good in 90% of patients. On the other hand, an interesting piece of data from our study, which should be taken cautiously due to the small number of cases, is that DGHAL has little if any value for permanent prolapsed hemorrhoids; in such cases, a different technique should be offered.Our results are similar to those presented by Arnold et al. (15) in the largest series on DGHAL reported thus far. The study is based upon 105 patients, 78 cases with grade III and 9 cases with grade IV hemorrhoids. Overall the technique failed in 10.4% of cases; this rate increased to near 70% in the grade-IV group.
A randomized study came out recently (16) comparing DGHAL versus hemorrhoidectomy. DGHAL showed much less anal pain, shorter hospital stays, and early return to work. Long-term recurrence rates were similar in both techniques.
According to our study, we support these results. In fact, all patients from our series were nearly pain-free after the operation, and were able to return to their normal life immediately. The most frequent postoperative complaints were mild anal discomfort, tenesmus, and limited rectal bleeding.
For most authors DGHAL failures result from poor technique performance, leaving behind an arterial branch unsutured. In this regard, Aigner et al. (17) showed in a detailed work that the terminal branches of the superior rectal artery have frequent unexpected variants. They pointed out the necessity of suturing all these branches for a correct procedure. Certainly, we agree on this analysis, but most failures happen in grade-IV patients; in such cases the main problem is a mucosal prolapse (not bleeding), and even with an appropriate technique the prolapsed mucosa remains in place, along with symptoms.
In conclusion, DGHAL is a simple and well-tolerated, easy to use technique with few postoperative complications. It has proven highly effective when used on patients with grade-III hemorrhoids.
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