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03-5156-mcDoppler-guided hemorrhoidal artery ligation
(DG-HAL): a safe treatment of II-III degree
hemorrhoids for all patients.
Could it be potentially also good prophylaxis?
Aim. Doppler-guided hemorrhoidal artery lig-
Department of Surgery, S. Peter Hospital ation (HAL Doppler) is an innovative hemor-
rhoid treatment mainly utilised for II-III degree
where bleeding is a predominant symptom.
This procedure aims at dearterialization of the
internal hemorrhoidal plexus by ligation of
®FBF, Rome, Italy
2Pediatric Surgery Unit, G. Salesi Children’s Hospital, Ancona, Italy the terminal branches of the superior rectal
artery detected using a special proctoscope and
ultrasound system; the procedure is performed A
which are a contraindication to the usual sur-
ely above the dentate line, so it is gen-
gical treatments. Moreover, they suppose the
uinely painless. The aim of this study was to
use of HAL Doppler in low degree hemorrhoids
evaluate the efficacy, safety and invasivity of
as a therapeutic and also prophylactic rule of
HAL Doppler technique to treat II and III degree
Methods. The authors treated 148 patients, from
Key words: Doppler - Hemorrhoids - Hemor-
May 2002 to December 2007, principally affect-
rhage - Vascular factor.
ed by II-III degree hemorrhoids characterized
by bleeding and pain at evacuation. These
patients were examined in a retrospective
observational study of 128 patients, 86% of the
group. Follow-up varied from 5 up to 72
gains interest. This is due to diffusion in months with an average observation time of
the population and to a constant search for 36.5 months.
more effective, less traumatic methods prin- Results. Success was registered in 90% of
cipally free of risk of early or later complica- patients affected by II-III degree hemorrhoids
tions. Some postoperative complications are and the absence of major complications (hem-
orrhage, incontinence, stenosis, perforation,
disease symptomatology as described in lit- Conclusion.
The authors suggest the safety, effi-
erature. Further, these complications are often cacy and low invasity of HAL Doppler for treat-
difficult to resolve: cases of fatalities were ment of II-III degree hemorrhoids, which also
found in the literature, and highlight its use in
Considering this it is easy to understand treating patients with unhealthy conditions
the recent tendency to seek methods of oper-ation which treat the early stages of hemor- Received on September 30, 2009.
Accepted for publication on June 1, 2010.
rhoidal disease where, the hygienic-behav-ioral therapy together with pharmacologicalsupport are ineffective with the symptoma- Corresponding author: A. Testa, MD, via Cassia 987, 00189 DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION TABLE I.—Total cases inserted in follow-up: 128. brilliant, distinctly innovative invention for Morinaga;4 he described the experience of patients affected by hemorrhoids with bleed- ing on a 1995 publication. Morinaga was ableto detect the branches of the upper and medi-an hemorrhoidal arteries in those patients, TABLE II.—Preoperative symptoms. using Doppler technology applied to a proc-toscope. He then performed sutures on the vessels with absorbable stitches verifying the TABLE III.—Number of vessels stitched for surgical ses- immediate and significant. The result, visi- ble to the patient, was a drastic reduction or indeed disappearance of the bleeding symp- tom from the early postoperative days.
Diverse interesting publications appeared about the encouraging results obtained in several series of cases in North American 5 and European centers,6-10 as described in the literature of the recent years. This aspect, A
V One-hundred and four patients (81%) had
together with the persuasion that the vascu- preoperative pain at evacuation, 120 (94%) lar aspect is definitely the core factor in hem- had bleeding and 100 patients (78%) had a orrhoidal pathogenesis, led us to use HAL prolapse of III and IV degree (Table II).
Doppler for selected patients, obtaining total- The aim of this study was to evaluate the efficacy, safety and invasivity of HAL Doppler ed in 106 cases, and local anesthetic was technique to treat II and III degree hemor- used in 14 cases (11%), using a 33% Naropin solution (perineal procedure sec. Marti) withsedation (propofol or ipnovel). The durationof the operation varied from 25 to 45 minutes.
Materials and methods
As to the number of ligatures performed, 4 to 6 ligatures were inserted in 16 cases (13%), The study enrolled 148 patients who under- 6 to 8 ligatures in 100 cases (78%), and 8 to 10 ligatures in 12 cases (9%) (Table III). COPYRIGHT
December 2007: 128 (86%) were included in The patients were discharged on the day of our retrospective observational study; they the operation (at least 6 hours after the oper- ation) in 20 cases (16%), and the morning females), and heterogeneous by age (25 to 78 after in the other 108 cases (84%) with refer- ence “one day surgery” procedure.
rhoids, 92 (72%) showed III degree hemor- were performed simultaneous to the DGHAL; rhoids (sec. Goligher). A total of 116 out of 8 due to the presence of anal fissure (fissure 128 cases treated were primitive hemorrhoids excision and minimal internal sphincteroto- and 12 were relapses (8 cases after multiple my) while 8 were due to the presence of a sessions of rubber band ligation and 4 after polypus in the anal canal (excision).
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION TABLE IV.—Postoperative pain analysis at one week. TABLE VI.—Total recurrences and its distribution. TABLE V.—Return to normal daily activity after sur- TABLE VII.—Disappearance of preoperative bleeding and, performed as follows: the first check There was pain up to the seventh day in 8 was performed 12 hours after the operationfirst verifying pain and post-operative bleed-ing or hematoma via rectal exploration.
Painkiller consumption was analysed (Ketoro-lac 30 mg e.v.), urinary function, and the patients (6%) and beyond the seventh dayfor a further 8 patients (6%) with additionalprocedures who took a daily 30 mg dose of examination of changes in preoperative A
Of the 104 patients with preoperative pain, V 96 indicated a complete absence of pain after
the HAL Doppler procedure after the firstweek (P<0.001).
symptoms, especially for bleeding, and con- sidering postoperative symptomatology con- As to a return to daily activities, the team Further follow-up visits were effected up to noticed that 56 patients (44%) returned to their regular activities within three days of the operation, 44 patients (34%) by the sev- contacted in May 2008, and asked a set of enth day, and 28 patients (22%) returned to their regular activities after a week (Table V).
pain, prolapse, and their degree of satisfaction All relapses in the group, 20 patients (16%) were registered at the six-month follow-up.
patients in the IV degree hemorrhoids group A statistical evaluation of the results was (100%), 12 patients in the III degree hemor- rhoids group (13%), no patients with II degree COPYRIGHT
hemorrhoids had a relapse (Table VI).
operatively in 120 patients disappeared com- pletely at the six month check in 100 patients of urinary retention were recorded at the ini- (P<0.001); 50% disappearance of bleeding tial postoperative visits within 12 hours of was observed in eight patients (7%), and per- the operation. Analysis of postoperative pain sistent bleeding in 12 patients (10%) (Table indicated an absence of pain in 96 of 128 patients after one week; while 16 patients (12%) reported pain in the first three days patients, 92 cases of III degree prolapse were required a daily 10 mg dose of Ketorolac.
examined: total resolution was registered in DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION TABLE VIII.—Resolution of III degree prolapse after HAL evaluation of the HAL Doppler, is the degree of satisfaction expressed by patients. Eighty-four (66%) stated that they were satisfied, 24 (19%) reasonably satisfied, four patients (3%) not particularly satisfied while 16 patients(12%) said they were dissatisfied (Table X).
months, was observed during the annualcheck up.
TABLE IX.—Postoperative complications. Discussion
Hemorrhoidal pathology is an area in con- description and treatment, aiming at achiev- ing better, more concrete, lasting results using increasingly less traumatic techniques. At pre- TABLE X.—Degree of satisfaction. of controversy. On the one hand there is a 24/128 (19%) A
theory which recognizes alteration of theParks ligament, the support frame of the inter-nal hemorrhoidal plexus, as the “primum V movens” of hemorrhoidal prolapse, which is
responsible for the symptomatology sequel in On the other, several studies regarding the vascular anatomy of the rectal anal canal 60 patients (P<0.001), a 50% reduction in 20 support a different theory. The most inter-esting of these is the work carried out by Aigner in 2006.13, 14 He subjected a group of patients (13%) (Table VIII). There was relapse patients with the four different degrees of research of the distant branches of the upper haemorrhoidal artery. Aigner compared them postoperative fissures was observed in eight with a group of patients who were included in the check, not affected with the patholo- (excision), the other four with anal dilata- gy. The study highlighted a structural alter- ation in the branches examined. In the first COPYRIGHT
were observed in certain patients who used mented calibre and were bearers of greater arterial flow to the entire haemorrhoidal plexus. The factor examined is called “vas- Further, four cases of proctitis were record- cular” and it becomes increasingly impor- ed and were treated with topical antinflam- tant in direct proportion to the degree of the illness studied. In Aigner’s paper, the values It can be stated that other complications as of both calibre and of arterial flow were rectal anal stenosis, incontinence, abscesses, iatrogenic perforation of the rectum, were not present in our cases (Table IX).
We are persuaded that the vascular factor In our opinion, a significant parameter for is determinant for hemorrhoidal pathogene- DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION sis and that the prolapsing character is an ence manoeuvre into the rectal anal canal effect of the volumetric increase with the rel- above the ano-rectal line not only at the lev- ative encumbrance of the haemorrhoidal piles el of the principal hemorrhoidal piles, which into the anal canal at the internal plexus lev- occupy those positions at hours 3, 7, 11, in el. Problems at evacuation impact all those the gynecological position, but also at the factors: even the tone alteration at rest of the terminal vessels level, which can be detect- ed in the interposed seats. Thus treatment of those sectors which are generally left as dur- We, therefore, think that precise suture of ing an hemorrhoidectomy for the integrity ever, cause relapse is also effected.
line and thus over the internal hemorrhoidal plexus (the technique is extensively described cessfully in some cases of relapse (4 cases of Milligan-Morgan); the patients complained to the reader),16, 17 may be the moment for of renewed bleeding after evacuation, due patients when the initial pathogenic hemor- to congested hemorrhoidal piles. Significant rhoidal process is finally terminated. Rapid improvement was rapidly obtained after the ultrasound verification of the suturing per- formed assures the result of treatment of thevascular factor.
The present study indicates that it is pos- sible to obtain far more satisfying results in In analysing the cases studied by our team, consistent with those described in the litera-ture, it is clear that the eventual complica- patients affected by II and III degree hemor-
rhoids with bleeding as the principal symp-
tom. Indeed, the degree of satisfaction was A
tions and relapses recorded in our study allappeared within the first six months of our V follow-up. The results registered after this
assume a favorable predictory value if pro- reduced to a minimum (disappearance of all jected into a longer observation time.
symptoms linked with the procedure in 88% after the third day, postoperatively); a return the operation and the almost total absence of to normal daily activities was registered by complications, lead to possible treatment of seventh day after operation, in some 80% of patients with severe pathology types which are disabling. Hemorrhoidal problems ren- der their quality of life worse, with painful seemed the total absence of early or later complications, by contrast with other con- patients, patients already incontinent due to Milligan Morgan procedures): postoperative prior surgical operation or trauma, patients hemorrhoidal stenosis, damage to anal con- with hepatic or hematological problems. The tinence, postoperative pain, urinary reten- extant illness is, in these cases, an effective contraindication for the demolishing manoeu- COPYRIGHT
vres of surgical resection at the level of the remains totally intact after the HAL Doppler rectal anal canal for excision of hemorrhoids, procedure; any eventual future operation in as the case of hemorrhoidectomy or stapled this anatomic site will not find any scar defor- repeated in the future given the absence of surgical trauma, in the case of complete or upper hemorrhoidal artery blocks arterial flow to the internal hemorrhoidal plexus.
It is interesting to notice that HAL Doppler development of the events which lead unre- DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION lentingly to the most advanced stages of hem- the most precocious degree of haemorrhoidal orrhoidal illness. That is true and evident in illness. With this technique both a therapeu- patients with structural alterations character- tic procedure and prophylaxis of the most ized by augmented calibre and flow which is advanced degree of hemorrhoidal illness may Eventually, when a group of at risk patients is recognized by simple transperineal ultra- Riassunto
sound study (as demonstrated by Aigner),our team considers treatment with the HAL Legatura Doppler-guidata delle arterie emorroidarie Doppler technique proper and suitable for (DG-HAL): un trattamento sicuro del II-III grado emor- those patients, since there is absence of sur- roidario per tutti i pazienti. Potrebbe potenzialmen- gical trauma and total absence of major com- te avere anche un ruolo nella profilassi? plications. This HAL Doppler treatment not Obiettivo. La legatura Doppler-guidata delle arte- only assumes therapeutic significance but it rie emorroidarie (hemorrhoidal artery ligation, HAL Doppler) rappresenta un trattamento innovativo perla patologia emorroidaria ed è principalmente utiliz- the more advanced stages of the illness. The zata per le emorroidi di II e III grado associate a san- question of hemorrhoidal prolapse is differ- guinamento. Questa tecnica mira alla dearterializza- ent as it requires treatment capable of direct- zione del plesso emorroidario interno mediante la ly correcting the prolapse, especially in III legatura dei rami terminali dell’arteria rettale superiore advanced degree or IV degree cases; the ver- utilizzando uno speciale proctoscopio ad ultrasuo- ification effected by our team indicates that ni. Tale procedura è eseguita interamente al di sopradella linea pettinata e pertanto non provoca dolore.
hemorrhoidal prolapse only partially benefits Scopo di questo studio è valutare la sicurezza, l’effi- from arterial ligation and only in the initial cacia e la bassa invasività di questa tecnica nel trat- postoperative period, whence it reappears tamento delle emorroidi di II-III grado.
albeit with minor improvement in the symp- A
Metodi. Gli autori hanno trattato 148 pazienti, da V maggio 2002 a dicembre 2007, affetti principalmen-
te da emorroidi di II-III grado, caratterizzate da san-guinamento e dolore all’evacuazione. Questi pazien- Conclusions
ti sono stati inclusi in uno studio osservazionale retro-spettivo; tale studio ha riguardato 128 pazienti pari The results of our study definitely appeared all’86% dei casi trattati. Il follow-up varia da 5 a 72 coherent with the data reported in the liter- mesi con un tempo medio di osservazione di 36,5 Risultati. È stato registrato un successo del 90% nei pazienti affetti da emorroidi di II-III grado con easy to perform; in our opinion, it is a first assenza di complicazioni maggiori (emorragia, incon- choice treatment in the therapy of II and III tinenza, stenosi, perforazione, sepsi).
degree hemorrhoids characterised by bleed- Conclusioni. Gli autori indicano, come dimostra- ing. Indeed, it surpasses the surgical alterna- to in letteratura, un ruolo efficace, sicuro e poco inva- tives (hemorrhoidectomy or prolassectomy) so dell’HAL Doppler nel trattamento delle emorroididi II-III grado e ne sottolineano un opportuno impie- with reference to operative trauma, compli- go nei pazienti affetti da patologia associate per le cations and postoperative comfort, obtain- quali è controindicato il trattamento chirurgico stan- COPYRIGHT
dard. Infine, gli autori ipotizzano nelle emorroidi di Moreover, we believe that it is important to basso grado un ruolo, per HAL Doppler, oltre che extend the indication for this technique, espe- terapeutico, anche profilattico, dei gradi più avanza- cially due to its low invasiveness, even to patients with neurological, hepatic and hema- Parole chiavi: HAL Doppler - Emorroidi - Emorragia - tological problems, who are often excluded from conventional treatments due to the highrisk of complications. References
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Dr. Annette Olsen Professional qualifications • M.Sc. Biology (Parasitology), University of Copenhagen, 1985 • Ph.D. degree in biology (Parasitology), University of Copenhagen, 1999 • In 2004 evaluated and found qualified as associate professor in epidemiology at the Department of Epidemiology, Institute of Public Health, University of Copenhagen Current position Senior Research