Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance / Distribución de las arterias hemorroidales en pacientes con hemorroides de grado III y IV tratados mediante ligadura arterial y reparación rectoanal. Evaluación del guiado Doppler

Introduction: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. Methods: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. Results: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21–84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2–12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1–4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. Conclusions: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.(AU)

Introducción: Aunque la desarterialización hemorroidal y mucopexia es técnica aceptada como alternativa válida a la hemorroidectomía, existen divergencias en lo que se refiere a una localización fija o variable de las arterias a ligar. Nuestro objetivo ha sido arrojar luz sobre esta cuestionada distribución arterial en pacientes quirúrgicos. Métodos: Se han incluido consecutivamente pacientes con diagnóstico de hemorroides de III y IV grado operados mediante desarterialización hemorroidal guiada por Doppler (D-HAL) y reparación rectoanal (RAR) en dos centros hospitalarios españoles. El principal objetivo fue evaluar el número necesario de ligaduras arteriales y su localización horaria para conseguir un silencio Doppler. Resultados: Se han incluido consecutivamente 146 pacientes, 111 (76%) varones y 35 (24%) mujeres, con una media de edad de 54 años (21–84), 106 (73%) fueron diagnosticados como grado III y 40 (27%) como grado IV. La media de ligaduras por paciente fue de 7 (2–12). Se encontraron porcentajes de ligaduras superiores al 60% en las posiciones horarias 7, 11, 10, 12, 9 y 1. La media de mucopexias por paciente fue 3 (1–4), siendo las localizaciones más frecuentes los octantes posterior izquierdo, posterior derecho y anterior derecho. Conclusiones: Aunque los puntos horarios impares son los de mayor frecuencia de localización arterial, porcentajes no despreciables de localización ocurren en las posiciones pares lo que, en nuestra opinión, hace que el uso del Doppler sea necesario dado que la distribución arterial no es constante en todos los pacientes. Hemos podido constatar también que en la semicircunferencia derecha han sido necesarias más ligaduras y pexias que en el lado izquierdo, lo que sugiere una mayor vascularización derecha.(AU)

Long-term results and quality of life after stapled hemorrhoidopexy vs Doppler-guided HAL-RAR: a propensity score matching analysis.

AIM: The study aimed to evaluate and compare the short and long-term outcomes of doppler-guided (DG) hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) using a wireless-doppler-guided probe and stapled hemorrhoidopexy (SH) for treatment of II-III hemorrhoids. METHODS: This cohort study included patients who underwent HAL-RAR (n = 89) or SH (n = 174) for grade II-III hemorrhoids between January 2020 and December 2021. After propensity score matching at a 1:1 ratio, 76 patients for each group were analyzed. Short and long-term outcomes were collected. Pain was measured using a Visual Analogue Scale (VAS) at POD1, POD 10, 1 month, and 6 months after surgery. The enrolled patients completed the Hemorrhoidal Disease Symptom Score and Short Health ScaleHD quality of life (HDSS/SHS QoL) questionnaire preoperatively and during a regular follow-up visit at 24 months after surgery. RESULTS: Groups exhibited comparable overall postoperative complication rates (23% HAL-RAR/ 21% SH; p = 0.295). Postoperative pain via VAS showed median scores of 4, 3, 1, 1 for HAL-RAR and 6, 4, 2, 1 for SH at POD1, POD10, 1 month, and 6 months, respectively (p = < 0.001, 0.004, 0.025, 0.019). At a median follow-up of 12 months, the recurrence rate was 10.5% in the HAL-RAR group and 9.2% in the SH group (p = 0.785), respectively. At 24 months, 15.7% of HAL-RAR patients and 19.7% of SH patients remained symptomatic (p = 0.223). Median post-op QoL index was 1 (HAL-RAR) and 0.92 (SH), p = 0.036. CONCLUSIONS: HAL-RAR is a safe and feasible technique in treating grade II-III hemorrhoids showing better outcomes in terms of postoperative pain and QoL. SIGNIFICANCE: This paper adds a new perspective in comparing the HAL-RAR and SH, focusing the attention on the patients and not surgical techniques. A long and difficult follow-up was completed to fully understand the long-term results and the impact on the QoL of the patients who underwent these procedures.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance.

INTRODUCTION: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. METHODS: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. RESULTS: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. CONCLUSIONS: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.

Clinical efficacy of ultrasound doppler-guided hemorrhoidal artery ligation combined with procedure for prolapse and hemorrhoids in treatment of severe hemorrhoids.

Hemorrhoids are a prevalent anorectal condition that affects a wide range of adult populations. The severity of this condition was graded using a validated hemorrhoidal grading system, specifically focusing on grade III and IV cases. This retrospective study aimed to compare the clinical efficacy of a standard Procedure for Prolapse and Hemorrhoids (PPH) with a combined Doppler-guided Hemorrhoidal Artery Ligation (DG-HAL) and a PPH approach in patients with severe hemorrhoids. Conducted from May 2021 to January 2023, the study included patients aged 18-65 with confirmed diagnosis of Grade III or Grade IV hemorrhoids. Patients with a history of anorectal surgery and significant comorbidities were excluded. The control group underwent standard PPH, whereas the observation group received DG-HAL followed by PPH. Clinical outcomes were measured using variables such as the operative duration, intraoperative blood loss, postoperative wound healing time, and length of hospital stay. Efficacy was evaluated using a hierarchical scale and a visual analog scale (VAS) for postoperative pain. The complication rates were also assessed. baseline characteristics were homogeneous between the 2 groups. The observation group demonstrated significantly faster postoperative wound healing and shorter hospital stay (P < .01). The overall therapeutic efficacy in the observation group was 90.0%, which was higher than that of the control group (75.0%; P = .025). The VAS pain scores were also significantly lower in the observation group (P = .002). A marked decrease in complication rates was observed in the observation group (3.3%) compared with that in the control group (17.9%) (P < .05). The combined DG-HAL and PPH surgical approach exhibited superior clinical efficacy in treating severe hemorrhoids. This technique offers high effectiveness, reduced postoperative VAS pain scores, and lower complication rates. The long-term efficacy requires further observation.

Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center.

PURPOSE: To evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. MATERIALS AND METHODS: Retrospective analysis of 134 patients who underwent hemorrhoidal artery embolization (HAE) for symptomatic internal hemorrhoids between August 2021 and June 2022 (76 men and 58 women) was performed. The mean age was 54.9 years, with a mean Goligher hemorrhoid grade (HG) of 2.1. Branches of the superior rectal artery (SRA) or middle rectal artery supplying the corpus cavernosum recti were embolized with both spherical particles and microcoils. Standard-of-care evaluations were performed at baseline and the 1 month follow-up, which included hemorrhoid-related pain (HRP) (0-10), hemorrhoid symptoms score (HSS) (5-20), quality of life (QoL) (0-4), French bleeding score (FBS) (0-9), and HG (0-4). Clinical success was defined as improvement of symptoms without additional treatment. RESULTS: Embolization of at least 1 hemorrhoidal artery was achieved in 133 (99%) of the 134 patients. The mean number of SRA branches embolized per patient was 2.9 ± 1.0. Clinical success was seen in 93% (124 of 134) of patients at the 1-month follow-up, with 10 patients requiring repeat embolization. There were significant improvements in all mean outcomes at 1 month: HSS (11-7.8; P < .01), HRP (4.1-1.3; P < .01), QoL (2.2-0.8; P < .01), FBS (4.4-2.2; P < .01), and HG (2.3-1.2; P < .05). There were no severe adverse events. CONCLUSIONS: HAE is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids in the short term.

Comparison Of Outcome Between Open Haemorrhoidectomy Versus Trans-Anal Doppler Guided Hemorrhoidal Artery Ligation With Recto-Anal Repair In 3rd And 4th Degree Haemorrhoids.

BACKGROUND: Haemorrhoids are very common but their exact prevalence is not known as most of the people suffering from them do not seek medical or surgical advice. The literature states their prevalence to be about 39% and commonly affect people aged between 45-65 years of age. Objective of the study was to compare the outcomes of open haemorrhoidectomy Vs Trans anal Doppler ultrasound guided hemorrhoidal artery ligation with recto-anal repair in 3rd and 4th degree haemorrhoids. It was a Randomized control trial, conducted at the Department of Surgery, King Edward Medical University, Lahore; from October 2019 to March 2021. METHODS: This was a randomized control trial study where the results of 70 patients of haemorrhoids including 3rd and 4th degree disease fulfilling the selection criteria, who underwent open haemorrhoidectomy (OH) and Doppler guided haemorrhoidal artery ligation with rectoanal repair (HAL RAR) procedure on elective and emergency operating lists, were analyzed with regards to post-operative pain, bleeding and hospital stay. RESULTS: From our seventy patients the minimum age was 23 and maximum age limit was 55 years (mean: 35.09±7.47). There were 49 (70%) males and 21 (30%) females. Mean post-op pain on day 7 for OH was 1.12±0.72 and for HAL RAR it was 1.06±0.52. Post-op bleeding (POB) occurred in 4 (10%) patients in OH group and 2(6.66%) patients in HAL RAR group. Mean hospital stay for OH group was 2±0.45 and for HAL RAR it was 1.20±0.40, for POB, it was 1.9±0.30 in OH group and 1.86±0.34 in HAL-RAR group. CONCLUSIONS: There was no significant difference in mean post-op pain on day seven, and post-op bleeding, but there was significant difference in terms of mean hospital stay between the two groups.

The Utility of Submucosal Linear Enhancement on Dynamic Computed Tomography for Patients With Internal Hemorrhoids.

OBJECTIVE: The purpose of this study was to evaluate the utility of submucosal linear enhancement on dynamic computed tomography (CT) for patients with internal hemorrhoids. METHODS: We retrospectively reviewed patients who were admitted to our institution due to acute lower gastrointestinal bleeding and underwent both dynamic CT and colonoscopy. The presence of submucosal linear enhancement of the intestinal wall from the lower rectum to the anal canal was evaluated using arterial-phase CT images. Based on these images, patients were then classified into 2 groups by 2 blinded radiologists, as follows: group A (absence of submucosal linear enhancement) and group B (presence of submucosal linear enhancement). The relationship between the groups and the risk of bleeding in internal hemorrhoids was evaluated using the size and range of internal hemorrhoids measured during colonoscopy as reference standards. RESULTS: A total of 94 patients were reviewed; of these, 62 patients without submucosal linear enhancement were classified into group A, and 32 patients with submucosal linear enhancement were classified into group B. Group B showed a significantly greater range ( P = 0.017) and size ( P = 0.002) of internal hemorrhoids. The Cohen κ coefficient value for the group classifications between the 2 radiologists was 0.66. CONCLUSIONS: Submucosal linear enhancement on arterial-phase CT images could be a predictive finding suggesting the presence of internal hemorrhoids with a high risk of bleeding.

Clinical Outcomes Following Rectal Artery Embolisation for the Treatment of Internal Haemorrhoids: A Systematic Review and Meta-Analysis.

OBJECTIVES: Haemorrhoidal disease (HD) is a common anorectal disorder which can substantially impair quality of life. Rectal artery embolisation (RAE) is a recently described technique for the management of HD, however, its clinical efficacy and safety are unclear at present. The objective of this systematic review and meta-analysis is to evaluate the clinical outcomes following RAE. METHODS: The PubMed, MEDLINE and EMBASE databases were searched for studies specifying the management of haemorrhoids with RAE from January 2000 to October 2021. Primary outcomes were: French bleeding score (FBS), Visual analogue scale (VAS) for pain, general quality of life (QoL) score, and the Goligher prolapse score (GPS). Secondary outcomes were technical success, clinical success, postoperative complications, and technical outcomes. A random-effects meta-analysis was conducted. Study heterogeneity was evaluated, and sensitivity analysis was performed. RESULTS: Thirteen eligible studies were identified including 381 patients. Rectal artery embolisation was associated with improvements in the FBS (mean difference [MD] 2.66; 95% confidence interval [CI] 2.10-3.23), VAS (MD 1.92; 95% CI 1.58-2.27) and QoL (MD 1.41; 95% CI 1.20-3.80), although the grade of internal haemerrhoids increased with uncertain clinical significance (MD 0.30; 95% CI 0.23-0.36). Technical success was achieved in almost all procedures (99%; 95% CI 94-100%) however clinical efficacy was lower (82%; 95% CI 73-89%). Procedural duration and radiation exposure were heterogeneous. No major complications occurred. CONCLUSION: RAE demonstrates early clinical efficacy with low rates of peri-procedural complications or morbidity. RAE is a promising addition to the treatment options available for HD and warrants ongoing research.

Does choroidal thickness change in advanced hemorrhoids patients?

BACKGROUND: This study was conducted to examine the choroidal thickness of patients with grade 4 hemorrhoids to see if vascular abnormalities in hemorrhoid patients may affect other `parts of the body. METHODS: 51 patients diagnosed with grade 4 hemorrhoids in the last two years and 49 healthy volunteers were included. Choroidal evaluation was done by measurements from various points of the choroid using a spectral domain Cirrus HD-OCT (Carl Zeiss Meditec Inc.) in enhanced-depth imaging mode. Choroidal thicknesses were compared between the two groups. RESULTS: Nasal choroidal thickness, temporal choroidal thickness and mean choroidal thickness measurements were significantly higher in the hemoroid group (p<0.05), while subfoveal choroidal thickness did not differ significantly between the groups. Macular thickness was also significantly higher in the hemoroid group compared to the control group (p<0.05). CONCLUSION: There was an increase in choroidal thickness in patients with grade 4 hemorrhoids. KEY WORDS: Choroidal thickness, Hemorrhoids, Macular thickness, Optical coherence tomography, Vascular pathologies.

Embolization of Hemorrhoidal Arteries: A Novel Endovascular Therapy Option for the Treatment of Hemorrhoidal Disease. / Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden.

BACKGROUND: Hemorrhoids are a widespread disease. Treatment options range from dietary measures to open surgery. A novel treatment approach is the embolization of the hemorrhoidal arteries. METHOD: A review was performed based on a selective literature search in PubMed representing the current state of research. The keywords "hemorrhoid" and "embolization" and "emborrhoid" were used. In addition, technical details of the hemorrhoidal embolization procedure are explained. RESULTS AND CONCLUSION: Embolization of hemorrhoidal arteries is a safe treatment, which allows efficient symptom control even in patients with contraindications for open surgery. KEY POINTS: · Embolization of hemorrhoidal arteries is a new approach to the treatment of hemorrhoids.. · Embolization of hemorrhoidal arteries is feasible in patients with contraindications for open surgery such as hypercoaguable states and contraindications for general anesthesia.. · The endovascular approach causes no rectal and anal trauma and associated complications can be avoided.. · The treatment of bleeding hemorrhoids seems to be particularly effective.. · No ischemic complications have been reported so far when coils as well as particles were used.. CITATION FORMAT: · Feyen L, Freyhardt P, Schott P et al. Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden. Fortschr Röntgenstr 2022; 194: 266 - 271.

Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial.

BACKGROUND: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure. METHODS: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis. RESULTS: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation. CONCLUSIONS: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed.

[Hemorrhoidal artery ligation without Doppler navigation in surgical treatment of hemorrhoidal disease]. / Ligirovanie gemorroidal'nykh arterii bez ul'trazvukovoi doplernoi navigatsii v khirurgicheskom lechenii gemorroidal'noi bolezni.

OBJECTIVE: To compare the immediate and long-term results of surgical treatment of hemorrhoidal disease (GD) stage II-III using two methods of identification of hemorrhoidal arteries (HA) with their subsequent ligation and mucopexy. MATERIAL AND METHODS: A prospective, randomized, controlled, single-center study was conducted to evaluate the effectiveness of HA ligation with and without Doppler navigation. The study included 120 patients: group A - Doppler-guided ligation (n=60) and group B - ligation without ultrasound (n=60). RESULTS: GD stage II was found in 27 patients of the group A and 30 patients of the group B (p=0.4). Mean number of ligated HA in the group A was 3.36, in the group B - 2.83 (p=0.062). Mean number of mucopexy was 3.2 and 3.5, respectively (p=0.8). Mean follow-up period was 8.3±2.1 and 8.1±1.9 months, respectively (p=0.96). Relapse of all preoperative symptoms was registered in 1 patient (1.6%) in the group A. Intermittent bleeding was observed in 5 (8.3%) and 3 (5%) patients, respectively (p=0.71). Periodic hemorrhoid prolapse (GP) occurred in 6 (10%) and 4 (6.6%) respondents, respectively (p=0.74). VAS score of pain syndrome after 2 months and later was 0 - 1 points (p=1.0). Most of patients in both groups (group A - 89%, group B - 94%; p=0.7) noted that surgery did not disrupt their usual lifestyle and relieved from symptoms of GD. CONCLUSION: There are no significant advantages of Doppler-guided HA ligation compared to palpation regarding incidence of hemorrhoid prolapse (p=0.74) and hemorrhoidal bleeding (p=0.71). Pain syndrome (p=0.24), incidence of postoperative complications (p=0.51) and relapses (p=0.31) showed comparable safety of both techniques.

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence.

PURPOSE: To assess the efficacy and safety of a catheter-directed hemorrhoidal dearterialization technique for the management of hemorrhoidal bleeding. MATERIALS AND METHODS: A systematic review and meta-analysis of pubmed, cochrane, and scopus databases was conducted according to the preferred reporting items for systematic reviews and meta-Analysis (PRISMA) guidelines. Clinical studies reporting on catheter-directed hemorrhoidal dearterialization for rectal bleeding were analyzed. RESULTS: Fourteen studies (n = 362) were identified. The mean maximum follow-up duration was 12.1 months (SD, 7.31; range, 1-28; median, 12), and the mean length of hospital stay was 1.5 days (SD, 1.1; range, 0-2.5). The mean technical success was 97.8% (SD, 3.5), and the mean clinical success was 78.9% (SD, 10.5). A statistically significant reduction in the french bleeding score before and after embolization was noted (P = .004). In subgroup analysis, when the coils-only group was compared with the coils and particles group, the average rebleeding rate was 21.5% (n = 111; SD, 18.2; range, 0%-44%) versus 10.05% (N = 108; SD, 4.8; range, 5%-15.7%), respectively (P < .0001). No bowel ischemia/necrosis or anorectal complications were reported. CONCLUSIONS: The current preliminary clinical evidence suggests that catheter-directed hemorrhoidal dearterialization is an effective and safe procedure for the treatment of hemorrhoidal bleeding. The standardization of the technique and the generation of higher level evidence will be required to compare this minimally invasive procedure with more invasive surgical options for patients with grades I-III hemorrhoids and chronic bleeding.

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization.

BACKGROUND: Arterial hyperflow to haemorrhoids has been implicated as a possible pathophysiological co-factor in haemorrhoidal disease. The purpose of this study was to investigate how transanal haemorrhoidal dearterialization (THD) can influence haemodynamic parameters at the level of the haemorrhoidal piles. METHODS: Patients with grade III haemorrhoids selected for THD between July and December 2018 were evaluated using endoanal ultrasonography and colour Doppler imaging at the level of internal haemorrhoids before and 1 year after the surgical procedure. Peak systolic velocity, pulsatility index, resistivity index, acceleration time, and end-diastolic velocity were measured, and preoperative and postoperative values compared. Symptom severity was measured using a symptom-based questionnaire (score range 0-20). RESULTS: Of 21 patients treated, 17 completed the study. Compared with preoperative values, postoperative peak systolic velocity (mean(s.d.) 18.7(1.1) versus 10.3(0.4) cm/s; P < 0.05), pulsatility index (5.5(0.3) versus 2.8(0.4); P < 0.050), and resistivity index (1.0(0.2) versus 0.8(0.5); P < 0.050) decreased significantly, whereas acceleration time increased significantly (65.6(3.6) versus 83.3(4.7) cm/s2; P < 0.050); end-diastolic velocity did not change (1.9(0.2) versus 2.0(0.4); P = 0.753). Symptoms disappeared or had improved significantly in all patients by 1 year after surgery. The mean(s.d.) total symptom severity score decreased from 15.8(1.1) to 1.2(1.6) (P < 0.001). CONCLUSION: THD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

Superior Rectal Artery Embolization with Tris-Acryl Gelatin Microspheres: A Randomized Comparison of Particle Size.

PURPOSE: To evaluate the safety and efficacy of superior rectal artery embolization (SRAE) with different-sized tris-acryl gelatin microspheres in symptomatic hemorrhoidal disease (HD). MATERIALS AND METHODS: Forty-two patients (male, 30; female, 12; median age, 45 years) with symptomatic HD (2 grade I, 8 grade II, 17 grade III, and 15 grade IV) were divided into 3 experimental arms (500-700 µm, 700-900 µm, and 900-1,200 µm groups; each had 14 patients) in a prospective randomized style to perform SRAE. Follow-up was performed by rectoscopy, clinical examination, and questionnaires. The primary outcome measure was the clinical success rate at 12 months. Secondary outcome measures were technical success rate, recurrence rate, procedure-related mortality, procedure-related complications, and any outcome changes between particle sizes. RESULTS: No procedure-related deaths or major morbidities were observed. There was a 54% minor complication rate (n = 23/42) in the treated zone: 45% sustained small superficial ulcerations (n = 19/42), 7% small rectosigmoid junction ulcerations (n = 3/42), and 2% small fibrotic scar tissue (n = 1/42). The clinical success rate was 93%. Of the groups, the best French bleeding score decrease was obtained in the 900-1,200 µm group. There were improvements in the quality of life score and visual analogue scale score after the SRAE procedure, although not in the Goligher score. No recurrent disease was observed. CONCLUSIONS: SRAE with tris-acryl gelatin microspheres for symptomatic HD is a safe and efficient treatment, with results favoring the use of larger microspheres.

A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL).

PURPOSE: We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD). METHODS: The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL. RESULTS: A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m2). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65). CONCLUSION: Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.

The Management of Hemorrhoidal Disease by Dearterialization and Mucopexy.

Several minimally invasive surgical procedures have been recently developed to treat hemorrhoids without any excision. About 25 years ago, a non-excisional procedure providing doppler- guided ligation of the hemorrhoidal arteries has been proposed - named "hemorrhoidal dearterialization". The original technique has been modified over the years, and indications were expanded. In particular, a plication of the redundant and prolapsing mucosa/submucosa of the rectum (named "mucopexy") has been introduced to treat hemorrhoidal prolapse, without excision of the hemorrhoidal piles. At present, the THD® Doppler procedure is one of the most used techniques to treat hemorrhoids. Aim of this technique is to realize a target dearterialization, using a Doppler probe with the final purpose to reduce the arterial overflow to the hemorrhoidal piles. In the case of associated hemorrhoidal prolapse, a mucopexy is performed together with Doppler-guided dearterialization. The entity and circumferential extension of the hemorrhoidal prolapse guide the mucopexy, which can be considered tailored to a single patient; the dearterialization should be considered mandatory. Advantages of this surgical technique are the absence of serious and life-threatening postoperative events, chronic complications, and limited recurrence risks. The impact of the procedure on the anorectal physiology is negligible. However, careful postoperative management is mandatory to avoid complications and to guarantee an improved long-term outcome. Therefore, regular physiologic bowel movements, excessive strain at the defecation and strong physical activity are advisable.