 Journal List

 Indian J Surg
 v.74(5); 2012 Oct
 PMC3477406

Indian J Surg. 2012 Oct; 74(5): 412–417.

Published online 2012 Mar 22. doi: 10.1007/s12262-012-0461-4
PMCID: PMC3477406

Transanal Suture Rectopexy for Haemorrhoids:

Chivate’s Painless Cure for Piles
Shantikumar D. Chivate, Laxmikant Ladukar, Mahesh Ayyar, Vinayak
Mahajan, and Sunil Kavathe

Author information ► Article notes ► Copyright and License information ►

Abstract
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Introduction
Since centuries, a large number of treatment modalities for haemorrhoidal
disease are known, but none is the ideal one. The ideal treatment was not
possible without understanding the definite pathology and pathological
anatomy [1]. Intense study of pathology of haemorrhoids was carried in
the last 35 years, which led to renew interest in, by which the development
of innovative procedures occurred [2–4].
Three anal cushions are present in respective to the superior rectal end
arteries at 3, 7 and eleven o’clock in the lithotomy position. The main part
of the cushion lies just above the dentate line and is covered by sensitive
mucosa. On cross section between the cushions and internal sphincter
muscles is the submucosal layer, which consists of veins, arteries and
muscular and connective fibre tissues. The piles mass is supported by
fibroelastic collagen tissue and the muscular structure of Treitz
(muscularis canalis ani) [5]. The venous plexus present in the form of
sinusoids is known as ‘corpus cavernosum of recti’ [2]. Special
consideration of mass, prolapse and recurrence is required for the
successful cure of piles.
The pressure of the haemorrhoidal plexuses is increased due to a variety of
activities, such as straining and sitting for long periods during bowel
movements, lifting heavy objects, obesity and severe coughing. Straining
during defaecation causes the anal sphincters to relax and simultaneously
portal veins that are without valves are engorged. The veins exit through
the seromuscular wall of the rectum drain into the portal tributaries. These
portal veins are trapped and blocked in the seromuscular wall during
strong contraction of the rectum during defaecation. At the same time,
arterial blood supply is continued, which keeps on engorging
haemorrhoidal plexus and piles mass progressively [6]. Rectal bleeding is
the main symptom of internal haemorrhoids. The blood is
characteristically bright red. It has been suggested that the internal
haemorrhoid plexus is like corpus cavernosum with direct arteriovenous
communications [7]. The blood is filtered without metabolic activity and,
therefore, it remains arterial, which is bright red in appearance and has a
pH of arterial blood [8]. The vascular theory explains why piles mass
increases in size.
The microscopic examination revealed that connective tissue fibres of the
submucosa are main factors that anchor the piles cushion to the internal
sphincter and longitudinal muscles of the rectum. The muscular-fibro
elastic supporting tissues of the piles cushion (Parks ligament) are
degenerated due to familial disorder or old age or loose elasticity due to
constant stretching during straining while defaecating [9]. As the piles
mass protrude out of anal canal the mucosal covering becomes fragile,
which bleeds easily. The fixation of these loose prolapsing piles cushions
has been understood to be the main principle of newer modalities of
treatment of haemorrhoids such as stapler and Doppler Guided
Haemorrhoid artery Ligation (DGHL).
The procedure was first described by Dr. Antonio Longo in 1993. It avoids
wounds in the sensitive perianal and anal areas and, as a result, has the
advantage of significantly reducing the postoperative pain [10]. Longo’s
procedure depends on shortening of long prolapsing tissue and fixing of
cushions to their original position by auto-suturing above the dentate line
[11–13]. In 1995, Morinaga reported a new technique for the
haemorrhoidal artery ligation (HAL), in which specially designed
proctoscope attached with a Doppler transducer is used for identification
and ligation of haemorrhoidal arteries. Because the arteries carrying the
blood inflow are ligated, internal pressure of the plexus haemorrhoidalis is
decreased [14].
All the existing procedures have a recurrence rate varying between 18 %
and 60 %. It is difficult to assure the patient that haemorrhoids are curable.
In all procedures, haemorrhoidal vessels are occluded at one place and that
is the major cause of recurrence. When an artery is ligated the viability of
the parts supplied by it depends on the efficacy of the development of the
collateral circulation. The latter is an accessory circuit that consists of pre-
existing branches of the artery above and below the site of the occlusion.
The anastomosis occurs with each other through their smaller branches
(mid-zone vessels), which normally have a resistance to forward flow.
However, in the event of an occlusion in the main vessel, the pressure
distal to the occlusion drops and this allows reversed flow into the
branches arising below the obstruction. The end result is physical
enlargement of these collaterals that allow increased forward flow to
nourish the area distal to the obstruction [15, 16]. The main etiological
factor of development of recurrence of the haemorrhoids is development
of the collaterals in all the present procedures in which ligation of vessels
is done at one site.
In the new procedure, mass, prolapse and recurrence have been taken care
of. We present the study of the new procedure and compare it with
Milligan-Morgan, Longo’s procedure and DGHL.
Go to:

Materials and Methods

Material
During the period from January 2006 to December 2008, 166 symptomatic
patients of haemorrhoids of grade II, III and IV were included in the study.
The study centres were at six different types of hospitals in different cities.
The procedure transanal suture rectopexy for haemorrhoids was designed
by Dr. S. D. Chivate; explained and demonstrated to four other surgeons.
All the surgeons were doing the procedure independently after hands-on
training. The thrombosed haemorrhoids were excluded from the study. The
evidence was collected from the meta-analysis longitudinal prospective
study, which is considered to be level one. All these patients were
clinically examined and evaluated for surgery. Sigmoidoscopy was done in
all the patients.
The permission from hospital ethical committee was taken, and informed
consent was taken from the patients after explaining the new procedure.

Method
The bowel was prepared by oral liquids for 24 h; 30 ml of lactitol 6 hourly.
Under the saddle block/spinal anaesthesia, patient was positioned in
lithotomy with steep head low position, which helped in reducing piles
mass in grade II, III and IV cases, and lax mucosal and submucosal tissues
were replaced upwards to their original position. The anal canal was
lubricated generously with lots of jelly and massaged. The Sim’s speculum
was used to compress and push the piles masses upwards, eventually lax
mucosal and submucosal layers, containing vessels, were replaced up. A
self-illuminated slit with sliding valve proctosope was used (Fig. 1). The
sliding plate was removed. The dentate line and engorged mucosa was
visualized. The replaced lax mucosa and submucosa were fixed to the
deeper muscles of the rectum by the stitches 0.5–1 cm in length. The
stitches were passed through the depth of the mucus-submucus and part of
muscle, started at three o’clock position at a distance of 4 cm proximal to
the dentate line. For the stitch a 2/o polyglactin on atraumatic 30 mm ½
circle needle was used. Precaution was taken that stitch was not passed
through and through the rectal wall, but only part of the rectal muscles was
taken. The first stitch was tied and the next stitch was started 1–2 mm
overlapping to the end of the first stitch, was double locked. The double
locking was continued for every stitch to avoid purse sting effect. The
suturing was continued all along the complete circumference of the rectum
at the same level. The second circumferential suture line was completed at
2 cm levels proximal to the dentate line (Fig. 2). Both the suture lines were
above the dentate line, which caused no pain in the postoperative period.
In short, only two circumferential suturing lines were implemented at 2
and 4 cm proximal to the dentate line in the rectal wall in the procedure.

Fig. 1
Operating proctoscope
Fig. 2
Diagrammatic view Dr Chivate’s procedure. Suture lines 2 & 4 cm above
dentate line

Proctoscope
The proctoscope is made up of a uniform metal tube of 3.6 inner and
3.8 cm outer diameters; along with fibro-optic connection. The tube is cut
of its 1/8 circumference and sliding flap is prepared opposite to the fibro-
optic connection. The leading end of the tube is conical and smooth that
closes the tube, which facilitates the introduction of the proctoscope and
prevents faecal matter to enter in the operation field. The sliding valve can
be adjusted at any length. The proctoscpe is calibrated at 1-cm marking
over the inner aspect of the tube. The scope retracts the anus and rectum
without excessive stretching. It is a good operating scope. In other
operating scopes, retraction is uncontrolled (Fig. 1).
Go to:

Results
The series included 102 males and 64 females, the average age was
47.5 years; ranged between 22 and 76 years. The haemorrhoids grading II
—54, grade III—88 and grade IV—24 were included in the series of 166
cases. In all the cases, frequent episodes of bleeding per rectum were
noted. In grade II—24, grade III—38 and grade IV—19 cases, itching
around the anus was present. Grade II—16, grade III—20 and grade IV—
16 cases were suffering from discharge per rectum and spoiling
underwears (Table 1). Sigmoidoscopy revealed no malignancy in any case.

Table 1
Preoperative symptoms
Postoperative, all the patients were discharged after 24 h, except for 2
cases. Postoperative minor bleeding was noted in 3 cases that required no
treatment. The haemorrhoid masses were reduced 90 % immediately
postoperatively on the table, and further reduced in 3–7 days (Figs. 3,
,44 and and5).5). The suture rectopexy for haemorrhoids had minor oozing
from some stitches in 11 % of cases during operation, which was
controlled by compression. The small area of the mucosal tear noted in the
early 3 cases required no treatment.

Fig. 3
Pre operative and post operative haemorrhoids grade IV

Fig. 4
Pre operative and post operative haemorrhoids grade IV

Fig. 5
Pre operative and post operative recurrent haemorrhoid grade IV
Mucosal oedema present in 6/166 cases required no special treatment.
The patients were called for follow-up after 1, 2, 4, 6, 12, 24 weeks and
later on yearly communicated by post for 2 years. After 6 months in 3
cases, haemorrhoid of grade I without bleeding were noted. No ischaemia
or stenosis was observed in the 2-cm area between the two circumferential
suturing lines on per rectal and proctoscopy examination. No recurrence of
haemorrhoids or no incidence of impairment of continence was noted.
Postoperative minimum pain was present in 12/166 cases. Oral antibiotics
and analgesics were given to all the patients for 5 days.
The patients were satisfied with the new procedure. There was no special
cost for machine or disposables. Laxatives were continued in patients with
constipation.
Go to:
Discussion
In the new procedures, simple suturing at 2 and 4 cm levels proximal to
the dentate line. The sutures were above the dentate line, pain free
postoperative as well as later on. Milligan and Morgan procedure was
presented as an excision of haemorrhoid and ligation of its pedicle in 1937
[17]. The method is very painful requiring 3–5 days of hospitalization and
sedations. The patients avoid not only surgery but also the surgeons.
Stapled haemorrhoidopexy, developed by Longo in the 1990s, reduces
prolapse by a circular stapled mucosectomy 4 cm above the dentate line
[18, 19]. The procedure is confined to the area above the dentate line,
should give no pain. But the reoperation rate after stapled
hemorrhoidopexy was 11 % and the most frequent indications for
reintervention were persistent, severe anal pain (visual analogue pain score
higher than 7) [20]. In 1995, Morinaga reported a new technique for
treatment of haemorrhoids by HAL. It was used for identification of
haemorrhoid arteries. In this procedure, the located arteries are ligated by
figure of eight sutures, 4 cm above the dentate line, which is a pain-free
area [14]. The procedures recto-ano repair for grade III and IV
haemorrhoids is involved in placation of anal mucosa, cannot be pain free
[21].
In the past and now, conventional open haemorrhoidectomy is considered
to be safer than stapled haemorrhoidopexy. Incidences such as sever
sepsis, perforation of the rectum, retroperitoneal abscess, severe bleeding
[22–25] are rarely reported complications, required anterior rectal
resection and colostomy which give injury to safety feeling of surgeons
about the procedure. The procedures DGHL and transanal suture
rectopexy for haemorrhoidsare technically safe and they are less likely
complications. In the last 3 years suture rectopexy has been used in 166
cases, no untoward incidences have occurred and it is totally safe. The
suture haemorrhoidopexy had minor oozing from some stitches in 11 % of
cases, which was controlled by compression. The mucosal tear was noted
in the early 3 % cases, but required no treatment. Surgical complications
consisted haemorrhages of the staple line (18.8 %) and haemorrhages due
to mucous tear (5.9 %), in staple haemorrhoidopexy [26]. The
haemorrhage during operation is not comparable with the conventional
haemorrhoidectomy.
The principle of open haemorrhoidectomy is to minimize the loss of skin
and the perianal mucosa of the anal canal that bridges between the excised
two haemorrhoids to prevent stricture. The pedicel ligation of haemorrhoid
is done to occlude blood supply at the top of anal cushions. Later on, the
smaller branches of the ligated vessels start dilating and developing
collaterals to join the blood vessels of the intermediating tissue; this is the
potential cause of recurrence that remains about 18–25 % [27].
In stapler haemorrhoidopexy, only mucosectomy and autosuturing is done,
the blood vessels are not ligated; it gives a similar situation in which piles
masses had develop before. The fibrous tissue in submucosa remains
defective and lax remains unfixed. The overall incidence of recurrent
haemorrhoidal symptoms, as early as fewer than 6 months, remain in
stapled versus conventional procedure: 24.8 versus 31.7 %; or as late as
1 year or more recurrence rate of stapled versus conventional procedure:
25.3 versus 18.7 % [28].
Doppler-guided HAL procedure has a recurrence rate of 12 % in 12.5-
month follow-up in non-prolapsing haemorrhoids. In III and IV degree
haemorrhoids, the recurrent rate was reported between 12 % and 40 %
during the first year [14, 16]. In follow-up of 3 years, Chivate’s rectopexy
reported 3 cases of piles cushions bulging into anal canal without bleeding.
In the suture rectopexy, mucosa is transfixed to the muscular layers of the
rectum, which prevents prolapse of the piles cushion.
The superior rectal artery and its branches at the level of the plexus are
numerous, which enhances the development of the collaterals in a short
period. There is free arteriovenous communication through capillary
circulation in the carpora cavernosa recti, which is the probable cause for
recurrence in stapler or DGHL procedure.
If a long segment of an artery is occluded, it is important that side
branches arising in the area are not available for the joining of collateral
circulation. In Chivate’s procedure, the vessels are blocked at two sites at
the distance of 2 cm, which reduces the chances of development of the
collaterals and recurrences.
The blood supply from seromuscular layer is unabated, which avoids the
necrosis of the area of the less vessel area. In the last 3 years of follow-up,
not a single case of partial or complete necrotic patch was revealed. A
remarkable incidence of failures after stapled anopexy has been recently
reported by several papers, with an incomplete resection of the prolapsed
tissue, due to the limited volume of the stapler casing as the possible cause
[29]. In Minimal Invasive Procedure for Haemorrhoids (MIPH), in few
months of operation 1–2 % recurrence of symptoms, such as bleeding,
were noted, and 5 years later, recurrence accounted 20–30 %. Certainly it
is true that there is no pain, but no gain too [30, 31].
In MIPH, the functional impairment is a result of multiple factors such as
excision of the sensitive lower 2–4 cm of the rectal mucosa, which tests
samples from the rectal content for flatus, faeces or fluid. The capacity of
the rectum is reduced as it is divided in two parts like an hourglass clock.
These factors cause incontinence, tenusmus and increased frequency of
stools [32]. In the conventional haemorrhoidectomy, piles cushions are
removed resulting in impairment of continence. In the mega series, faecal
soiling/leakage 31 %, and faecal urgency 40 % were observed in stapled
haemorrhoidopexy [33]. In suture rectopexy, no mucosa is excised. No
change in bowel habit or any incontinence was reported. Same is true for
DGHL.
Go to:

Conclusion
Chivate’s transanal suture rectopexy for haemorrhoid is a very simple
stitching procedure, and the learning curve is minimal. It has equal
successful outcome in all grades of haemorrhoids and similar results were
achieved by five different surgeons. The procedure had been successful in
controlling mass, prolapse and recurrence of haemorrhoids. Other
procedures such as DGHL and Longo’ procedures are simple and without
pain, but cost is exuberant and recurrence is about 18–40 %. The evidence
was collected from meta-analysis longitudinal prospective study, which is
considered as evidence level one. All the surgeons had similar good
results, gives the degree of the recommendation A. It has evidence number
one and recommendation A. The new method still requires long follow-up
to consider it as accepted painless cure for the haemorrhoids.
Go to:

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 Transanal Suture Rectopexy for Haemorrhoids: Chivate’s Painless Cure for Piles

Transanal Suture Rectopexy for Haemorrhoids: Chivate’s Painless Cure for Piles

The Indian Journal of Surgery. 2012 Oct; 74(5)412

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 De haemorrhois; a study in surgical history.[Guys Hosp Rep. 1955]

 Review Haemorrhoids: pathology, pathophysiology and aetiology.[Br J Surg. 1994]

See more ...

 Role of anal cushions in maintaining continence.[Lancet. 1986]

 Review Haemorrhoids: pathology, pathophysiology and aetiology.[Br J Surg. 1994]

 Review [Pathophysiology of hemorrhoids].[Chirurg. 2001]

 Arterio-venous anastomoses in the anal region with reference to the pathogenesis and
treatment of haemorrhoids.[Acta Chir Scand. 1973]
 Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested
aetiology.[Br Med J. 1972]

 Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids.[Br J Surg.

1988]

 Stapled haemorrhoidectomy: pain or gain.[Br J Surg. 2001]

 Stapled anopexy and stapled hemorrhoidectomy: two opposite concepts and procedures.
[Dis Colon Rectum. 2002]
 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]

 Arterial adaptations to altered blood flow.[Can J Physiol Pharmacol. 1991]

 Collateral arteries grow from preexisting anastomoses in the rat hindlimb.[Am J Physiol
Heart Circ Physiol. 2002]

 Review A systematic review of stapled hemorrhoidectomy.[Arch Surg. 2002]

 Persistent pain and faecal urgency after stapled haemorrhoidectomy.[Lancet. 2000]
 Reinterventions after complicated or failed stapled hemorrhoidopexy.[Dis Colon Rectum.
2004]
 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]
 Doppler-guided hemorrhoidal artery ligation.[Am J Surg. 2006]
 Life threatening pelvic sepsis after stapled haemorrhoidectomy.[Lancet. 2000]
 Uncontrollable intra-abdominal bleeding necessitating low anterior resection of the
rectum after stapled hemorrhoidopexy: report of a case.[Surg Today. 2007]

 Prospective randomized study of bacteraemia in diathermy and stapled

haemorrhoidectomy.[Br J Surg. 2003]

 Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and

hemorrhoid artery ligation: a randomized study.[Int J Colorectal Dis. 2004]

 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]
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Techniques in Coloproctology
July 2016, Volume 20, Issue 7, pp 461–466| Cite as

Transanal hemorrhoidal dearterialization

(THD): a safe procedure for the
anticoagulated patient?
 Authors
 Authors and affiliations
 S. AtallahEmail author
 G. K. Maharaja
 B. Martin-Perez
 J. P. Burke
 M. R. Albert
 S. W. Larach

o

o

o

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1. 1.
Open Access
Original Article
First Online: 12 May 2016
 4Citations

 15Shares

Abstract
Background
Approximately one in five persons living in the USA is maintained on oral
anticoagulation. It has typically been recommended that anticoagulation be
withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal
dearterialization (THD) is a minimally invasive treatment for symptomatic
hemorrhoids, and outcomes with patients on anticoagulation who have undergone
this procedure have not been previously reported. Here, we report our preliminary
results of patients who underwent THD while on anticoagulation.

Methods
During a 53-month period (February 2009–July 2015), patients with symptomatic
hemorrhoids refractory to medical management who underwent surgical treatment
 with THD were retrospectively reviewed. The subset of patients who underwent
THD while anticoagulated was compared to a cohort of patient who were not taking
anticoagulation and who otherwise demonstrated normal coagulation profiles and
who did not have a known predisposition to bleeding or inherited coagulopathy. The
primary study endpoint was to assess postoperative bleeding in patients who were
maintained on anticoagulation before and after surgery.

Results
During the 53-month study period, 106 patients underwent the THD procedure for
symptomatic hemorrhoids. Of these, seventy patients underwent THD without
anticoagulation therapy, while 36 patients underwent THD while taking one or more
oral anticoagulants. The postoperative morbidity between the two cohorts was
similar, and specifically there was no statistical difference in the rate of
postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455–
3.688, p = 0.785). No patient, in either cohort, required re-intervention for any
reason during the study period. Patients who underwent THD while on
anticoagulation were less likely to have recurrent hemorrhoidal disease during the
study’s 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049).

Conclusions
These preliminary data reveal that THD can be performed on anticoagulated
patients without cessation of oral agents without increasing morbidity from
postoperative bleeding.

Keywords
THD Anticoagulation Postoperative hemorrhage Transanal hemorrhoidal
dearterialization Hemorrhoids
Download fulltext PDF

Introduction
A significant proportion of the Western population is prescribed maintenance
anticoagulation with a variety of agents including oral acetylsalicylic acid (ASA),
warfarin, clopidogrel, and/or direct thrombin inhibitors. Approximately one in five
(19.3 %) persons living in the USA is maintained on monotherapy with the oral
antiplatelet medication ASA [1, 2]. Among individuals aged 45–75, the incidence is
higher, with more than half (52 %) of this population segment taking oral ASA
therapy daily [2]. Clopidogrel has also become an anticoagulant of choice, and in
2010 it was the second most prescribed drug in the world, generating a $9 billion
industry [3]. Warfarin, although less utilized than other anticoagulants, is
commonly administered, and a total of 1 % of the UK’s 64.1 million population is
prescribed this medication annually [4]. Combined, up to one-quarter of the adult
population in the USA and Europe are estimated to be taking oral anticoagulation as
monotherapy or as a multi-drug regimen (e.g., combination of ASA and clopidogrel).
Because of this, surgeons must contend with the anticoagulated patient. With the
increasing use of synthetic, direct thrombin inhibitors, e.g., argatroban (univalent),
 hirudin (bivalent), surgeons must also be able to surgically manage this subset of
patient for which reversal is not always possible [5], and only recently andexanet
alfa has been shown to reverse factor Xa inhibitors (apixaban and rivaroxaban)
when given minutes after administration of these anticoagulants [6].

The frequent use of anticoagulation has likely led to an increased incidence of

patients presenting with clinically significant internal hemorrhoidal bleeding. When
medically refractory, surgeons must consider invasive procedures and surgery to
resolve patient symptoms, and in some instances the cessation of anticoagulation or
dose reduction is not safe.

One in 20 Americans and almost one-half of persons older than 50 experience

hemorrhoidal symptoms during their lifetime, and surgical intervention is often
required [7, 8]. It is recommended that anticoagulation—including ASA—be
withheld for 7 days prior to office-based procedures, such as hemorrhoidal banding,
or surgical interventions, such as hemorrhoidectomy and especially procedure for
prolapsed hemorrhoids (PPH) [9, 10]. The risk of significant bleeding after
hemorrhoidal banding, although uncommon, has been well documented
[11, 12, 13]. Post-hemorrhoidectomy bleeding also occurs, to a lesser degree—
approximately 1 % of the time [14]—range 0.5–2.0 % [15]. In one series, among the
patients who had post-hemorrhoidectomy bleeding, 37 % were on maintenance
anticoagulation [15]. For these reasons, most surgeons and society guidelines
recommend that anticoagulation be held prior to hemorrhoidal surgery and
procedures. However, whether or not this is mandatory for all types of hemorrhoidal
procedures has not been fully studied. Transanal hemorrhoidal dearterialization
(THD) is a relatively recent minimally invasive treatment for symptomatic
hemorrhoids and may have important advantages over conventional
hemorrhoidectomy [16, 17, 18]. Its application toward the control of rectal outlet
bleeding has been previously realized [19]. However, outcomes with patients on
anticoagulation who have undergone THD have not been previously reported, to our
knowledge. Here, we report our preliminary results of patients who underwent THD
while on anticoagulation and compared them to a cohort of patients who underwent
THD without anticoagulation.

Materials and methods

During a 53-month period (February 2009–July 2015), patients with symptomatic
hemorrhoids refractory to medical management who underwent surgical treatment
with THD were retrospectively reviewed. The study was performed with internal
review board (IRB) approval [Florida Hospital, Orlando, FL USA, IRB #670312-2],
and all THD operations were performed at a single hospital system. The data were
collected, tabulated, and placed into a prospective database, which was then
analyzed retrospectively.

Under the study protocol, patients taking oral anticoagulation medications

continued taking these medications before and after the procedure, but
anticoagulation was held on the day of surgery. Exclusion criteria included patients
on warfarin with an international normalized ratio (INR) greater than 3X normal
and patients with a platelet count measuring <10,000, known inborn error of
 metabolism with coagulopathy due to genetic mutation, age <18 or >95, and severe
comorbidity (ASA IV, or higher).

The subset of patients who underwent THD while anticoagulated was compared to
patient who were not taking anticoagulation and who otherwise demonstrated
normal coagulation profiles (PT, PTT, INR, and PLT) and who did not have a known
predisposition to bleeding or inherited coagulopathy. Indication for THD was the
same in both cohorts. The indications were medically refractory hemorrhoidal
disease in patients who failed to respond to standard conservative therapy,
including dietary changes and topical corticosteroid application in combination with
(a) persistent, clinically significant rectal outlet hemorrhage and/or (b) grade III
hemorrhoidal prolapse in more than one hemorrhoidal column according to the
Goligher classification system [20]. The primary study endpoint was to assess
postoperative bleeding in patients who were on anticoagulation. The secondary
endpoint was control of hemorrhoidal disease with THD.

Surgical technique
THD was performed in a standardized fashion with figure-of-eight ligation using
absorbable suture under Doppler guidance at six positions correlating with the odd
numbers of the clock in the patient positioned in dorsal lithotomy. No fewer than 6
ligations were performed on each patient, but if a Doppler signal was detected after
6 ligations, then an additional suture ligation was performed, up to a maximum of
eight. Mucopexy was performed for all patients with prolapsing hemorrhoidal
mucosa, and the number of columns in which mucopexy was performed varied
depending on degree and number of hemorrhoidal columns which exhibited
prolapse. The surgical technique for THD was the same regardless of whether or not
the patients were on anticoagulation.

Statistical analysis
Data analyses were performed using the SPSS version 20.0 (SPSS Inc., Chicago,
Illinois, USA). A two-sided Fisher’s exact test was used, and odds ratio analysis was
conducted to evaluate the differences between the two cohorts. A statistical
difference was denoted by p ≤ .05, and all clinically relevant data were evaluated in
each of the two study cohorts.

Results
During the 53-month study period, 106 patients underwent the THD procedure for
symptomatic hemorrhoids. Of these, seventy patients underwent THD without
anticoagulation therapy, while 36 patients underwent THD while taking one or more
oral anticoagulants, without discontinuation except for the day of surgery. There
was no statistical difference in the demographics of the two groups or the
hemorrhoidal grade (Table 1). However, prolapse was more likely to be the
indication for THD for the cohort of patients not taking anticoagulation, while
bleeding was more likely to be the reason why THD was performed on
anticoagulated patients. There was no statistical difference between median
operative times, which measured 31 min (14–102 min) for patients on
anticoagulation and 28.5 min (18–76 min) for patients off anticoagulation.
Interestingly, the median blood loss was less during THD in which patients were
anticoagulated, with 15 ml (5–15 ml) vs. 20 ml (2–100 ml) for patients not on
anticoagulation, p = 0.03. The postoperative morbidity between the two cohorts was
similar, and specifically there was no statistical difference in the rate of
postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455–
3.688, p = 0.785) (Table 2). Of the 7 patients who presented with postoperative
bleeding in the anticoagulated cohort, two re-presented to the emergency center.
One of these presentations was on postoperative day 11 in a 73-year-old male on
apixaban monotherapy, while the other was on postoperative day seven in a 73-year-
old male who was on monotherapy with 81 mg ASA. Neither patient required re-
intervention, admission, or transfusion as these were self-limited bleeding events
that resolved without therapy. The remaining 5 patients only reported self-limited
bleeding on their 4-week follow-up appointment. No patient, in either cohort,
required re-intervention for any reason during the study period. Patients who
underwent THD while on anticoagulation were less likely to have recurrent
hemorrhoidal disease during the study’s 6-month (3–24 months) median follow-up
period (2.8 vs. 7.1 %, p = 0.049).
Table 1
Clinical characteristics of patients undergoing THD

THD on anticoagulation THD off anticoagulation pvalue

(%) (%)

n 36 70

Age 64 (35–79) 48 (22–86) NS

(range)a(years)

Male/female 2.6:1 1.6:1

BMIa 28 (24–35) 27 (23–33) NS

Grade of hemorrhoidb

Grade 1 5 (13.8) 10 (14.2)

Grade 2 17 (47.2) 35 (50.0)

Grade 3 13 (36.1) 24 (34.2)

Grade 4 1 (2.7) 1 (1.4)

Presenting preoperative symptoms

Bleedingc 33 (86.8) 49 (73.1) 0.006

Prolapsec 9 (25.0) 27 (38.5) 0.0004

Otherc 10 (26.3) 8 (11.9) NS

THD Transanal hemorrhoidal dearterialization, BMI Body mass index expressed in
kg/m2
a
Age and BMI reported as median (range)
b
Grade of hemorrhoid and presenting symptoms reported in absolute value. Patients
reported by preoperative graded severity of hemorrhoids according to Goligher’s
classification
Presenting preoperative symptoms (bleeding, prolapse, and other) reported as
c

absolute values
Table 2
Operative outcomes for patients undergoing THD

THD on anticoagulation THD off anticoagulation pvalues

(%) (%)

OR timea 31 (14–102) 28.5 (18–76) NS

EBLa 15 (5–50) 20 (2–100) 0.03

ASA scorea 2.2 1.4

Mucopexyb 33 (91.7) 54 (77.1) 0.019

Postop morbidity

Bleedingb 7 (19.4) 11 (15.7) NS

Painb 7 (19.4) 9 (12.8) NS

Urinary 1 1 NS
retentionb

Recurrenceb 1 (2.8) 5 (7.1) 0.049

THD Transanal hemorrhoidal dearterialization, ORtime Median operating time in
minutes (range); EBL Median estimated blood loss in milliliters
(range); ASA American Society of Anesthesiologists score reported as mean
a
values reported in median (range)
b
Mucopexy, bleeding, pain, urinary retention, and recurrence reported in absolute
value (percent); NS Not significant
The type of anticoagulation varied and is detailed in Table 3. The most common
type of anticoagulation was once daily oral 81 mg ASA with 20/36 (55.6 %) taking
this medication once daily. Of the seven patients in the THD + anticoagulation
group who experienced bleeding in the postoperative period, only two were on ASA
monotherapy, while 5/7 were taking warfarin as monotherapy or dual
anticoagulation therapy in combination with either fondaparinux, enoxaparin, or
apixaban (Table 3).
Table 3
List of specific anticoagulation medications for patients who underwent THD while
on anticoagulation
 Patients on anticoagulation Postoperative bleeding
(n) (n)

Aspirin 81 mg 20 1

Aspirin 325 mg 5 1

Clopidogrel 3 0

Warfarin 3 2

Apixaban 1 1

Apixaban + warfarin 1 1

Fondaparinux + warfarin 1 1

Enoxaparin + warfarin 1 0

Aspirin/dipyridamole 1 0

Total 36 7
THD Transanal hemorrhoidal dearterialization

Discussion
The approach to the treatment of hemorrhoidal disease remains individualized, and
management often requires the ability to provide a spectrum of interventions based
on extent, chronicity, and pathoanatomy. But treatment must also be tailored to a
given patient in the context of clinical parameters, which commonly—and
importantly—include the requirement for anticoagulation [21, 22]. This is a key
component of the surgeon’s decision matrix when determining how to proceed with
intervention, once surgery is considered a necessary pathway toward ameliorating
hemorrhoidal symptoms. Physicians and surgeons understand that some patients
present an increased risk of thromboembolic or cardiac events when anticoagulation
is held—even temporarily. In the ROCKET AF trial, 4.8 % of patients experienced
gastrointestinal (GI) bleeding and 29 % rectal origin [23]; however, the risk of
gastrointestinal bleeding related to novel oral anticoagulants appears similar to that
of warfarin [24].

Furthermore, there is a risk of so-called rebound hypercoagulability in patients who

undergo cessation of anticoagulants and then restart them, thus increasing the risk
of adverse thrombotic events [25, 26, 27]. For patients with bare-metal or drug-
eluting stents [28, 29], prosthetic heart valves [30, 31], recent prosthetic
peripheral arterial grafts [32], and recent thromboembolic events [33], the risk of
anticoagulant cessation can be significant. Thus, for select patients, the surgeon
must estimate the procedural bleeding risk and weigh this against the estimated
thromboembolic or cardiac event risk when deciding whether or not anticoagulation
 can be safely interrupted, and whether or not bridging is required
[34, 35, 36, 37, 38, 39, 40].

In this study, it is demonstrated that the incidence of hemorrhage requiring

intervention after THD is not statistically different between anticoagulated and non-
anticoagulated patient cohorts undergoing the procedure. These early data suggest
that THD could be a safe operation for anticoagulated patients, which is an
important clinical demographic confronting colorectal surgeons. However, the
authors recognize important limitations of this study, which are principally the
small sample size and the retrospective non-randomized nature of the study design.
A blinded, randomized trial in which patients already on anticoagulation were
assessed for the morbidity of postoperative hemorrhage and also thromboembolic
events would be necessary to support or refute the validity of performing THD on
patients on systemic anticoagulation therapy. Furthermore, the study is limited by
the heterogeneity of the types of anticoagulation agents, and because the majority
(55.6 %) of the anticoagulated cohort were on monotherapy with low-dose, oral
81 mg ASA. Since complications of aspirin treatment increase proportionally with
dose, the results of the present study may not reflect the complication rate of
patients taking moderate (100–200 mg/day) or high (>200 mg/day) doses [41].
Notwithstanding, in this study only two patients (5.6 %) in the anticoagulated
cohort presented for medical evaluation after THD at an emergency center, but
neither required transfusion, surgical intervention, or other specific therapy and
were categorized as self-limited postoperative hemorrhage. Thus, for high-risk
cardiovascular patients the need to bridge with low molecular weight heparin as a
bridge to surgery may be obviated by using THD procedure—without significantly
increasing the risk of postoperative bleeding.

Because patients with cardiovascular disease are often recommended to remain on

anticoagulation to maintain homeostasis and also to prevent the described
phenomenon of rebound hypercoagulability, surgeons must often tailor the
approach to hemorrhoidal disease based on these factors which can restrict the safe
and permissible options to manage hemorrhoidal disease. For example, many
experts do not recommend hemorrhoidal band ligation for anticoagulated patients
unless the anticoagulation has been held prior to (and after) hemorrhoidal ligation
[42, 43]. Likewise, excisional hemorrhoidectomy mandates that anticoagulation be
held due to the increased risk of significant bleeding postoperatively. THD could be
a ‘middle ground’ between less invasive procedures such as hemorrhoidal band
ligation and excisional procedures (Ferguson or Milligan–Morgan) for
hemorrhoidal treatment, for which—as these data suggest—the cessation of oral
anticoagulation may not be necessary.

Conclusions
These preliminary data suggest that THD can be performed on anticoagulated
patients without cessation of oral agents without increasing the morbidity from
postoperative bleeding. Although encouraging, the small sample size limits the
overall generalizability of the study findings, and further investigation is necessary
prior to concluding that THD should be routinely performed without prerequisite
cessation of oral anticoagulants.
Notes
Compliance with ethical standards

Funding
The study was not funded and did not receive financial support. Dr. S. Atallah is a
paid consultant for THD America, ConMed, Inc., and Applied Medical, Inc. Dr. M
Albert is a paid consultant for The Medicines Company, Applied Medical, Inc., and
ConMed, Inc. Dr. G. Maharaja, B. Martin-Perez, J. Burke, and S. Larach have no
financial disclosures to report.

Conflict of interest
The authors declare that they have no conflict of interest.

Ethical approval
This research was conducted in accordance with the ethical standards set forth by
the institution and are in compliance with the 1964 Helsinki Declaration and its
later amendments or comparable ethical standards.

Informed consent
All patients enrolled in this study received informed consent as mandated by the
code of ethics at our institution and by the internal review board.

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 DOIhttps://doi.org/10.1007/s10151-016-1481-z

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Techniques in Coloproctology
April 2016, Volume 20, Issue 4, pp 235–242| Cite as

High-grade hemorrhoids requiring

surgical treatment are common after
laparoscopic ventral mesh rectopexy
 Authors
 Authors and affiliations
 J. J. van IerselEmail author
 H. A. Formijne Jonkers
 P. M. Verheijen
 W. A. Draaisma
 E. C. J. Consten
 I. A. M. J. Broeders

o
o

o

o

o

o

o
o
1. 1.
2. 2.
Open Access
Original Article
First Online: 16 February 2016
 1Shares

Abstract
Purpose
To describe patients developing grade III and IV hemorrhoids requiring surgery
after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship
between developing such hemorrhoids and recurrence of rectal prolapse after
LVMR.

Methods
All consecutive patients receiving LVMR at the Meander Medical Centre,
Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier
estimates were calculated for recurrences.

Results
A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-
year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed
symptomatic grade III/IV hemorrhoids requiring stapled or excisional
hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was
required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI
23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed
an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse
(IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–
53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest
of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355)
showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP
(11 %, p = 0.020) recurrence rates.

Conclusion
High-grade hemorrhoids requiring surgery may be common after LVMR. The
development of high-grade hemorrhoids after LVMR might be considered a
predictor of rectal prolapse recurrence.

Keywords
Hemorrhoids Hemorrhoidectomy Laparoscopic ventral mesh rectopexy Rectal
prolapse Recurrence
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Introduction
Disorders of the pelvic floor, including urinary and fecal incontinence, pelvic organ
prolapse, obstructed defecation and chronic pelvic pain, are socially disabling
conditions. In the Western world, this pathology is common, affecting more than
40 % of the middle-aged and older women, with a lifetime risk of undergoing
surgery of 10–20 % [1, 2]. The rectum is often involved in this multi-organ problem
[3]. Various conditions including rectoceles, internal and external rectal prolapse
may cause fecal incontinence and the obstructed defecation syndrome (ODS) [4].

Laparoscopic ventral mesh rectopexy (LVMR) is increasingly applied for the

treatment of external rectal prolapse (ERP) and internal rectal prolapse (IRP). This
technique proved to be safe and effective in terms of functional results in large
cohorts of patients [5, 6, 7, 8]. For prolapse surgery, the recurrence rate is a key
indicator of success. ERP recurrence is easily assessed, but diagnosing IRP
recurrence remains challenging. One hypothesis is that IRP could be the cause of
high-grade hemorrhoids (III and IV), but the development of such hemorrhoids
after LVMR is not well known [9]. In the past 25 years, the incidence of high-grade
hemorrhoids has been quoted as up to 18 % after different types of rectopexy
[10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25], but specific
literature regarding LVMR is scarce. Only a handful of relatively small series
mention the incidence [5, 26, 27, 28], but none of these discuss the issue in depth.
The aim of this study, therefore, was to identify patients developing high-grade
hemorrhoids requiring surgical treatment after LVMR and to explore the
relationship between such hemorrhoids and the recurrence of rectal prolapse
following LVMR.

Materials and methods

Study design
This observational cohort study was a retrospective analysis of a prospectively
maintained database and was undertaken in a large teaching hospital in the
Netherlands. All consecutive patients undergoing LVMR for rectal prolapse
syndromes (Table 1) between March 2004 and May 2013 were analyzed.
Table 1
Patient characteristics, medical history and initial indications for LVMR

Patient characteristics LVMR N = 420 Hemorrhoidectomy

(%) group N = 65 (%)

Woman/men [mean age] 404/16 [61.8] 61/4 [60.4]

History

Mean para (range) [episiotomy] 2.4 (0–10) [37]a 2.6 (0–5) [12]b

Hysterectomy 139 (33.1) 47 (72.3)

 Patient characteristics LVMR N = 420 Hemorrhoidectomy
(%) group N = 65 (%)

Cystopexy 39 (9.3) 4 (6.2)

Anterior colporrhaphy 56 (13.3) 13 (20.0)

Sphincter operation 6 (1.4) 0

Other abdominal surgery 137 (32.6) 23 (35.4)

Rubber band ligation before LVMR 28 (6.7) [7]c 3 (3.1) [2]d

[second session]

Pre-hemorrhoidectomy—before 20 (4.8) 2 (3.1)

initial LVMR

RBL between LVMR and 39 (9.3) [13] 4 (6.2) [1]

hemorrhoidectomy [second RBL]

Indication for initial LVMR

ERP 55 (13.1) 5 (7.7)

IRPe and/or symptomatic rectocele 266 (63.3) 44 (67.7)

IRPe and/or symptomatic rectocele 99 (23.6) 16 (24.6)

with enterocele
LVMR laparoscopic ventral mesh rectopexy, ERP external rectal
prolapse, IRP internal rectal prolapse, RBL rubber band ligation
a
In 25 patients
b
In 7 patients
c
Two patients underwent a third and a fourth session
d
One patient underwent a third and a fourth session
e
Oxford rectal prolapse grade III/IV

Patients and evaluation

Postoperatively, all patients were prescribed a laxative (Macrogol 3350/electrolytes,
Movicolon®, Norgine Limited, Mid Glamorgan, UK). Follow-up after LVMR was
carried out according to a standardized protocol and performed at 6 weeks after
surgery by one of the three participating experienced pelvic floor surgeons (P.V.,
E.C. and I.B.). At the 6-week follow-up, the presence of hemorrhoids, recurrence of
rectal prolapse, incontinence and constipation was assessed. All patients were asked
to return in the event of anorectal complaints. Patients were examined for
hemorrhoids in the standing and lithotomy position using leg supports, both in rest
and during straining. In addition, proctoscopy was performed. Hemorrhoids were
 graded using the Goligher classification [29]. Patients with grade II and III
hemorrhoids were treated with rubber band ligation (RBL) first. Persisting
symptomatic grade III/IV hemorrhoids (‘high grade’) were considered an indication
for surgery, but results of LVMR were awaited for at least 10 weeks. Lower grades of
hemorrhoids were not operated on. ERP recurrence was clinically assessed. IRP
recurrence was defined as Oxford rectal prolapse grade III/IV IRP with symptoms of
obstructed defecation or fecal incontinence. Most of these patients had a coexisting
rectocele or enterocele. A dynamic MRI of the pelvic floor was done on all patients
suspected of an IRP recurrence. A large part of the study cohort (most patients
operated from 2004 to 2011) had participated in a previous study about the
outcomes of LVMR, and therefore, a longer follow-up period was available for these
patients [7]. For those patients not included in this previous study, no additional
effort was made to systematically follow them up. Kaplan–Meier curves were used
to establish whether there was a difference in outcome between the two groups.

Surgical technique
All laparoscopic ventral mesh rectopexies were performed according to the
technique described by D’Hoore et al. [6]. All meshes used were synthetic. Either a
stapled hemorrhoidectomy (SH) or a traditional excisional hemorrhoidectomy
(TEH) was performed. Where a SH was not technically possible, a TEH was done.
Surgery was performed by, or under direct supervision of, one of the three pelvic
floor surgeons (P.V., E.C. and I.B.). Operations were performed under general or
spinal anesthesia. The patients were placed in the lithotomy position using adaptive
leg supports with swing stirrups. The PPH 03 stapler produced by Ethicon
(EndoSurgery, Cincinnati, Ohio, USA) was used for SH. The stapled procedure had
been previously standardized and was performed according to the technique
described by Singer et al. [30]. Excisional hemorrhoidectomy was performed
according to standard protocol [31].

Statistical analysis
Statistical Package for the Social Science Advanced version 20.0 (IBM Corp.,
Armonk, NY, USA) was used for statistical analysis. Data are presented as
percentage, median and range. Because of differences in follow-up between patients,
the Kaplan–Meier method was used to estimate the incidence of postoperative high-
grade hemorrhoids and recurrence rates at various points in time. The risk
estimates after a period of 5 years are shown in the text. p < 0.05 was considered
statistically significant.

Results
Patients characteristics
Before LVMR, twenty-eight patients (6.7 %) underwent RBL for grade II
hemorrhoids and 20 patients (4.8 %) underwent a hemorrhoidectomy for grade
III/IV hemorrhoids.
A total of 420 patients (16 men; 404 women) underwent LVMR. Indications for
surgery were ERP (n = 55, 13.1 %), IRP (Oxford rectal prolapse grade III/IV) and/or
symptomatic rectocele (n = 266, 63.3 %) and IRP and/or symptomatic rectocele
combined with enterocele (n = 99, 23.6 %). General patient characteristics are
presented in Table 1.

Follow-up
The median follow-up after LVMR was 16.0 months (range 0.4–93.7). Three
hundred and ninety-one patients (93.1 %) were available for follow-up after the
standardized outpatient visit at 6 weeks postoperatively. Nine patients (2.1 %) died
of causes unrelated to the LVMR within the study period.

During follow-up after LVMR, 89 patients required treatment for hemorrhoids, of

which 24 were treated sufficiently by RBL. The remaining 65 patients (Kaplan–
Meier estimate of 24.3 % at 5 years, 95 % CI 18.6–30.0, Table 2) received surgical
treatment for symptomatic grade III/IV hemorrhoids and are referred to as the
‘hemorrhoidectomy group’ (63 SH, 2 TEH). Four of the hemorrhoidectomy group
(6.2 %) received RBL between LVMR and the hemorrhoidectomy without sufficient
result (flowchart Fig. 1). The median duration between LVMR and hemorrhoid
surgery was 6.2 months (2.5–45.3).
Table 2
Kaplan–Meier estimates (%) for incidence and recurrence of gr. III/IV hemorrhoids
and recurrence of rectal prolapse in the hemorrhoidectomy group (n = 65) and the
non-hemorrhoidectomy group (n = 355) at various time points

Kaplan–Meier estimates % Years

[CI]
1 3 5

Gr. III/IV hemorrhoids after LVMR 16.5 [CI 12.4– 22.2 [CI 17.1– 24.3 [CI 18.6–
20.6] 27.3] 30.0]

Recurrence high-grade hemorrhoids

Hemorrhoidectomy group (n = 65) 31.2 [CI 16.9– 35.2 [CI 19.7– 40.6 [CI 23.2–
45.5] 50.7] 58.0]

External rectal prolapse recurrence

Hemorrhoidectomy group (n = 65) 0 2.0 [CI 0–5.9] 25.3 [CI 0–53.9]

Non-hemorrhoidectomy group 0.8 [CI 0–2.0] 0.8 [CI 0–2.0] 0.8b [CI 0–2.0]
(n = 355)a

Internal rectal prolapse recurrence

Hemorrhoidectomy group (n = 65) 1.9 [CI 0–5.6] 20.2 [CI 6.5– 24.4 [CI 9.1–
33.9] 39.7]
 Kaplan–Meier estimates % Years
[CI]
1 3 5

Non-hemorrhoidectomy group 2.1 [CI 0.3–3.7] 5.7 [CI 2.0–9.4] 11.0 [CI 4.3–
(n = 355)a 17.7]
CI 95 % confidence interval, LVMR laparoscopic ventral mesh rectopexy, gr. grade
This cohort contains the 420 patients receiving a LVMR minus the patients
a

developing postoperative high-grade hemorrhoids; 420–65 = 355

b
One ERP recurrence after 64.6 months
Open image in new window

Fig. 1
Flowchart. LVMR laparoscopic ventral mesh rectopexy, RBL rubber band
ligation, SHstapled hemorrhoidectomy, TEH traditional excisional
hemorrhoidectomy, RP rectal prolapse, Gr. grade. ERP external rectal
prolapse, IRP internal rectal prolapse. aFour of these patients received an re-SH first
High-grade hemorrhoids recurrence
Fifteen patients of the hemorrhoidectomy group (15/65) needed re-do surgery
(n = 13 SH) for recurrent grade III/IV hemorrhoids after a median of 8.3 months
(1.5–40.5) after the primary hemorrhoidectomy. The estimated percentages
(Kaplan–Meier) were 31.2 % after 1, 35.2 % after 3 and 40.6 % after 5 years (95 % CI
23.2–58.0, Table 2). One patient received an excisional hemorrhoidectomy after
twice a SH in a period of 8.9 months. This was the only patient receiving more than
two hemorrhoidectomies after LVMR.

Rectal prolapse recurrence—ERP

In the hemorrhoidectomy group, three patients (3/65) developed a clinical full-
thickness external prolapse generating a recurrence percentage (Kaplan–Meier
estimates) 0 % after 1, 2.0 % after 3 and 25.3 % after 5 years (95 % CI 0–53.9). Two
of these patients underwent re-do LVMR and the third patient declined surgery. The
ERP recurrence rate (Kaplan–Meier estimates) in the group of patients who did not
received additional surgery for hemorrhoids after LVMR (‘non-hemorrhoidectomy
group,’ n = 355) was 0.8 % after 5 years (95 % CI 0–2.0). This is significantly
(p = 0.011) lower compared to the hemorrhoidectomy group (n = 65, Fig. 2a and
Table 2).
Open image in new window
Fig. 2
a Kaplan–Meier curve for ERP recurrence (cohort n = 420). The green
line represents the cohort developing high-grade hemorrhoids after LVMR
(‘hemorrhoidectomy group,’ n = 65), and the blue line represents the rest of the
LVMR cohort not developing high-grade hemorrhoids after LVMR (‘non-
hemorrhoidectomy group’ n = 355, p = 0.011). bKaplan–Meier curve for IRP
recurrence (cohort n = 420). The green line represents the cohort developing high-
grade hemorrhoids after LVMR (‘hemorrhoidectomy group,’ n = 65), and the blue
line represents the rest of the LVMR cohort not developing high-grade hemorrhoids
after LVMR (‘non-hemorrhoidectomy group,’ n = 355, p = 0.020). The duration of
event-free survival was measured from date of LVMR to the time of the event
(complete) or the last follow-up (censored) for both curves. At the bottom of the
figure, a table with the number of patients left for analysis per year is presented
 Rectal prolapse recurrence—IRP
Additionally, eight patients of the hemorrhoidectomy group (8/65) were diagnosed
with an IRP recurrence. The Kaplan–Meier estimates for IRP recurrence were 1.9,
20.2 and 24.4 % after 1, 3 and 5 years (95 % CI 9.1–39.7). One patient decided
against surgery and the rest received re-do rectopexy. One patient required a SH
9 months after the re-do rectopexy. Due to persistent fecal incontinence without
curative surgical options, a stoma was created in a further three patients.

The estimated IRP recurrence percentage after 5 years was significantly lower
(11 %, p = 0.020, 95 % CI 4.3–17.7) in the non-hemorrhoidectomy group (n = 355)
compared to the hemorrhoidectomy group (n = 65, Fig. 2b and Table 2).

Discussion
The exact incidence of high-grade hemorrhoids following LVMR is not known. Our
study found a high actuarial 5-year incidence of 24.3 %. In the literature, only four
articles report on this issue, quoting a lower incidence varying from 1.6 to 5 %
(Table 3) [5, 26, 27, 28]. However, these studies describe the outcome of LVMR
rather than focus on the development of postoperative high-grade hemorrhoids. Of
the two studies with substantial follow-up, the study of D’Hoore et al. only followed
up the patients by telephone and Slawik et al. did not perform an anorectal
examination after 3 years [5, 27]. In the other two studies, the follow-up period was
substantial shorter [26, 28]. As a result, in these studies the occurrence of high-
grade hemorrhoids after LVMR may have been underestimated. Furthermore, in the
reported studies the main indication for LVMR was ERP, whereas in our study
86.9 % of the patients presented with IRP. Also, two studies combined the LVMR
with other procedures (e.g., STARR or resection rectopexy) [27, 28]. This
heterogeneity among studies might explain the differences in reported percentages
of high-grade hemorrhoids after LVMR. In our study, 53.8 % of the
hemorrhoidectomy group (35/65) suffered from ODS complaints before LVMR and
most of them had a long history of straining and incomplete evacuation. After
LVMR, still 15 patients of the hemorrhoidectomy group (15/65, 23.1 %. p = 0.004)
reported persisting ODS complaints. Other studies quote a slightly lower figure (up
to 19 %) of patients suffering from persisting ODS after LVMR [5, 6, 7, 8]. The high
incidence of grade III/IV hemorrhoids after LVMR and the high recurrence rate of
grade III/IV hemorrhoids after hemorrhoidectomy might be the result of persistent
straining. The actuarial 5-year recurrence rate of 40.6 % for grade III/IV
hemorrhoids after hemorrhoidectomy was very high compared to several
randomized controlled trials showing recurrence rates from 0 to 5 % for both
excisional as stapled hemorrhoidectomy [32, 33, 34, 35]. It is also possible that
some of the patients in the hemorrhoidectomy group were not properly assessed
before LVMR. Possibly, some patients underwent LVMR for symptomatic IRP
combined with a rectocele, whereas retrospectively the symptoms might have been
caused mostly by a mucosal prolapse. Consequently, it could be that high-grade
hemorrhoids following LVMR might be attributed to residual mucosal prolapse in
some cases. In these patients, it seems that LVMR repairs the rectal prolapse, but
fails to correct the mucosal prolapse. If so, a different operation instead of LVMR
(e.g., STARR) might have been more appropriate. Because of the retrospective
character of this study, it is unfortunately not possible to verify if mucosal prolapses
were missed before LVMR.
Table 3
Available literature concerning high-grade hemorrhoids requiring surgery after
LVMR

First No. of Indication Follow-up High-grade Treatment

author patients LVMR in months hemorrhoids
(median) after LVMR

D’Hoore [5] 42 ERP 61 1 (2.4 %) SH

Slawika[27] 80 44 ERP 54 4 (5 %) 3 SH, 1 TEH

36 IRP

Wijffels 80 ERP 23 2 (2.5 %) 1 SH, 1

[26] STARR

Randallb[28 190 ERP 29 3 (1.6 %) 3 SH

]
LVMR laparoscopic ventral mesh rectopexy, SH stapled
hemorrhoidectomy, STARR stapled transanal rectal resection
Seven patients underwent a laparoscopic resection rectopexy, and 74 females
a

underwent concurrent posterior colporrhaphy and vaginal sacrocolpopexy

LVMR was combined with Orr–Loygue (n = 3), anterior colporrhaphy (n = 7),
b

posterior STARR (n = 10) and SH (n = 2)

The role of mucosal prolapse in hemorrhoidal disease is in debate. Gaj et al. [36]
showed that 40 % of the proctologists do not consider mucosal prolapse as
independent from hemorrhoidal disease in a national survey. We believe that
mucosal prolapse is an integral part of the hemorrhoidal disease. However, whether
mucosal prolapse is a completely different entity or not, with excising a
circumferential band of excessive rectal mucosa and submucosa and interrupting
the blood supply of the superior hemorrhoidal artery proximal to the hemorrhoidal
tissue, the clinical condition is treated either way.

In addition, it is worth noting that the hemorrhoidectomy group includes more

patients with a history of hysterectomy (72.3 % vs. 33.1), re-do of the initial LVMR
(12.3 % vs. 8.8 %) and number of past episiotomies (8.8 % vs. 18.5 %) than the non-
hemorrhoidectomy group. All these variables might constitute an increased risk of
developing high-grade hemorrhoids after LVMR. No other differences worth
mentioning were found between the groups.

The incidence of recurrence of rectal prolapse in the hemorrhoidectomy group was

also high, with an actuarial 5-year ERP recurrence rate of 25.3 % and an actuarial 5-
year IRP recurrence rate of 24.4 %. In contrast, the non-hemorrhoidectomy group
(n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and
 IRP (11 %, p = 0.020) recurrence rates (Fig. 2a/b; Table 2). The literature quotes
similar incidences to our non-hemorrhoidectomy group with rates varying from 1.6
to 4.8 % [5, 6, 28, 37] for ERP and from 0 to 15 % for IRP [8, 38]. This could
suggest that patients with high-grade hemorrhoids after rectopexy are susceptible to
developing a rectal prolapse recurrence after LVMR. The hemorrhoidectomy group
seems to contain a cohort of patients with persisting symptoms possibly not well
responding to the standard therapy. Both high recurrence rates of rectal prolapse
and grade III/IV hemorrhoids are indicative. The three patients requiring a stoma
due to persistent fecal incontinence support this impression. It may be that high-
grade hemorrhoids after LVMR are a sign of laxity of (a part of) the posterior
compartment and represent the first stage of a continuum, eventually developing
into rectal prolapse. Consequently, the findings of this study could suggest that the
development of high-grade hemorrhoids following LVMR might be considered
predictive of a rectal prolapse recurrence. In order to exclude a rectal prolapse
recurrence, additional radiological imaging should be considered when a patient
presents with grade III/IV hemorrhoids following LVMR. Unfortunately, our data
did not offer a clear explanation for the relationship between post-LVMR high-grade
hemorrhoids and rectal prolapse recurrence. As there is no literature available on
this potential relationship, it would be an interesting topic for future studies.

LVMR has been performed in our hospital since 2004. Analysis shows that the
occurrence of post-LVMR hemorrhoidectomy is fairly stable over the years. This
indicates that there is probably no learning curve problem, or sign of insufficient
repair. This is supported by the rates for ERP and IRP recurrence in the non-
hemorrhoidectomy group which are comparable to the contemporary literature.

A limitation of this paper is the differences in follow-up between patients. Although

the Kaplan–Meier method yields appropriate estimates for recurrence rates at
various points in time, underestimation remains possible. When we compared
patients receiving extended follow-up in the context of a previous study (n = 149)
[7] with those followed up according to the standardized postoperative protocol
(n = 271), the risk of high-grade hemorrhoids was somewhat higher with the
standardized postoperative follow-up. However, estimates were unstable and the
difference was not statistically significant (p = 0.149). In the standardized follow-up
protocol, the probability of the patient presenting at the outpatient clinic after the
standard 6 week postoperative control might be related to the degree of
postoperative complaints, and therefore, selection bias may have occurred.

Conclusion
High-grade hemorrhoids requiring surgery may be common after LVMR. The
development of high-grade hemorrhoids after LVMR might be considered a
predictor of rectal prolapse recurrence.

Notes
Compliance with ethical standards

Conflict of interest
 The authors declare that they have no conflict of interest.

Ethical approval
All procedures performed in this study were in accordance with the ethical
standards of the institutional research committee and with the 1964 Declaration of
Helsinki and its later amendments.

Informed consent
Formal consent is not required for this type of study.

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Open AccessThis article is distributed under the terms of the Creative Commons
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van Iersel, J.J., Formijne Jonkers, H.A., Verheijen, P.M. et al.
Tech Coloproctol (2016) 20: 235.
https://doi.org/10.1007/s10151-016-1432-8
 DOIhttps://doi.org/10.1007/s10151-016-1432-8

 Publisher NameSpringer Milan

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Techniques in Coloproctology
April 2015, Volume 19, Issue 4, pp 255–257| Cite as

Hemorrhoidopexy with the HemorPex

System
 Authors
 Authors and affiliations
 M. TagliabueEmail author
 C. Cusumano
 E. S. Kechoud
 D. Paternicò
 M. Rasini
 D. Carriero
 F. P. Paladino

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Open Access
Trick of the Trade
First Online: 23 January 2015
 2Citations

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Introduction
Transanal Doppler-guided hemorrhoidal artery ligation with mucopexy and
hemorrhoidopexy with the HemorPex System (HPS) (ANGIOLOGICA B.M. S.r.l.,
Pavia, Italy) are minimally invasive non-excisional methods available to treat
symptomatic hemorrhoids not responding to more conservative treatment. The HPS
makes possible mucopexy and the ligature of superior hemorrhoidal artery
branches, treating at the same time two important causes of hemorrhoids.

Surgical technique
HemorPex System, used for hemorrhoidopexy, consists of a rotating part, through
which the sutures are placed, and a fixed part of the anoscope. This surgical
instrument is provided with a fixed light focused on the surgical field (Fig. 1).

Open image in new window

Fig. 1
HemorPex System © ANGIOLOGICA B.M. S.r.l., Pavia, Italy. Available
at: http://www.hemorpexsystem.it/index.php?lang=1&id=home
All but one of our patients were given spinal anesthesia and positioned in the prone
decubitus or “jackknife” position. For one patient, we used the gynecological
position and general anesthesia. As antibiotic prophylaxis, we used intravenous
metronidazole (500 mg).

After introducing the operative device into the anal canal, 6 or 7 running sutures of
polyglycolic acid 2/0 are positioned at 1,3,5,7,9, 11 o’clock [1], the usual locations of
the 6 main terminal branches of the superior rectal artery. We put another running
suture (consisting of a glycolic acid and trimethylene carbonate copolymer) at 12
o’clock for severe prolapse (grades III and IV) (Fig. 2). The running sutures are
placed in a clockwise direction starting from 11 o’clock. In each of the 6 or 7
positions, the continuous suture is characterized by 4 or 5 passages and
corresponding knots through the wall so as to obtain a plication. During
hemorrhoidopexy with the HPS, prolapse is exposed by retracting it outside the anal
canal (Fig. 2b).
Open image in new window

Fig. 2
Pre-, intra- and postoperative pictures. a Pre-treatment, b intraoperative treatment,
and c post-treatment with HPS in a male patient with grade II
hemorrhoids. b Plication of the mucosa and submucosa at 11 o’clock with the second
step; the prolapse is highlighted with the traction exerted by the operator from
inside the anal canal toward the outside. dPre-treatment, e intraoperative
hemorrhoidopexy and f post-treatment in a male patient with grade IV
prolapse. e At the end of the plication, the spray function of the monopolar electric
scalpel is used to minimize edema and congestion of the area just treated and create
a retracting scar
 In this way, it is possible to lift up the sliding mucosa and submucosa for 3–4 cm,
about 2 cm above the dentate line, and close the arterial branches, like in the
Doppler technique but without the aid of the Doppler signal.

To avoid local edema and promote the creation of a retractile scar, we usually used
the spray function of the monopolar electric scalpel at the end of the
hemorrhoidopexy (Fig. 2e).

In the long term, these sutures create a sort of “anchoring scar” between the
mucosa, submucosa and the underlying musculature.

The average duration of the surgical procedure is 40 min (range 20–60 min).

Results
Between January 2010 and August 2014, we used HPS to treat 116 patients with
symptomatic hemorrhoids at the surgical division of Uboldo Hospital, in Cernusco
sul Naviglio, and Vaprio D’Adda Hospital (Milan). There were 83 males (72 %) and
33 females (28 %) with an average age of 51 years (range 22–81 years).

Eighty-eight patients had grade II (76 %), 21 grade III (18 %) and 7 grade IV (6 %)
hemorrhoidal disease; 6 of these patients had recurrent hemorrhoids after having
underwent prior surgical treatment, while 6 had an associated local pathology such
as anal fissures or anal polyps that we treated at the time of surgery for the prolapse.
For all patients, we recorded pain levels after surgery by means of the visual analog
scale (VAS), obtaining a mean VAS score of 2 (±1): The postoperative immediate
pain was intense (VAS 6–10) in only 8 cases (11 %), medium in 5 cases (7 %) and
light (VAS 1–3) in 95 cases (82 %). The postoperative pain was treated with
paracetamol or nonsteroidal antiinflammatory drugs and at the time of the
discharge, only oral painkillers were prescribed.

First defecation after the operation came spontaneously 24 h after the operation and
at discharge, a diet regimen and stool softeners were prescribed for preventing
constipation.

We never recorded immediate postoperative hemorrhage, but we registered 4 cases

of severe bleeding (3.4 %) on day 7 and day 15 which needed surgical revision.

Only 1 patient had acute urinary retention after surgery. As for the presence of other
symptoms, we observed anal and perianal edema in 2 cases (1.7 %) lasting 24–48 h
after the operation and we recorded only 1 case of tenesmus in the first 3 months.
One patient who had had prolapse associated with fissure developed a fistula.

At follow-up, we found hemorrhoids had recurred in 6 patients (5.2 %), 3 of whom

had recurrence for the second time (patients treated with HPS for recurrent
prolapse), while the other 3 patients had not been operated on previously. The mean
interval between the surgical procedure and the recurrence was 11.5 months.

Discussion
 HPS is quite a new minimally invasive technique for the treatment of hemorrhoids,
and the literature on this topic is limited. We operated on grades II and III prolapse,
for which HPS proved to be a good option in terms of percentage of complications
(i.e., a 3.4 % incidence of postoperative bleeding and a mean postoperative VAS of
2) and relapse, which are similar to the data found in the literature (postoperative
bleeding between 0.5 and 4 %).

Postoperative bleeding was recorded in 3 cases on day 7 and in 1 case on day 15. In 3
of these patients, bleeding was apparently due to the falling of the anchoring scar
from mucosa and submucosa. In 1 patient, the bleeding seems to have been
determined by sutures placed too deep with subsequent necrosis. Aiming at
minimizing the postprocedure bleeding, we have made some changes in the surgical
technique over the years: at the beginning, we used the monopolar scalpel with the
coagulative function at the end of the pexis; recently, in order to avoid deep damage
to the tissues and prevent postoperative bleeding, we preferred the spray function.

In the literature, recurrent prolapse is not considered a contraindication to

hemorrhoidopexy, even when performed for the second time. We treated 6 patients
with a recurrent prolapse: At follow-up, 3 of them still had symptoms related to
hemorrhoids. This result seems to show that HPS is not the best treatment for
recurrence, but these considerations need to be validated with bigger studies.

Hemorrhoidopexy is not recommended in grade IV prolapse in the literature [2].

We treated 7 patients with grade IV prolapse and 2 of them with a recurrent
prolapse. Three of these 7 patients had postoperative complications: 1 patient
developed bleeding on day 7 which required surgical revision; 2 patients
experienced recurrent prolapse, after a mean time period of 6 months. Because of
the limited data and short follow-up, we cannot state a significant trend, but our
experience seems to confirm the literature data.

Conclusions
Hemorrhoidopexy with HPS is a valid and safe treatment for II and III degree
prolapses, offering satisfying results in terms of postoperative bleeding and
recurrence of symptoms and minimal patient discomfort postoperatively.

Notes
Conflict of interest

None.

References

1. 1.

Basile M, Di Resta V, Ranieri E (2014) Transanalanopexy with HemorPex System

(HPS) is effective in treating grade II and III haemorrhoids: long term
results. http://www.hemorpexsystem.it/pubblicazioni/Articolo-HPS-Dr-Basile.pdf
 2. 2.

Boccasanta P, Capretti PG, Venturi M et al (2001) Randomised controlled trial

between stapled circumferential mucosectomy and conventional circular
hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am J
Surg 182:64–68CrossRefPubMedGoogle Scholar

Copyright information
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About this article

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Tagliabue, M., Cusumano, C., Kechoud, E.S. et al. Tech
Coloproctol (2015) 19: 255. https://doi.org/10.1007/s10151-
015-1268-7
 DOIhttps://doi.org/10.1007/s10151-015-1268-7

 Publisher NameSpringer Milan

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Techniques in Coloproctology
March 2015, Volume 19, Issue 3, pp 153–157| Cite as

Evaluation of transanal hemorrhoidal

dearterialization: a single surgeon
experience
 Authors
 Authors and affiliations
 G. D. LaBellaEmail author
 W. P. L. Main
 L. R. Hussain
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Open Access
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Abstract
Background
There is an increasing, though still limited, amount of evidence describing the use of
the transanal hemorrhoidal dearterialization (THD) device for the treatment of
hemorrhoidal disease. This study assesses postoperative outcomes from a single
surgeon experience with the THD device.

Methods
From January 2009 to December 2011, 108 THD procedures were performed. With
Doppler guidance, the THD device makes possible precise ligation of the branches of
the superior hemorrhoidal artery. Patients were seen postoperatively at 3 weeks and
6 months. They underwent physical examination to determine whether there was
recurrence of hemorrhoidal prolapse. They were asked to describe any bleeding, to
rate pain using the visual analog scale, and to rate their level of satisfaction on a
scale of 1–5 (with 5 = highly satisfied). A phone interview was used for follow-up at
1 year to determine the rate of recurrent prolapse.

Results
Of the 108 patients who underwent THD, two were lost to follow-up and excluded.
All of the remaining 106 patients completed follow-up at 3 weeks and 6 months. At
3 weeks, 92 % of patients had no pain and 88 % were highly satisfied with the
procedure at 3 weeks. This increased to 92 % satisfaction at 1 year. Prolapse
recurrence was 7.5 % at 6 months and 10.3 % at 1 year. Bleeding was the most
common complication, but did not require re-intervention or transfusion.

Conclusions
THD is a same-day procedure for the treatment of hemorrhoidal disease that is safe
and effective, and offers the potential for immediate return to normal activity.

Keywords
Transanal hemorrhoidal dearterialization Doppler-guided hemorrhoidal artery
ligation THD DGHAL Hemorrhoids
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Introduction
Hemorrhoids are highly vascularized tissue located in the submucosa of the anal
canal that helps in maintaining fecal continence. When hemorrhoids are associated
with bleeding, prolapse, or pruritus, this is considered hemorrhoidal disease (HD).
The prevalence of HD is reported to be 4–10 %, making it the most common
disorder of the anal canal [1]. HD is usually treated conservatively for 6–8 weeks.
However, about 10 % of patients will ultimately require surgical intervention [2].
Milligan–Morgan (open) or Ferguson (closed) hemorrhoidectomy is considered the
gold standard for the surgical treatment of hemorrhoids [3, 4]. However, these
procedures are associated with significant postoperative complications including
pain, sepsis, anal stenosis, bleeding and incontinence [5]. In an effort to decrease
postoperative pain, two new techniques have been proposed in the last two decades:
stapled hemorrhoidopexy (SH) and Doppler-guided hemorrhoidal artery ligation
(DGHAL). Both techniques result in less postoperative pain, a shorter hospital stay,
and greater patient satisfaction [6, 7, 8, 9, 10, 11, 12, 13]. Numerous case reports
have exposed some of the potential risks with SH including bleeding, large bowel
obstruction, retroperitoneal sepsis, rectovaginal fistula, and rectal perforation
[14, 15, 16, 17, 18]. DGHAL was first described by Morinaga in 1995 [19]. It has
been shown to be safe and effective in the treatment of hemorrhoids and to be
associated with a small learning curve [8, 20]. Since its introduction, numerous
devices have been developed. Transanal hemorrhoidal dearterialization is
sometimes used interchangeably with DGHAL; however, there is a specific THD
device. This device (THD S.p.A., Correggio, Italy) consists of an anoscope with
Doppler probe and light source for precise ligation of the hemorrhoidal branches of
the superior hemorrhoidal artery. The THD device has a removable centerpiece
which facilitates mucopexy. Through ligation, arterial inflow is decreased allowing
the prolapsed hemorrhoid to shrink. Ligation with mucopexy has been shown to
decrease the rate of recurrent prolapse [20, 21, 22, 23, 24, 25].

Hemorrhoidal disease has marked differences in epidemiology and clinical

presentation which may affect selection for surgical treatment and ultimately
treatment results. Perception of pain, patient’s expectations, and satisfaction are
also highly dependent on the patients’ population and the healthcare settings. In
this regard, most of the studies on THD were carried out by academic centers in
Europe. The aim of this study was to assess the postoperative outcome of a
consecutive series of patients operated on in the USA by a single surgeon using the
THD device.

Materials and methods

This was a prospective observational study. Institutional Review Board approval was
obtained and all patients provided written consent. Between January 2009 and
December 2011, a total of 108 consecutive THD procedures were performed for
patients with grade II, III, and IV internal hemorrhoids. THD was not offered to
patients with both external and internal hemorrhoids. In these patients, LigaSure
(Covidien) hemorrhoidectomy was performed. All patients underwent preoperative
 history and physical examination, and hemorrhoids were graded according to
Goligher’s classification [26]. Patients were asked about preoperative symptoms
including bleeding, pain, incontinence, and pruritus ani. They were also asked about
dietary habits and fiber intake, medical therapy used to initially treat the
hemorrhoids, and history of prior procedures for hemorrhoids. Preoperatively all
patients received 10 mg of oral oxycodone 30 min to 1 h prior to surgery, and just
prior to the procedure a perianal injection of 30 ml 0.5 % marcaine with
epinephrine. Patients were discharged with a prescription for narcotic pain
medication for no more than a week. Patients were evaluated postoperatively at
3 weeks and 6 months followed by a phone interview at 1 year after surgery. At each
follow-up, patients were asked to rate their satisfaction with the surgical procedure
on a scale of 1–5, with five signifying highly satisfied. Three weeks after surgery,
patients were asked to assess their pain on a visual analog scale (VAS) of 0–10, with
0 representing no pain and 10 representing the worst possible pain. Postoperative
complications such as bleeding and recurrence were also noted at each follow-up.
All information was recorded and evaluated by the surgeon.

The surgical procedure has been described in detail by Ratto et al. [22]. Briefly, the
anoscope was inserted into the anal canal gaining access to the distal rectum. Six
branches of the superior hemorrhoidal artery were ligated with Doppler guidance (at
the 1, 3, 5, 7, 9, 11 o’clock positions). This was done with a figure of eight 2-0 Vicryl
suture. Following ligation, the suture was used in a running fashion distally and tied
for mucopexy.

Results
Of the 108 patients who underwent THD, two patients lost to follow-up were not
included in the study results. Of the remaining 106 patients, four (4 %) had grade II,
69 (64 %) had grade III, and 33 (32 %) had grade IV hemorrhoids. Overall, the mean
age was 51 (±15 SD) years. Forty-one patients were male (39 %) and 65 patients
were female (61 %). Bleeding was the predominant complaint, followed by pain
(Table 1). Thirty patients (28 %) had a prior procedure: 62 % had undergone
banding, 6 % had prior hemorrhoidectomy, and 32 % had undergone infrared
coagulation. In all but five cases (95 %), ligation of all six hemorrhoidal arteries was
performed. Ninety-eight patients (92 %) had mucopexy in addition to ligation.
Table 1
Preoperative symptoms

Symptom Number of patients (% of 106 patients)

Prolapse

Grade II 4 (4)

Grade III 69 (64)

Grade IV 33 (32)

Bleeding 63 (59)
 Symptom Number of patients (% of 106 patients)

Pain

None 15 (14)

Minimal 34 (32)

Moderate 38 (36)

Severe 19 (18)

Pruritus 34 (32)

Incontinence 13 (12)

Seventy-five patients (71 %) reported some form of bleeding postoperatively. Of

these 75 patients, 65 (87 %) experienced bleeding for less than 1 week. No patients
required surgical re-intervention or transfusion. Twelve men with benign prostatic
hyperplasia had a straight catheterization prior to extubation in the operative
theater. There was no urinary retention postoperatively.

All 106 (100 %) patients had follow-up at 3 weeks and 6 months, and 93 (88 %)
completed follow-up at 1 year. At 3 weeks, 98 patients (92 %) had no pain, while
seven patients (7 %) rated pain as one on the VAS and one patient (1 %) as two. At
3 weeks, 93 patients (88 %) were highly satisfied with the procedure. Prolapse
recurrence was noted in eight patients (7.5 %) at 6 months. Of these eight patients,
six originally had grade IV hemorrhoids, while the other two had grade III
hemorrhoids. At 1 year, 11 patients (10.3 %) reported recurrent prolapse and 98
patients (92 %) were highly satisfied with the procedure. Of the patients with
prolapse, two underwent a repeat THD procedure, while the remainder underwent
excisional hemorrhoidectomy.

Discussion
Hemorrhoidal tissue is an important component of fecal continence. Hemorrhoidal
disease is common and can significantly affect quality of life. While most
hemorrhoidal disease can be managed non-operatively, about 10 % of patients will
require surgery. Ideal surgical treatment should allow a rapid return to normal
activities, while maintaining normal anal anatomy and minimizing morbidity.
Conventional hemorrhoidectomy is the gold standard; however, patients may be
unable to return to normal activities for up to 3 weeks after this procedure because
of pain. After conventional hemorrhoidectomy, 25 % of patients may experience
sphincter dysfunction, 5–15 % postoperative bleeding or infection, and up to 30 %
recurrence [6].

THD has been shown to be safe and effective [22]. It allows patients to return to
normal activities immediately and to avoid many of the complications associated
with SH. In comparison with SH, THD has been associated with less pain [6]. In a
study by Festen et al., there was no significant difference in resolution of
preoperative symptoms between SH and THD at 6 weeks (SH 83 %, THD 78.3 %, p
0.648) [8]. Avital et al. showed that in comparison with SH, DGHAL was associated
with decreased hospital stay, time to first bowel movement, and time to complete
functional recovery (p = 0.001) [6]. However, patient satisfaction was significantly
higher with SH in this study (SH 92 %, DGHAL 82 %, p = 0.016). The authors
concluded that they still preferred DGHAL to SH due to decreased perioperative
morbidity [6].

Although, 75 of our patients (71 %) had some bleeding postoperatively with the
majority of them (87 %) experiencing it for less than a week, no patients required re-
intervention or transfusion. In a study done by Greenberg et al. following DGHAL,
11 % of patients required re-intervention for bleeding [27]. Felice et al. had one
patient who needed a transfusion secondary to postoperative bleeding [28]. While
bleeding is a common complication, re-intervention is usually not required.

Most of the patients treated in this study had grade III and IV hemorrhoids. Our 1-
year prolapse recurrence rate of 10.3 % is comparable to the 3–25 % recurrence rate
reported in the literature [5, 20, 21, 23, 25, 26]. In a review of DGHAL by
Giordano et al., the recurrence rate was noted to be 10.8 % at 1 year or more [29]. In
our study, two of the patients with recurrence underwent repeat THD and the
remainder underwent excisional hemorrhoidectomy.

Distal Doppler-guided dearterialization (DDD) is a newer variation of THD. Using

endorectal ultrasound, Ratto et al. showed that the hemorrhoidal arteries were
primarily extrarectal at 5–6 cm proximal to the anorectal junction (ARJ) as defined
by the puborectalis muscle and submucosal within 2 cm of the ARJ [30]. By
performing suture ligation within 2 cm of the ARJ, more consistent dearterialization
may be achieved. Mucopexy can still be performed with this technique. Using DDD,
Ratto et al. showed that only three out of 100 patients had postoperative bleeding.
Eight patients (8 %) had residual prolapse at 3 months, and five of those patients
required repeated mucopexy [31]. With mucopexy, as performed in our study, there
may have been unintentional ligation of more of the hemorrhoidal arteries than if
proximal dearterialization was performed without mucopexy. Incorporation of DDD
instead of a more proximal dearterialization may have improved our results
especially with regard to postoperative bleeding.

Ninety-eight patients (92 %) were highly satisfied with the procedure at 1-year
follow-up. Numerous studies have shown similar results ranging from 84–95 %
[5, 20, 27, 30, 32]. Scheyer et al. reported that 71 % of patients were satisfied with
DGHAL; however, a higher percentage, 91 %, would request it again and 93 % would
recommend it to a friend [33].

The cost-effectiveness with THD is equivocal with other procedures such as SH. At
our institution, the price difference between the hemorrhoid stapler and the THD
device is $120, in favor of the stapler. However, in a study done by Infantino et al.
[34], the stapler was $200 more expensive than the THD device. Further studies
will need to be conducted to evaluate cost-effectiveness.
 Since this is a single surgeon series, results may not be reproducible and there are
numerous other limitations to this study, including the small size, lack of recording
of pain medication, and lack of a protocol to assess specific symptoms other than
prolapse and patient satisfaction.

Conclusions
THD is a safe and effective treatment option and should be considered as an
alternative to those procedures associated with high morbidity. This same-day
procedure offers low morbidity with high potential for immediate return to normal
activity. Additionally, 92 % of patients were satisfied with the procedure.

Notes
Conflict of interest

None.

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LaBella, G.D., Main, W.P.L. & Hussain, L.R. Tech Coloproctol
(2015) 19: 153. https://doi.org/10.1007/s10151-015-1269-6
 DOIhttps://doi.org/10.1007/s10151-015-1269-6

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 Techniques in Coloproctology
February 2015, Volume 19, Issue 2, pp 83–87| Cite as

Abnormalities in collagen composition

may contribute to the pathogenesis of
hemorrhoids: morphometric analysis
 Authors
 Authors and affiliations
 Y. Y. Nasseri
 E. Krott
 K. M. Van Groningen
 M. Berho
 M. C. Osborne
 S. Wollman
 E. G. Weiss
 S. D. WexnerEmail author

o

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
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
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
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
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
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1. 1.
2. 2.
Open Access
Original Article
First Online: 09 November 2014
 4Citations
  9Shares

Abstract
Purpose
While hemorrhoidal disease is common, its etiology remains unclear. It has been
postulated that disturbances in collagen lead to reduced connective tissue stability,
and in turn to the development of hemorrhoidal disease. We aimed to compare the
quality and quantity of collagen in patients with hemorrhoidal disease versus
normal controls.

Methods
Specimens from 57 patients with grade III or IV internal hemorrhoids undergoing
hemorrhoidectomy between 2006 and 2011 were evaluated. Samples from 20
human cadavers without hemorrhoidal disease served as controls. Quality of
collagen was analyzed by collagen I/III ratio, and quantity of collagen was
determined by collagen/protein ratio. The study group was subdivided into gender
and age subgroups.

Results
The male:female ratios in the study and control groups were 30:27 and 10:10,
respectively. Median age was significantly less in the study group [46.9 years (range
20–69)] compared to the control group [76 years (range 46–90)] with P < 0.05.
Tissues from patients in the study group had significantly lower collagen I/III ratio
as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.0001). Nevertheless,
despite a trend toward lower collagen/protein ratio in the study group, it did not
reach statistical significance (57 ± 42.4 vs. 73 ± 32.5 g/mg; P = 0.167). There was no
difference in collagen I/III or collagen/protein ratios among different age groups
and genders.

Conclusions
Hemorrhoidal tissues from patients with hemorrhoidal disease appear to have
reduced mechanical stability as compared to normal controls.

Keywords
Hemorrhoids Collagen Pathogenesis Connective
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Introduction
Hemorrhoids have been described as far back as the pre-Christian era [1]. In 1830,
de Montégre [2] assembled an early literature review of 78 articles on hemorrhoids
published between 1582 and 1817. His manuscript remarked how little was known
about the overall prevalence and risk factors of hemorrhoidal disease; not much
 changed during the past 200 years. Although most colorectal surgeons recognize
that hemorrhoids are common, they are unaware of their true prevalence. Previous
studies have reported rates ranging from 4.4 [3] to 86 % in the general population
[4].

Hemorrhoidal disease is defined as the symptomatic enlargement and distal

displacement of the normal anal cushions [5]. The main theory regarding the
pathophysiology of hemorrhoidal disease suggest that they are the result of
abnormal dilation of veins of the internal hemorrhoidal venous plexus, abnormal
distention of the arteriovenous anastomosis, and prolapse of the cushions and the
surrounding connective tissue. Numerous factors have been linked with
hemorrhoidal disease including inadequate fiber intake, prolonged lavatory sitting,
constipation, diarrhea, and pregnancy. Family history of hemorrhoidal disease has
also been suggested as a possible etiology. However, there is no conclusive evidence
of hereditary predisposition.

Thompson [6] and Aigner et al’s [7] studies have shown that hemorrhoidal disease
is the consequence of disintegration of muscular and elastic components, leading to
distal shift of the vascular padding, and increased arterial blood flow of the terminal
branches of the superior rectal artery, respectively. Further, it has been suggested
that the degradation of the extracellular matrices in hemorrhoids during aging is a
decisive pathway in the development of hemorrhoidal disease [8]. The elastic and
tensile strength of hemorrhoids, as provided by elastic fibers and collagen,
respectively, and collagen metabolism, have also been postulated to have effects on
the development of hemorrhoidal disease [9]. Willis et al. [9] analyzed the quantity
and quality of collagen formation in the corpus cavernosum recti in patients with
grades III/IV internal hemorrhoids in comparison with a control group of
individuals without hemorrhoidal disease. They found that disturbances in collagen
I/III and collagen/protein ratios lead to reduced connective tissue stability, possibly
contributing to the development of hemorrhoidal disease. Nevertheless, their study
analyzed a relatively small number of patients with hemorrhoidal disease.

We sought to study a larger cohort of patients and compare the quality and quantity
of collagen in patients with internal hemorrhoidal disease (study group) versus
normal controls (control group) and among different genders and age groups within
the study group.

Methods
Patients
Patients with grade III or IV internal hemorrhoids who underwent standard
hemorrhoidectomies between 2006 and 2011 were identified. Specimens from these
patients were collected and fixed in 10 % formalin and immediately embedded in
paraffin for later analysis. The study group was further subdivided into one of two
genders and one of three age groups (20, 40, and 60 s).

The control group was made up of 20 human cadavers without hemorrhoidal

disease. In review of the past medical histories of these cadavers, hemorrhoidal
 disease was never listed as a condition they had. All 20 cadavers died of natural
causes and were made available from the Institute of Anatomy of the RWTH
Aachen, Germany. The cadavers were analyzed immediately after their arrival at the
institute, and the anal and deep rectal skin and submucosa were resected by
traditional hemorrhoidectomy. Specimens from the 20 controls were collected and
fixed in 10 % formalin after the procedure and immediately embedded in paraffin
for later analysis. An Institutional Review Board at the Cleveland Clinic Florida
approved this HIPAA compliant study. No identifiers were included in our study.

Collagen/protein ratio
The relative amount or quantity of collagen was measured by the collagen/protein
ratio. Fifteen-micrometer-thick specimens sealed in paraffin were collected from
each group and placed in test tubes. After the paraffin was removed, the slices were
stained with Sirius red and Fast green dyes (Polysciences, Warrington, PA, USA).
The samples were then rinsed several times with distilled water until the
supernatant was colorless. Next, the dyes were eluded from the sections by using
0.1 N NaOH in absolute methanol. The resulting fluid was then immediately
measured in a spectrophotometer at the wavelengths corresponding to the
maximum absorbance of Sirius red (535 nm) and Fast green (605 nm). Results were
expressed as the ratio of collagen (g) to non-collagenous protein (mg).

Collagen type I/III ratio

The quality of the collagen from the specimens was evaluated by the collagen I/III
ratio by means of cross-polarization microscopy at the same institution. Each
specimen was sliced into five-micrometer sections that were then stained for 1 h in
Picrosirius solution (0.1 % solution of Sirius Red F3BA in saturated aqueous picric
acid, pH 2). The sections were then washed for 2 min in 0.01 N HCl, dehydrated,
cleared, and mounted in synthetic resin. Thicker collagen I fibers were stained in re-
orange shades while thinner type III appeared as pale-green shades. For every
sample, 10 regions within the interface (400x, area 50 × 50 m) were captured by a
digital camera (Olympus C-3030, Hamburg Germany). The varying amounts of
collagen I/III ratios were obtained by analysis of the amount of collagen type I and
III using digital image analysis software (Image-Pro Plus, Media Cybernetics, Silver
Spring, Maryland, USA). Results are expressed as ratio of area of collagen type I and
III.

Statistics
Statistical analysis was performed by PGS Medical Statistics using SAS Statistical
software, V9.3. For the descriptive analysis, the mean, standard deviation (SD),
median, minimum, and maximum values (range), and the number of valid
observations were calculated in each group. A student’s t test was used to compare
the study and control groups and genders. Analysis of variance (ANOVA) was used
to compare the three age groups for the collagen I/III ratio, while a Kruskal–Wallis
test was used to compare the age groups for the collagen/protein ratio. A Pvalue
of <0.05 was used to indicate statistical significance.

Results
The mean age of the study group was 46.9 (20–69), which was significantly lower
than the mean age of the control group 76 (46–90) years with P < 0.05. The
male:female ratios for the study and control groups were 30:27 and 10:10,
respectively.

Collagen type I/III ratio

The mean collagen I/III ratio was significantly lower in patients with hemorrhoidal
disease as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.001;
Table 1). See Figs. 1 and 2 for representative comparative collagen I/III ratio slides.
Within the study group, there was no significant difference in the collagen I/III ratio
between men and women (4.4 ± 1.2 vs. 4.3 ± 1.0; P = 0.612) and among the 20 s
(n = 17), 40 s (n = 18), and 60 s (n = 22) aged subgroups (4.3 ± 1.2, 4.8 ± 1.2,
4.4 ± 1.0; P = 0.124; Table 2).
Table 1
A direct comparison of study versus control groups

M:F Mean Collagen P value Collagen/protein P value

ratio age in I/III (collagen ratio (g/mg) (collagen/
years ratio I/III)
(range)

Study 30:27 46.9 4.4 ± 1.1 P < 0.001 57 ± 42.4 0.167

(n = 57) (20–69)

Control 10:10 76 (46– 5.5 ± 0.6 73 ± 32.5

(n = 20) 9)
Open image in new window

Fig. 1
Sirius red—staining of collagen I (red) and collagen III (green) in a healthy control
person
 Open image in new window

Fig. 2
Sirius red—staining of collagen I (red) and collagen III (green) in a patient with
hemorrhoidal disease
Table 2
Comparison of different gender and age groups within the study group

Study Collagen P value Collagen/protein P value

(n = 57) I/III ratio (collagen ratio (g/mg) (collagen/protein)
I/III)

Gender

Male 4.4 ± 1.2 0.612 50.8 ± 32.6 0.258

(n = 30)

Female 4.3 ± 1.0 64 ± 50.9

(n = 27)

Age

20 s 4.3 ± 1.2 0.124 65 ± 62.8 0.314

(n = 17)

40 s 4.8 ± 1.2 46.3 ± 23.6

(n = 18)

60 s 4.1 ± 1.0 59.7 ± 34.4

(n = 22)

Collagen/protein ratio
The mean collagen/protein ratio was not significantly lower in patients with
hemorrhoidal disease as compared to the control group (57 ± 42.4 vs.
73 ± 32.5 g/mg; P = 0.167; Table 1). Within the study group, there was no
significant difference in the mean collagen/protein ratio between men and women
(50.8 ± 32.6 vs. 64 ± 50.9 g/mg; P = 0.258) and among the 20, 40, and 60 s aged
subgroups (65 ± 62.8, 46.3 ± 23.6, 59.7 ± 34.4 g/mg; P = 0.124; Table 2).

Discussion
Collagen is the major insoluble fibrous protein in the extracellular matrix and
connective tissue and is the single most abundant protein in the animal kingdom.
While there are at least 16 types of collagen, 80–90 % of the collagen in the body
consists of types I, II, and III [10]. Type I collagen fibers have immense tensile
strength and can withstand enormous forces, while type III collagen are thinner and
more immature [10, 11]. The strength and quality of connective tissue is primarily
determined by the amount and ratio of collagens Type I and III. Decreased Type I to
III collagen ratio translates into decreased amount of cross-linking and hence,
reduced mechanical stability of connective tissue.

Our data clearly indicated a decrease in Type I/III collagen ratio in patients with
hemorrhoidal disease as compared to normal controls. This finding may link
reduced mechanical stability and tensile strength in extracellular matrix with
development of hemorrhoidal disease. Our study further demonstrated a lower
trend in the collagen/protein ratio in patients with hemorrhoidal disease, although
this did not reach statistical difference as was seen in the Willis et al. [9] study. This
difference can be attributed to difference in the power of the two studies.

Although hemorrhoidal disease has been associated with older age, we failed to
demonstrate any difference in quality or quantity of hemorrhoids among different
age groups within the study group. This finding may be due to either the small
number of patients in each age group or to the fact that only patients with known
hemorrhoidal disease were compared. Perhaps there is a true degradation in
collagen with age in the general population, but due to genetic/hereditary factors,
patients with hemorrhoidal disease are subject to earlier and more rapid tissue
degradation.

The previously held belief that connective tissue disease directly correlates with
hernias and genitourinary prolapse may also hold true with hemorrhoidal disease
[12, 13]. As mentioned in the study by Willis et al., we too believe that
hemorrhoidal turnover and degradation is likely the sequelae of genetic, metabolic,
and environmental components.

One of the limitations of our study is the relatively small number of control patients.
One must bear in mind that it is difficult to find hemorrhoidal tissue from live
surgical patients without hemorrhoidal disease as those are usually found in
patients who have undergone abdominoperineal resections. Tissues from these
patients would not be ideal for the control group as they are usually from patients
with inflammatory bowel disease or low rectal or anal cancers, following
immunosuppressive use and chemoradiation, respectively; as such, we had to limit
our control group to cadaver tissues of patients who died of natural causes. A
possible criticism may be that cadaver tissues are different and not completely
comparable with live human tissue due to possible differences in processing and
preservation, as well as natural decay of tissues following death. Moreover, the
German cadavers’ collagen composition may differ from the control group in Florida
due to genetic influences and patient location. There is also a large difference in age
between the study and control groups. While the use of cadaver tissue as our
controls may be a potential weakness, it could also add strength to our study for
various reasons. First, we were able to show that the control group had better
quality collagen despite being at an advanced age with postmortem processing of
 tissue and subsequent morphological changes. Secondly, one could hypothesize that
age and postmortem processing may lead to lower quality collagen, but we found
this correlation not to be true. These findings support our point that genetic and
hereditary factors may lead to reduced quality collagen and thus an earlier onset of
hemorrhoidal disease. Within this study, we did not focus on collagen-vascular
disorders such as Ehlers–Danlos or osteogenesis imperfecta and the belief that these
disorders have a higher propensity to develop hemorrhoidal disease remains a
subject of future investigation.

The main strength of our study lies in the relatively large number of patients with
hemorrhoidal disease that were included. Additionally, our study likely gains further
validity as it re-enforces the results of the study by Willis et al. relative to collagen
I/III ratio and in the lack of difference among different age groups and genders.

The clinical relevance of our study may lie in the possible treatment options
targeting enhancement and stimulation of collagen as extrapolated from other
specialties. Bovine collagen injections have been used in the USA since the 1980s
and have proven effective for correcting soft tissue contour irregularities [14].
Intra-anal collagen injections have shown to be simple, safe, and effective in the
long-term treatment of fecal incontinence [15]. Additionally, fractional ablative
lasers have been shown to induce wound healing and collagen remodeling responses
[16]. Thus, collagen injections and lasers that enhance and stimulate collagen may
prove effective in the treatment of hemorrhoidal disease.

Notes
Conflict of interest

None.

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Copyright information
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Open AccessThis article is distributed under the terms of the Creative Commons
Attribution License which permits any use, distribution, and reproduction in any
medium, provided the original author(s) and the source are credited.

About this article

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Cite this article as:
Nasseri, Y.Y., Krott, E., Van Groningen, K.M. et al. Tech
Coloproctol (2015) 19: 83. https://doi.org/10.1007/s10151-014-
1238-5
 DOIhttps://doi.org/10.1007/s10151-014-1238-5

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
November 2014, Volume 18, Issue 11, pp 1081–1085| Cite as

Hemorrhoidal dearterialization with

mucopexy versus hemorrhoidectomy: 3-
 year follow-up assessment of a
randomized controlled trial
 Authors
 Authors and affiliations
 P. Denoya
 J. Tam
 R. BergamaschiEmail author

o

o

o
1. 1.
Open Access
Original Article
First Online: 24 September 2014
 17Citations

Abstract
Background
A randomized controlled trial showed that patients with grade III or IV internal
hemorrhoids had similar symptomatic relief of symptoms up to 3 months following
dearterialization with mucopexy or hemorrhoidectomy albeit with less postoperative
pain after the former. This study aimed to compare hemorrhoidal recurrence and
chronic complications at 3-year follow-up.

Methods
This study was carried out on 40 patients with grade III or IV internal hemorrhoids
previously enrolled to a randomized trial comparing dearterialization to
hemorrhoidectomy. Recurrence was defined as internal hemorrhoids diagnosed on
proctoscopy. Chronic complications were nonresolving adverse events related to
surgery. Outcome measures included patient-reported outcomes and quality of life
measured by brief pain inventory (BPI), SF-12, and fecal incontinence surveys.

Results
At median follow-up of 36 (27–43) months, 13 patients (32.5 %) were lost to follow-
up. Patient-reported outcomes suggested no difference between dearterialization
and hemorrhoidectomy in persistent symptoms, occurring in 1 (8.3 %) vs. 2 (13.3 %)
patients (p = 0.681) and in symptom recurrence, occurring in 6 (50 %) vs. 4 (26.7 %)
 patients (p = 0.212). On proctoscopy, recurrence was seen in 2 (13.3 %) vs. 1 (6.7 %)
patients (p = 0.411), all with index grade IV disease. One patient in each arm
required reoperation (p = 0.869). Chronic complications were not seen in the
dearterialization arm while they occurred in 2 (13.3 %) hemorrhoidectomy patients
(p = 0.189) and included unhealed wound (n = 1), anal fissure (n = 1) and fecal
incontinence (n = 1). There was a trend toward more patient reported than actual
recurrence on proctoscopy (10 vs. 3, p = 0.259). There was no difference in BPI, SF-
12, and fecal incontinence quality of life scores.

Conclusions
Recurrence rates did not differ significantly at 3-year follow-up and occurred in
patients with index grade IV hemorrhoids. Chronic complications occurred only
after hemorrhoidectomy.

Keywords
Hemorrhoids Ligation Doppler Dearterialization
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Introduction
Hemorrhoidal artery dearterialization was first described as a treatment for internal
hemorrhoids in 1995 by Morinaga [1] and has been popularized over the last decade
with the development of specialized anoscopes, which facilitate this procedure.
However, there is still controversy and skepticism surrounding this procedure as an
alternative to hemorrhoidectomy or stapled hemorrhoidopexy. While there is a
sufficient short-term data in the surgical literature, long-term data and randomized
data are lacking. While three quadrant excisional hemorrhoidectomy is considered
the gold standard procedure for advanced hemorrhoidal disease, it is not a perfect
operation. There is a significant pain and morbidity in the short term, and
recurrence and chronic complications are reported in the long term. A British study
with 17-year follow-up reported 26 % recurrence of hemorrhoids after excisional
hemorrhoidectomy [2], and another study with median of 7-year follow-up reported
that 40 % of patients complained of recurrent symptoms and 4 % developed anal
strictures [3]. In 2013, we published the short-term results of a randomized
controlled study treating grade III and IV internal hemorrhoids with either
hemorrhoidal dearterialization with mucopexy or Ferguson hemorrhoidectomy [4].
The study found less postoperative pain in the dearterialization patients and similar
resolution of preoperative symptoms with up to 3-month follow-up. The aim of this
study is to report and characterize the long-term results of these two techniques.

Methods
Study design
This was a follow-up study performed by telephone survey of patients who
underwent either hemorrhoidal dearterialization with mucopexy or excisional
hemorrhoidectomy as part of a randomized double-blinded trial [4]. All the patients
included in the study had grade III or IV internal hemorrhoids in a minimum of
three quadrants. Grade III internal hemorrhoids prolapse but are reducible and
grade IV internal hemorrhoids prolapse and are not reducible by the patient or do
not remain reduced [5]. Diagnosis was established by examination and anoscopy or
proctoscopy by a colorectal surgeon. As patients often present with anorectal
symptoms, which may be due to causes other than internal hemorrhoids, only
patients who were symptomatic and were found to have grade III or IV internal
hemorrhoids on examination were included in the study. This assured a
reproducible patient population. Patients were excluded if they had undergone
surgery for hemorrhoids previously. The procedures were performed under general
anesthesia or intravenous sedation with local anesthetic infiltration, in the
ambulatory surgery setting. Hemorrhoidal dearterialization with mucopexy was
performed using the THD kit (THD Italy, Corregio, Italy). The surgical technique
involves identifying six hemorrhoidal arteries by Doppler guidance and suture
ligating each one separately with a 2–0 absorbable suture. The same suture is then
used to perform the mucopexy up to 1 cm proximal to dentate line. This technique
was described by Ratto et al. [6]. The hemorrhoidectomy was performed as
described by Ferguson and Heaton [7]. Each hemorrhoid was excised by an
elliptical incision under exposure by an anal retractor. The incision was extended
cephalad. The hemorrhoidal pedicle was suture ligated, and the incision was closed
primarily. Patients were all discharged to home on the same day, with a prescription
for hydrocodone or oxycodone and instructions to use stool softeners, water baths,
and laxatives. They were seen 2 weeks after surgery and followed routinely up to
3 months. Following that period, they were seen on an as needed basis.

Institutional review board approval was obtained for this study. Patients were
contacted by telephone and asked to participate in the survey. The telephone
surveys were conducted by a blinded research assistant, who also reviewed the chart
for additional data. Patients who reported continued or recurrent anal symptoms
were asked to return to the office for examination by the surgeon.

Study endpoints
The primary endpoint for this study was rate of recurrence of internal hemorrhoids.
Recurrence was defined as internal hemorrhoids seen by the colorectal surgeon on
anoscopic or proctoscopic examination in patients who were symptomatic.
Additional endpoints examined included chronic complications, need for
reoperations, and patient-reported outcomes such as anal pain, anal bleeding, other
anal symptoms, current level of pain, level of fecal continence, and overall quality of
life. Chronic complications included anal stenosis, unhealed wounds, and anal
fissures persistent since surgery, and fecal incontinence developing immediately
after surgery. Current level of pain was measured using the brief pain inventory
(BPI), which is a validated pain assessment tool based on the Wisconsin Brief Pain
questionnaire [8, 9, 10]. Fecal continence was measured using the Fecal
Incontinence Quality of Life tool [11]. Overall quality of life was measured using the
SF-12 tool [12].

Statistical methods
 Patient data were entered into a Microsoft Excel© spreadsheet. SPSS© software
was used to analyze the data. Pearson’s chi-squared test was used for categorical
data, and Student’s t test was used for continuous data. Significance was
predetermined at α = 0.05.

Results
Of the original 40 patients, 12 were lost to follow-up and 1 dearterialization patient
refused to participate, resulting in a 68 % retention rate. A total of 12
dearterialization patients and 15 hemorrhoidectomy patients were included in the
study. The median follow-up was 35 months (range 27–43). The two arms of
patients had similar demographics except for gender distribution (42 vs. 94 %
male, p = 0.003). Demographics are summarized in Table 1.
Table 1
Demographics

Dearterialization n = 12 Hemorrhoidectomy n = 15 P

Gender 5 (41.7 %) 14 (93.9 %) 0.003

Age at index surgery 53.8 ± 8.8 53.1 ± 9.0 0.854

BMI 28.5 ± 6.9 29.3 ± 5.6 0.732

ASA 2.1 ± 0.3 1.9 ± 0.5 0.333

All of the patients who reported recurrent or persistent anorectal symptoms on the
telephone survey returned to the office for examination. Recurrence of internal
hemorrhoids was found on physician examination in two dearterialization patients
and one hemorrhoidectomy patient (16.7 vs. 6.7 %, p = 0.411). One dearterialization
patient was found to have a single grade III internal hemorrhoid, which was treated
with repeat dearterialization, and the other patient had recurrent grade IV
hemorrhoids and opted for nonoperative management with stool softener and fiber
supplementation. The patient who recurred after hemorrhoidectomy was found to
have grade IV hemorrhoids and was treated with repeat hemorrhoidectomy. This
patient had three very large prolapsing hemorrhoids at the index operation. On
examination at the time of recurrence, he again had three large prolapsing
hemorrhoids and significant bleeding requiring blood transfusion. These results are
summarized in Table 2. All three patients who had a recurrence had grade IV
internal hemorrhoids prior to the index surgery. Additional findings reported on
physician examination were external residual skin tags in five dearterialization
patients and one hemorrhoidectomy patient. Chronic complications were reported
in no dearterialization patients and two hemorrhoidectomy patients (Table 3).
These included an unhealed wound in one patient and a fissure and fecal
incontinence in another.
Table 2
Physician-reported recurrence of internal hemorrhoids
 Dearterialization n = 12 Hemorrhoidectomy n = 15 P
(%) (%)

Recurrence of 2 (16.7) 1 (6.7) 0.411

internal
hemorrhoids

Treated by 1 (8.3) 1 (6.7) 0.869

intervention

THD 1 (8.3) 0 (0.0) 0.255

Ferguson 0 (0.0) 1 (6.7) 0.362

Nonoperative 1 (8.3) 0 (0.0) 0.255

management
Table 3
Physician-reported chronic complications

Dearterialization n = 12 Hemorrhoidectomy n = 15 P
(%) (%)

Any 0 (0.0) 2 (13.3) 0.189

complication

Anal stenosis 0 (0.0) 0 (0.0) −

Unhealed 0 (0.0) 1 (6.7)* 0.362

wound

Fissure 0 (0.0) 1 (6.7) 0.362

Fecal 0 (0.0) 1 (6.7)* 0.362

incontinence
* Same patient
In the telephone survey results, one dearterialization patient and two
hemorrhoidectomy patients reported that the symptoms for which they had surgery
never resolved (p = 0.681). Six dearterialization patients and four
hemorrhoidectomy patients reported recurrent symptoms, including anal pain,
bleeding, and itching (p = 0.212). (Table 4) These symptoms were treated with stool
softeners, fiber supplements, warm water baths, and ointments, or suppositories.
Interestingly, there was a difference between patient-reported recurrent symptoms
(10) and actual confirmation of recurrent internal hemorrhoids (3) by a physician
(p = 0.259), though it was not statistically significant.
Table 4
Patient-reported outcomes
 Dearterialization n = 12 Hemorrhoidectomy n = 15 P
(%) (%)

Symptoms never 1 (8.3) 2 (13.3) 0.681

went away

Pt reported 6 (50.0) 4 (26.7) 0.212

recurrence of
hemorrhoids

Anal pain 1 (8.3) 1 (6.7) 0.869

Anal bleeding 2 (16.7) 2 (13.3) 0.809

Anal itching 1 (8.3) 0 (0.0) 0.255

The BPI was used to assess current pain in the patients. Results were similar in both
pain severity (p = 0.481) and interference in lifestyle due to pain (p = 0.259)
between the two arms. Quality of life was assessed both in terms of overall quality
(SF-12) and in terms of incontinence (FIQOL). In both scales, the quality of life
results were similar in both arms of the study. Results are summarized in Table 5.
Table 5
Functional data

Dearterialization n = 12 Hemorrhoidectomy n = 15 P

BPI pain severity 0.25 ± 0.62 0.60 ± 1.60 0.481

BPI pain interference 0.08 ± 0.29 0.40 ± 0.91 0.259

FIQOL

Lifestyle 1.18 ± 0.60 1.13 ± 0.52 0.827

Coping 1.27 ± 0.91 1.13 ± 0.52 0.623

Depression 1.18 ± 0.60 1.20 ± 0.56 0.938

Embarrassment 1.27 ± 0.91 1.13 ± 0.52 0.623

SF-12

PCS 56.09 ± 2.59 55.47 ± 3.31 0.609

MCS 55.09 ± 6.91 55.80 ± 6.86 0.797

Discussion
The gold standard surgical treatment for hemorrhoids is excisional
hemorrhoidectomy. While this method seems to have the best long-term result in
terms of recurrence of disease, it has several drawbacks. These include significant
postoperative pain, bleeding, constipation, urinary retention, and long-term
complications such as anal stenosis, nonhealing wounds, residual skin tags, and anal
incontinence. Surgeons have developed several less invasive procedures in the
search for a balance between acceptable relief of symptoms and less postoperative
pain and other complications. As with all new procedures, long-term results take
years to study, and the technology often becomes accepted into practice without
knowing how the procedure will hold up to the test of time.

Hemorrhoidal artery dearterialization was described two decades ago, but did not
become popular until more recently; therefore, long-term results are not widely
available. Additionally, many different terms are used to describe essentially the
same procedure in the literature. In order to identify studies reporting on this
procedure, one must use multiple terms, including combinations of “transanal
hemorrhoidal dearterialization (THD),” “Doppler-guided hemorrhoidal artery
ligation (DGHAL),” “mucopexy,” “anopexy,” “suture mucosal pexy,” and “rectoanal
repair.” Randomized trials or even comparative studies such as case–control
retrospective series are rarely available.

Zampieri et al. [13] reported in 2012 on a randomized trial studying transanal

hemorrhoidal dearterialization with proctopexy and ligasure hemorrhoidectomy.
The study included 114 patients, and follow-up was 1 year. Follow-up was conducted
by telephone interview. Patients included had at least grade III internal
hemorrhoids. The primary-reported outcome was resolution of pain. At 6 months,
THD patients had statistically significantly less pain than hemorrhoidectomy
patients, but at 1 year, pain was similar between the two groups. Recurrence of
internal hemorrhoids was not reported.

Another researcher randomized 40 patients to either THD with anopexy or

hemorrhoidectomy [14]. All patients had grade II or III internal hemorrhoids. At 1-
year follow-up, two patients who underwent THD had remaining grade III
hemorrhoids and seven patients had grade II hemorrhoids, and one patient who
underwent hemorrhoidectomy had remaining grade III hemorrhoids and three
patients had Grade II hemorrhoids. This difference in residual hemorrhoids was not
statistically significant between the groups.

Infantino et al. [15] randomized 167 patients to receive either stapled

hemorrhoidopexy (PPH) or THD. All patients had grade III internal hemorrhoids.
The authors report similar short-term complications, with long-term complications
occurring only in the PPH group. They report persistence or recurrence of internal
hemorrhoids in 14 % of THD patients and 7 % of PPH patients, which was not a
statistically significant difference. The mean follow-up was 17 months.

Avital et al. [16] reported 5-year follow-up on 100 patients who underwent DGHAL
without mucopexy by a single surgeon for grade II and III internal hemorrhoids.
Ninety-six patients answered the survey at 1 year and 92 at 5 years. In total, 89 %
were asymptomatic at 1 year and 73 % at 5 years. They found that most recurrences
occurred during the first year after surgery, and there was a trend toward more
recurrence in patients with grade III internal hemorrhoids.
Faucheron et al. [17] reported long-term results of 100 patients with grade IV
internal hemorrhoids who underwent DGHAL with rectoanal repair. The patients
were prospectively followed for a mean of 34 months. In total, 9 % had a recurrence
of hemorrhoidal prolapse at 11 months. Treatment for recurrence included repeat
DGHAL in three patients, hemorrhoidectomy in three patients, and nonoperative
management in the other three patients.

De Nardi et al. [18] recently reported a randomized trial of 50 patients with grade
III internal hemorrhoids who underwent either THD with mucopexy or
hemorrhoidectomy. The study period was up to 24 months. The authors noted less
pain in the THD arm in the first postoperative week, but no difference in pain
thereafter. Regarding recurrent symptoms, both techniques were equivalent after
2 years of follow-up.

In this study, we report long-term results of a randomized trial of patients with

grade III or IV internal hemorrhoids who underwent either transanal hemorrhoidal
dearterialization (THD) with mucopexy or three quadrant excisional
hemorrhoidectomy and were followed for a median of 35 months. The recurrence of
internal hemorrhoids did not differ significantly between the two groups.
Additionally, all the patients who recurred in both arms had grade IV internal
hemorrhoids at the time of the index operation. Long-term complications, including
unhealed wounds, fissures, and incontinence, were only found in patients who
underwent hemorrhoidectomy, though this difference was not statistically
significant. The patients themselves reported similar numbers of symptoms and
recurrence in both arms, and quality of life and pain scores were similar in both
arms as well.

This study has several weaknesses. We lost 13 patients from follow-up, which leads
to lower numbers and selection bias. This is an unfortunate consequence of our
patient population, which tends to change address or phone numbers frequently
when compared to some European populations. However, this reflects the real-life
scenario of any long-term follow-up study in the USA. The demographics of the
patients were similar in both arms except for gender distribution. Additionally,
there were no changes in surgical technique during the study period, and the two
surgeons involved performed both operations during the entire period of time. As
with any long-term study, the patients themselves choose whether to participate in
the survey or not, so this may lead to some selection or reporting bias. This may lead
to over or under reporting of recurrences or complications depending on which
patients choose to answer the questions. The total number of patients was small, so
it is possible that in a larger patient population, the difference in recurrence of
hemorrhoids would have been statistically significant. However, the number of
patients included is similar to other two-arm studies.

However, the study has significant strengths. We compared two surgical treatments
for hemorrhoids. We had strict definitions of the severity of disease being treated, as
well as definitions of complications. We used validated means of collecting patient-
reported outcomes, such as the BPI, SF-12 scale, and FIQOL questionnaire. The
length of the follow-up period is almost 3 years, which makes this one of the longer
studies reporting on hemorrhoidal dearterialization in the literature. As reported in
several other studies, most recurrences occur within the first postoperative year, so
 it is safe to assume that 3-year follow-up is an adequate measure of success for this
technique.

In conclusion, this study suggests that hemorrhoidal dearterialization with suture

mucopexy is as good as hemorrhoidectomy in the longer term, both in terms of
actual recurrence of internal hemorrhoids and in terms of patient satisfaction. It
may be more appropriate for grade III internal hemorrhoids, but may successfully
be used in grade IV disease as well. In addition, dearterialization is a safe procedure,
which not only provides less postoperative pain in the short term, but also enjoys a
low occurrence of chronic complications.

Notes
Conflict of interest

None.

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Denoya, P., Tam, J. & Bergamaschi, R. Tech Coloproctol
(2014) 18: 1081. https://doi.org/10.1007/s10151-014-1219-8
 DOIhttps://doi.org/10.1007/s10151-014-1219-8

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
May 2014, Volume 18, Issue 5, pp 495–501| Cite as

Usefulness of 3D transperineal
ultrasound in severe stenosis of the anal
canal: preliminary experience in four
cases
 Authors
 Authors and affiliations
 M. Kołodziejczak
 G. A. SantoroEmail author
 R. Z. Słapa
 T. Szopiński
 I. Sudoł-Szopińska

o

o
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o

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4. 4.
5. 5.
Open Access
Technical Note
First Online: 01 October 2013
 2Citations
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Abstract
Background
Organic or functional anal canal stenoses are uncommon conditions that occur in
the majority of cases as a consequence of anal diseases. A proper assessment is
fundamental for decision making; however, proctological examination and endoanal
ultrasound are often unfeasible or very difficult to perform even under local or
general anesthesia. We therefore began to use 3D transperineal ultrasound to assess
patients. The aim of this study was to compare the results of evacuation
proctography and 3D transperineal ultrasound in patients with severe anal canal
stenosis.

Methods
Four consecutive patients with high-grade anal canal stenosis were evaluated using
both proctography and 3D transperineal ultrasound with a micro-convex transducer
between March and June 2011.

Results
In all cases, 3D transperineal ultrasound provided detailed information on the
length and level of stenosis and on the integrity of the anal sphincters.

Conclusions
Our preliminary experience suggests that 3D transperineal ultrasound makes it
possible to plan optimal surgical treatment.

Keywords
Anal stenosis Three-dimensional ultrasound Transperineal ultrasound
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Introduction
Anal canal stenosis is an uncommon condition. Only rarely is it primary, due to
congenital malformations. The majority of cases develop as a consequence of anal
diseases leading to organic or functional stenosis [1]. Organic stenosis (i.e.,
stricture) typically results from scarring following crypt-related inflammatory
diseases (abscess, fistula), inflammatory bowel disease, overly extensive
hemorrhoidectomy, radiation therapy to the anorectal area or pelvis, anal canal
trauma, or a stenotic tumor [1]. Functional stenosis is caused by internal anal
sphincter hypertonus related to anal fissure or inflammation of the anal crypt
leading to sphincter hypertrophy [2, 3, 4, 5, 6, 7].
 The most common three-grade classification of anal stenosis takes into account the
results of rectal examination and evaluation with the Hill–Fergusson retractor [8].
Patients with first- and second-degree stenoses may be treated conservatively, while
third-degree stenosis requires surgical correction.

Preoperative assessment is fundamental for surgical planning; however, the digital

rectal examination, under local or general anesthesia, is often unfeasible or very
difficult. The most relevant information that the surgeon needs are length and level
of the stenosis, i.e., whether it is limited to the anal canal or includes the rectum,
and the status of the anal sphincters. Endoanal ultrasound (US) is the gold standard
investigation for the evaluation of the anal canal
[9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21]; however, it cannot be used in
patients with severe stenosis. Transperineal US has been used as an alternative
modality for the evaluation of the anal canal, with good agreement compared to
endoanal US [22, 23, 24, 25, 26, 27, 28]. Proctography can be also useful for the
assessment of the length of a stenosis in the anal canal.

We report our preliminary experience on the usefulness of three-dimensional (3D)

transperineal US compared to proctography in surgical decision making in 4 cases
of severe anal canal stenosis.

Materials and methods

Four consecutive patients with high-grade anal canal stenosis (one with a second-
degree and three with a third-degree stenosis) were evaluated between March and
June 2011. The three-grade classification of anal stenosis used in the study took into
account the results of rectal examination and evaluation with the Hill–Fergusson
retractor [8], where first-degree stenosis is a mild stenosis when digital rectal
examination is feasible with the use of a lubricant or middle-size Hill–Fergusson
retractor; second-degree stenosis—inability to introduce the index finger nor a mild
Hill–Fergusson retractor into anal canal; third-degree stenosis—inability to
introduce the 5th finger nor small Hill–Fergusson retractor.

The initial clinical patient evaluation and treatment were conducted at the
Department of Proctology, Hospital at Solec, whereas ultrasound examinations were
performed in the Department of Diagnostic Imaging, Medical University of Warsaw.

The protocol was approved by the Medical University’s review board, and all
participants gave written informed consent.

Imaging techniques
In all cases, proctography with the administration of uropolinum through a thin
catheter was performed prior to ultrasound examination.

Transperineal US was performed using a Voluson 730 scanner (General Electric

Medical Systems, Kretz Ultrasound, Zipf, Austria) with a multifrequency (3.3–
10 MHz) micro-convex, front-side view, automatic 3D transducer. The patient was
examined in dorsal lithotomy, with the hips flexed and abducted. The probe was
 placed on the perineum slightly anterior to the anus. Initial two-dimensional (2D)
US made possible adequate definition of the region of interest between the anal
margin and the lower third of the rectum. Then, 3D automatic acquisition was
performed. Analysis was conducted off-line from stored 3D data, using multiplanar
reconstructions, tomographic US imaging, and various volume rendering modes,
including minimum intensity projection, maximum intensity projection, and static
volume contrast imaging [9, 10]:

 Multiplanar reconstruction provided images of the region of interest in three

perpendicular planes (axial, sagittal, and coronal; Figs. 1a, 2a, c, 3). All three planes
are displayed simultaneously and can be moved and rotated to allow the operator to
visualize a lesion/area at different angles and to measure them precisely in any
desired direction. The unique feature of multiplanar reconstruction presentation is
the display of US data similar to anatomical sections or computed tomography
(CT)/magnetic resonance imaging (MRI) slices, which enables precise evaluation of
the pathology in regard to anatomical structures.

Open image in new window

Fig. 1
a Multiplanar reconstruction: on axial plane (upper left), irregular outlines of the anal
canal are visible (between calipers); on sagittal (upper right) and coronal (lower)
planes, short (1 cm long) stenosis of the anal canal with distended rectal ampulla
(arrow) is visible; b maximum intensity projection: distended rectal ampulla
(arrow) and proximal part of the anal canal above stenosis
Open image in new window
Fig. 2
a Multiplanar reconstruction: on axial view (upper left), a thin circular (arrow) scar in
the external anal sphincter and a bulky scar (arrowhead) that involves both
sphincters and is adherent to the anoderm are seen. Short (1 cm long) obstruction
with distended rectal ampulla (double arrowheads) is visible on sagittal (upper
right) and coronal (lower) planes. b Tomographic ultrasound imaging with static
volume contrast imaging. Bulky scar (arrowheads) on consecutive axial slices seen
in the upper part of anal canal (see the pilot sagittal image—upper
left). c Evaluation of volume of the bulky scar and its 3D presentation (lower right)
Open image in new window

Fig. 3
Multiplanar reconstruction: axial, sagittal, and coronal views of anal canal show
hypertrophy of internal anal sphincter (10 mm thickness; calipers) and hypoechoic
mucosa (arrows) devoid of normal folded pattern
 Tomographic US imaging, like CT or MRI scans, enables visualization of the whole
anal canal or just the lesion in consecutive planes (e.g., axial) to optimally present
the whole pathology in one display (Fig. 2b);

 Volume render mode enables the assessment of the content of 3D presentation of

the anal canal and surrounding tissues more precisely [11], using different post-
processing techniques:

 Minimum intensity projection, which employs an algorithm displaying an

interactive (e.g., with 360° rotation around the longitudinal axis of the anal canal)
3D image of dark (hypoechoic or anechoic) structures, e.g., hypoechoic internal anal
sphincter or hypoechoic scar.
 Maximum intensity projection, which employs an algorithm displaying an
interactive (e.g., with 360° rotation around the longitudinal axis of the anal canal)
3D image of bright (hyperechoic) structures, e.g., hyperechoic contents of a
distended rectal ampulla in a patient with anal canal stenosis (Fig. 1b). Such images
may resemble radiologic proctography with uropolinum.
 Static volume contrast imaging, which is a thin slice volume rendering technique
with combination of various algorithms, including surface algorithm (Fig. 2b). It
renders slices as thick as 2–10 mm and provides higher contrast and less noise than
a conventional display.

Analysis of 3D data was performed independently by 2 radiologists experienced in

proctological ultrasound and blinded to both each other’s evaluation and to the
patient’s clinical history. Assessment of inter-observer variability showed an overall
very good agreement (0.99, Kappa statistic 0.951) [29].

Results
Four patients with high-grade anal canal stenosis were evaluated using both
proctography and 3D transperineal ultrasound with a micro-convex transducer.
Patient’s characteristics, results of proctography, 3D ultrasound, and treatment
adopted are shown in Table 1.
Table 1
Proctographic and ultrasonographic findings in patients with anal stenosis

Patient Grade Etiology Proctography 3D Transperineal Surg

No. of ultrasonography treat
stenosis

1. 3rd Radiotherapy for Anal stenosis Stenosis of the Excisi

prostate cancer 1.5 cm long and distal 2/3 of the poste
dilated rectal anal canal and the an
ampulla dilated rectal and p
ampulla. Fibrotic intern
irregularities of the sphin
internal sphincter.
Regular external
sphincter

2. 3rd Sphincter repair Anal stenosis Anal stenosis 1cm Remo

1 cm long and long below the poste
dilated rectal dentate line. and a
ampulla Posterior scar flap in
involving the
internal and
external sphincters
and adherent to the
anoderm

3. 3rd Chronic anal Anal stenosis Anal stenosis 3.5 cm Partia

fissure 3 cm long long. Hypertrophic intern
 Patient Grade Etiology Proctography 3D Transperineal Surg
No. of ultrasonography treat
stenosis

(1 cm) internal sphin

sphincter with and
fibrotic changes fissur

4. 2nd Hemorrhoidectomy Anal stenosis Anal stenosis 3 cm Excisi

3.5 cm long long. Thickened poste
(1 cm) internal and a
sphincter with flap in
posterior scar
involving the
mucosa

Case 1
A 71-year-old man had a third-degree stenosis of the anal canal 3 years after
radiotherapy for prostate cancer. Uropolinumproctography showed a 1.5-cm-long
stenosis of the anal canal and a dilated rectal ampulla. 3D transperineal US
demonstrated a stenosis of the posterior distal 2/3 of the anal canal with dilatation
of the rectal ampulla proximal to the stenosis. Multiplanar reconstruction clearly
showed slight fibrotic irregularities of the internal anal sphincter (Fig. 1a).
Visualization of the rectum with maximum intensity projection was similar to
proctography. At surgery, the posterior scar was excised and the internal
sphincterotomy was performed in the same position. At 2-month follow-up, the
patient had no stenosis and did not complain of fecal incontinence.

In this case, proctography and 3D transperineal US (Table 1) were concordant,

showing that the whole rectum was distended and not affected by inflammation or
stenosis, as may occur following radiotherapy. In addition, US demonstrated normal
morphology of the external anal sphincter and only slight fibrotic changes in the
internal anal sphincter. These findings were crucial for surgical planning and to
avoid a colostomy, which would have been indicted in case of compromised anal
sphincters.

Case 2
A 40-year-old man had a third-degree stenosis of the anal canal secondary to
reconstruction of muscles damaged by sexual assault. Uropolinumproctography
showed a short (1 cm) stenosis of the anal canal and dilated rectal ampulla. 3D
transperineal US revealed a 1-cm stenosis below the dentate line, and an extensive
(0.6 cm3), posterior, hypoechoic scar, involving both the internal and external anal
sphincter and adherent to the anoderm. However, no residual of or recurrent
damage to the sphincters was found. Dilatation of the proximal anal canal on
coronal image at multiplanar reconstruction confirmed a short stenosis. Minimum
intensity projection provided images of the hypoechoic scar from different
angulations (Fig. 2). At surgery, the stenosing scar was removed and an anodermal
 flap was inserted. At 2-month follow-up, the patient had no stenosis and did not
complain of fecal incontinence.

In this case, both proctography and 3D transperineal US (Table 1) assessed the level
and length of the stenosis. Additionally, 3D ultrasonography provided a
preoperative evaluation of the anal sphincters, which was important in the surgical
strategy of removing the scar and fashioning a flap, rather than reconstructing the
sphincter muscles.

Case 3
This patient was a 73-year-old man with a third-degree stenosis of the anal canal
secondary to a chronic anal fissure. For several years, he had difficulty defecating
with more recent development of significant pain. Uropolinumproctography showed
a 3-cm stenotic anal canal. 3D transperineal US revealed a 3.5-cm stenosis of the
anal canal with a hypertrophic internal anal sphincter (1 cm thickness) presenting
an hyperechoic pattern due to fibrosis. The mucosa appeared hypoechoic; however,
it did not show the folded pattern seen on normal transperineal scans (Fig. 3).
Severe stenosis of the anal canal was confirmed at surgery. After dilatation,
hypertrophy and fibrosis of the internal anal sphincter and a posterior chronic anal
fissure were visualized. Partial lateral internal sphincterotomy with fissurectomy
was performed. Recovery was uneventful.

In this case, both proctography and 3D ultrasonography (Table 1) determined the

level and length of the stenosis. Additionally, 3D transperineal US provided relevant
preoperative information, demonstrating abnormal inflammatory changes in the
internal anal sphincter, but excluding an invasive anal cancer.

Case 4
A 39-year-old man with a history of hemorrhoidectomy, complained of obstructed
and painful defecation. On proctological examination, he had second-degree
stenosis of the anal canal due to scarring, as well as a posterior fissure.
Uropolinumproctography visualized a stenotic, 3.5-cm-long anal canal. On 3D
transperineal US, the length of the anal canal was 3 cm and the internal anal
sphincter appeared thickened (1 cm) with a posterior hyperechoic scar involving the
mucosa. At surgery, anal fissure and stenosing scar were excised with the insertion
of an anodermal flap. Recovery was uneventful.

In this case, proctography and 3D transperineal US (Table 1) were concordant on

the level and length of stenosis. However, the ultrasonographic finding of a
thickened internal anal sphincter with posterior scar guided the surgical decision to
construct a flap.

Discussion
The most relevant information needed for planning optimal surgical treatment for
anal canal stenosis are the length and level of the stricture, and whether the stenosis
is limited to the anus or involves the rectum as well the status of the anal sphincters.
 Assessment of severe stenosis with digital rectal examination or using conventional
endoanal US is often unfeasible or very difficult to perform even under local or
general anesthesia. Proctography may be used to measure the length of the stenosis,
but it requires radiation and complex instrumentation. External phased-array MRI
[30] could be a technique of choice in these patients; however, it is limited by costs
and availability. Conventional 2D transperineal US has been found to be a feasible
alternative to endoanal US, providing information on internal and/or external
sphincter defects [28]. Our preliminary study showed that transperineal US is also a
feasible, reliable, noninvasive, easy to perform, and rapid modality for the
evaluation of anorectal stricture. Compared to proctography, transperineal US not
only allows the measurement of the level and length of the stenosis, but also
provides additional information on the integrity of the anal sphincters, the status of
mucosal layer, and the presence of invasive anal cancer. The introduction of 3D US,
constructed from the synthesis of a large number of 2D images, has extended the
range of indications and improved the diagnostic accuracy due to multiplanar
reconstruction and tomographic US imaging [10, 11, 16, 17]. In our study, the
visualization of the anal canal in the axial, sagittal, and coronal planes made it
possible to differentiate and measure a “low” stenosis (from the anal verge to 0.5 cm
below the dentate line) due to scarring (patients 1 and 2) from a “complete” stenosis
due to hypertrophy or fibrosis of the internal anal sphincter caused by fissure
(patient 3) and hemorrhoidectomy (patient 4). The ultrasonographic data were
fundamental for surgical planning: sphincterotomy (patients 1 and 3) and various
techniques of anoplasty (patients 2 and 4), respectively.

A disadvantage of 3D transperineal US, however, is that it cannot visualize the

whole rectum due to its limited field of view. For this reason, in patients with
ultrasonographic evidence of a complete anal stenosis which may occur after
radiotherapy or in Crohn’s disease, proctography is also necessary.

In conclusion, the results of our assessment of anal stenosis with 3D transperineal

US are promising. In cases where standard digital rectal examination and/or
endoanal US are unfeasible, painful or potentially dangerous for the anal sphincters,
the transperineal ultrasonographic approach should be considered the technique of
choice [24]. Further studies with larger series of patients are needed to confirm our
preliminary findings.

Notes
Conflict of interest

None.

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Cite this article as:
Kołodziejczak, M., Santoro, G.A., Słapa, R.Z. et al. Tech
Coloproctol (2014) 18: 495. https://doi.org/10.1007/s10151-
013-1078-8
 DOIhttps://doi.org/10.1007/s10151-013-1078-8

 Publisher NameSpringer Milan

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Techniques in Coloproctology
March 2014, Volume 18, Issue 3, pp 291–298| Cite as
 THD Doppler procedure for hemorrhoids:
the surgical technique
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 Authors and affiliations
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Abstract
Transanal hemorrhoidal dearterialization (THD) is an effective treatment for
hemorrhoidal disease. The ligation of hemorrhoidal arteries (called
“dearterialization”) can provide a significant reduction of the arterial overflow to the
hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called
“mucopexy”) can provide a repositioning of prolapsing tissue to the anatomical site.
In this paper, the surgical technique and perioperative patient management are
illustrated. Following adequate clinical assessment, patients undergo THD under
general or spinal anesthesia, in either the lithotomy or the prone position. In all
patients, distal Doppler-guided dearterialization is performed, providing the
selective ligation of hemorrhoidal arteries identified by Doppler. In patients with
hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a
continuous suture including the redundant and prolapsing mucosa and submucosa.
The description of the surgical procedure is complemented by an accompanying
video (see supplementary material). In long-term follow-up, there is resolution of
symptoms in the vast majority of patients. The most common complication is
transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal
bleeding occurs in a very limited number of patients. Neither fecal incontinence nor
chronic pain should occur. Anorectal physiology parameters should be unaltered,
and anal sphincters should not be injured by following this procedure. When
accurately performed and for the correct indications, THD is a safe procedure and
one of the most effective treatments for hemorrhoidal disease.

Keywords
Hemorrhoids Dearterialization Mucopexy Hemorrhoidal
artery Prolapse Recurrence Complication

Electronic supplementary material

 The online version of this article (doi:10.1007/s10151-013-1062-3 ) contains
supplementary material, which is available to authorized users.

Download fulltext PDF

Introduction
Recent findings concerning the pathophysiology of the hemorrhoidal disease
[1, 2, 3, 4], and the development of new technologies for surgical treatment [5],
have favored a rapid spread of an innovative approach, the ligation of hemorrhoidal
arteries, with or without pexy of prolapsing rectal mucosa/submucosa. A number of
procedures have been devised using Doppler guidance and different surgical
devices. Recent reviews [6, 7] have evaluated these techniques grouping them
together, generating some confusion between different procedures. This paper
provides an overview of the technical aspects and perioperative management of one
of the most widely used techniques, transanal hemorrhoidal dearterialization
(THD). This surgical procedure is primarily oriented toward the management of the
main symptoms of hemorrhoidal disease (i.e., bleeding, prolapse, and pain),
intervening on its pathophysiological processes. THD is based on two technical
steps: (1) the targeted ligation of hemorrhoidal arteries (called “dearterialization”),
using a very sensitive continuous Doppler probe able to identify the maximal flow;
(2) the plication and lifting of redundant and prolapsing rectal mucosa/submucosa
(called “mucopexy”).

Patient assessment
An accurate assessment of patient’s history is mandatory, particularly concerning
symptoms related to hemorrhoidal disease. Then, both anorectal examination and
anoscopy are carried out to evaluate hemorrhoidal engorgement, spontaneous
bleeding, and eventual prolapse of piles and rectal mucosa/submucosa, both at rest
and during straining. In particular, reducibility of hemorrhoidal prolapse should be
assessed. Anal skin tags should also be noted and distinguished from real
hemorrhoidal prolapse. Other anal and/or rectal diseases and functional disorders
must be diagnosed/excluded. In particular, patients complaining of symptoms of
obstructed defecation should be further investigated. Finally, endoscopic
assessment of the colon and rectum should be performed according to the guidelines
for colorectal cancer screening.

Indications
Transanal hemorrhoidal dearterialization should be reserved for patients presenting
active hemorrhoidal disease despite lifestyle/diet interventions, drug therapy, and
minor office procedures such as rubber band ligation or sclerotherapy. Indications
should be established on the basis of the patient’s symptoms and physical findings.
If the main complaint is bleeding, this can be addressed by dearterialization alone,
ligating of the hemorrhoidal arteries along the low rectal circumference. Usually, at
least 6 arteries are found and ligated using the THD Doppler device. In case of
bleeding associated with hemorrhoidal or mucosal and hemorrhoidal prolapse,
mucopexy should be added to the dearterialization. In fact, mucopexy can be
 regarded as an “on-demand” step of THD, depending also on the location and
severity of mucosal prolapse (in terms of its length). It is mandatory that the
prolapsing hemorrhoidal piles and rectal mucosa should be reducible, so that they
will reach their respective anatomical sites. Therefore, fibrosed piles cannot be
treated with THD. When the prolapse involves the whole rectal circumference, 6
separate mucopexy sutures may be placed. Alternatively, if there is only limited
circumferential involvement, a smaller number of running sutures should be used.
Patients, who complain of mucosal and hemorrhoidal prolapse or hemorrhoidal
prolapse alone, usually have a history of bleeding, which disappeared in the later
phase of hemorrhoidal disease in accordance with the pathophysiological evolution
of the disease. These patients should undergo both dearterialization and mucopexy
following the same criteria mentioned above. Mucopexy can be adapted to different
lengths of mucosal prolapse, making longer or shorter running sutures. However,
attention must be paid to misdiagnosed internal rectal intussusception, which is not
amenable to mucopexy used for the hemorrhoidal prolapse. According to the
Goligher’s classification, 1st degree or initial 2nd degree hemorrhoids, unresponsive
to conservative treatment or minimal surgery, may be addressed by dearterialization
alone. More advanced 2nd degree, 3rd degree, and 4th degree (except in the case of
fixed, fibrotic piles) should undergo dearterialization and mucopexy.

Patients with skin tags should be advised that these are not real hemorrhoids, but
the consequence of previous engorgement and dislodgement of hemorrhoidal
cushions toward the perianal skin. Since THD does not provide any specific
treatment for skin tags, only surgical excision can be a reliable treatment when
indicated or desired.

Patients with hemorrhoids who suffer from inflammatory bowel disease deserve a
special mention. There is a lack of studies specifically addressing patients with
Crohn’s disease or ulcerative colitis operated on with THD. However, providing that
no severely active inflammation is demonstrated on the rectal mucosa, this method
may be suitable in patients with hemorrhoids resistant to conservative treatments.
The same concept applies to hemorrhoidal disease in patients with chronic radiation
proctitis.

Preparation for surgery

This is a matter of the surgeon’s preference as there are no absolute guidelines in
hemorrhoidal surgery. The same is true also for the THD procedure. Because it is
performed within the lower rectum, one or two enema(s) should be prescribed. The
Author does not consider antibiotic prophylaxis as mandatory as in his experience
no infections have been observed following this operation.

Anesthesia
Transanal hemorrhoidal dearterialization can be performed under both general and
locoregional anesthesia. Propofol-remifentanil anesthesia, with the placement of a
laryngeal mask, combines general anesthesia, complete control of vital parameters,
and quick reversion and discharge from the hospital. Spinal anesthesia may be
limited to the most caudal metameric nerve roots avoiding any prolonged stay in
bed. Unfortunately, spinal anesthesia is usually associated with a higher risk of
 urinary retention, especially following hemorrhoid surgery. More limited
locoregional anesthesia (i.e., posterior perianal block) does not ensure a complete
intraoperative analgesia due to the visceral pain elicited by surgical ligation,
suturing for plication, and tying knots on the rectal mucosa.

Intraoperative management
The patient can be placed in either the lithotomy or the prone position, based on the
surgeon’s preference. However, it should be taken into consideration that the
lithotomy position allows a more realistic position of the prolapsing hemorrhoids
and rectal mucosa. An accurate intraoperative monitoring of blood pressure could
be helpful. In particular, systolic pressure higher than 100–110 mmHg allows
auscultation of a Doppler signal necessary for the identification of the hemorrhoidal
arteries.

Equipment
Transanal hemorrhoidal dearterialization is performed using a specific device
produced by THD S.p.A., Correggio, Italy. It consists of a proctoscope equipped with
a Doppler probe and a light source (Fig. 1). The Doppler probe utilizes a double
crystal, which allows a more precise focusing of the ultrasound waves and capturing
of large-diameter arteries located in the superficial layers of the rectal wall.
Sufficient space is provided around two crystals for their adequate vibration. The
Doppler probe is mounted on an oblique support, oriented toward the operative
window, so that the artery identified by the Doppler signal lies within the operative
window and can be selectively ligated.

Open image in new window

Fig. 1
Surgical instruments specifically designed for the THD procedure

The latest proctoscope model (THD Slide ®, THD S.p.A., Correggio, Italy) has a
sliding part comprising the operating window and the Doppler probe, so that the
operator can move them proximally and distally without repositioning the
proctoscope. The section of the proctoscope is elliptical, with an external maximum
diameter of 32–34 mm and an internal diameter of 20–34 mm.

The recommended suture is 2–0 absorbable polyglycolic acid with a 5/8-in. needle.
This is mounted on a specially designed needle holder, providing a mark on the tip
where the needle should be held. With this configuration, the needle holder tip can
be inserted into the pivot, and the needle rotates to transfix the rectal mucosa in a
standard fashion. The depth of the transfixed stitches can be easily and safely
 calibrated up to a maximum depth of 6.5 mm, which includes only mucosa and
submucosa avoiding penetration through the full thickness of the rectal wall and
therefore lowering the risk of perirectal fistula and abscess. A knot-pusher is also
provided in case is needed.

Distal Doppler-guided dearterialization (DDD)

Surgical anatomy of the hemorrhoidal arteries
Aim of hemorrhoidal dearterialization is to significantly reduce the arterial overflow
in the hemorrhoidal tissue, characteristic of patients with hemorrhoidal disease. The
anatomical and physiological characteristics of hemorrhoids have not been fully
elucidated. Microscopically, hemorrhoidal tissue is composed of sinusoids, i.e.,
vascular structures without a muscular wall [8]. Direct arteriovenous
communications have been demonstrated histologically and radiologically, and
some authors have noted a resemblance to erectile tissue [9]. Traditionally, with the
patient in the lithotomy position, hemorrhoids frequently appear to be localized to
the left lateral, right posterolateral, and right anterolateral areas of the anal canal.
However, this configuration is demonstrated in less than 20 % of patients [10]. In
reality, a wider network of arterial and venous vessels has been described [11].
Schuurman et al. [1] studied 10 non-fixed human cadavers in order to assess the
arterial vasculature of the rectum and arterial supply to the hemorrhoids. Selective
injections of different colors were used. The authors found that, about 2–3 cm above
the dentate line, thin tortuous arteries (a mean number of 8, all branches of the
superior hemorrhoidal artery) were seen lying in the submucosa, reaching into the
hemorrhoidal tissue. Smaller branches from these arteries formed a plexus in the
corpus cavernosum recti area.

In our recent study [12], the majority of arteries in the upper part of the lower third
of the rectum (4–6 cm from the anorectal junction) were located outside the rectal
wall. In contrast, within 2 cm from the anorectal junction, hemorrhoidal arteries
were detected in the submucosa in 98 % of the 6 sectors of the rectal circumference
(96.6 and 100 % of sectors at 2 and 1 cm above the anorectal junction, respectively).
Therefore, in their course through the lower third of the rectum, the hemorrhoidal
arteries traverse the muscularis propria of the rectum and become more superficial.
These features can be easily confirmed during Doppler-guided surgical procedures.
The different Doppler signals are dependent on the position of the artery (perirectal,
perforating the rectal muscle, or submucosal), the distance from the Doppler probe,
and the direction of blood flow in relation to the ultrasound waves emitted by the
probe. In fact, the intensity of the Doppler signal is the inverse of the cosine of the
angle between the ultrasound waves and blood flow. As a consequence, the more
perpendicular the blood flow to the ultrasound waves (i.e., artery into the perirectal
tissue or submucosa) the higher the Doppler signal. On the other hand, the more
parallel the flow (i.e., artery traversing the rectal muscle) the lower the signal
(Fig. 2). The proximity of the artery to the probe when the artery is submucosal
makes the Doppler signal higher than that perceived at the proximal sites.
 Open image in new window
Fig. 2
Schema justifying different Doppler signals occurring during THD as related to
arterial blood flow. According to this physical law, the intensity of the Doppler signal
is the inverse of the cosine of the angle between the ultrasound waves and blood
flow. The more perpendicular the blood flow to the ultrasound waves (i.e., artery
into the perirectal tissue or submucosa) the higher the Doppler signal; the more
parallel the flow (i.e., artery perforating the rectal muscle) the lower the signal

Technique
Following gel lubrication, the proctoscope is inserted through the anal canal
reaching the low rectum, about 6–7 cm from the anal verge. The surgeon can decide
to start the operation at any point of the rectal circumference and proceed in a
clockwise or anticlockwise direction. The Doppler system is then turned on. The
Doppler signal corresponding to all 6 main trunks of the hemorrhoidal arteries,
which are usually located at 1, 3, 5, 7, 9, and 11 o’clock of the low rectal
circumference, is sought by slowly rotating and/or tilting the proctoscope. However,
searching with the Doppler probe makes possible correct identification of those
arteries not located at the usual odd hours positions. The proctoscope is pulled
slowly back to follow the artery distally up to hemorrhoidal apex, and the best
Doppler signal is searched for. According to the above-mentioned features from our
previous study [12], the Doppler signal is quite clear at the proximal site
(corresponding to the proximal part of the lower rectum, where, however, arteries
could lie in the perirectal fat), attenuated or absent at the intermediate site (where
the artery is perforating the rectal muscle), and again clear at the distal site (within
the most distal 2 cm of lower rectum, where the artery lies in the rectal submucosa,
just above the internal hemorrhoidal piles, Fig. 3). As a consequence of anatomical
and acoustic findings, the best place to find the hemorrhoidal arteries should be the
most distal part of the rectum: This is the fundamental principle of distal Doppler-
guided dearterialization (DDD) [13]. After identification of the best place for artery
ligation, the Doppler system is turned off.
Open image in new window
Fig. 3
Schema of the anatomical course of a hemorrhoidal artery and different levels of
Doppler signal related to the position of the artery
If the patient is a candidate for dearterialization alone (i.e., the patient only has
bleeding without prolapse), the artery, once identified, can be directly ligated with a
“Z-stitch” at the site of the best Doppler signal (Fig. 4). When the patient needs to
undergo dearterialization and mucopexy (due to hemorrhoidal or muco-
hemorrhoidal prolapse), the rectal mucosa can be marked with electro-cautery
(“marker point”) at the site of the best Doppler signal (Figs. 5, 6) to indicate where
the artery will be ligated. Then, a mucopexy follows (see below).

Open image in new window

Fig. 4
Suture of a hemorrhoidal artery during DDD procedure
 Open image in new window
Fig. 5
Schema of mucopexy fixation point and continuous suture

Open image in new window

Fig. 6
“Marker point” on the distal rectal mucosa to identify the best Doppler signal
obtained from the submucosal hemorrhoidal artery

Mucopexy (MP)
Pathological anatomy of hemorrhoidal prolapse
Normally, the hemorrhoidal cushions are loosely attached to the circular muscle
through the elastic rectal submucosa, which keeps the piles in the anal canal at rest.
During defecation, rolling of the hemorrhoids inside the lumen occurs, favored by
the internal anal sphincter relaxation. The fecal bolus has a shearing effect on the
cushions and facilitates their prolapse [14, 15, 16]. On the other hand, the
elasticity of the rectal submucosa keeps the piles inside the rectum. In patients with
hemorrhoidal disease, due to altered defecation and other predisposing factors [17],
the rectal submucosa progressively loses its elasticity, determining hemorrhoidal
prolapse [15, 16, 18]. The progressive disruption of both the connective tissue
stroma (Park’s ligaments) and anchoring system (Treitz’s muscle) plays a major
role. Severity of prolapse is related to persistence of pathogenic factors,
engorgement of piles, and progressive loss of the elasticity of the rectal submucosa.
Transanal hemorrhoidal dearterialization with mucopexy provides plication of the
rectal submucosa affected by the loss of elasticity. It is reduced stably into the rectal
ampulla, recovering its anatomical position. Furthermore, the scarring process
induced by the mucopexy attaches the plicated mucosa and submucosa to the
underlying rectal muscle.

Technique
Following the identification of the hemorrhoidal artery, the proctoscope is again
pushed fully inside the distal rectum, and a “Z-stitch” is made as a proximal
“fixation point” of MP. The circular device pivot can be used to do this. The proximal
end of MP is not standard, depending on the length of prolapsing mucosa and
submucosa. Then, the knot is tied (Fig. 7). Thereafter, the main proctoscope
remains in place, and only its sliding part is moved back, exposing the rectal mucosa
so that MP can be performed under direct vision. MP is carried out with a
continuous suture, including the redundant and prolapsing mucosa and submucosa,
in a proximal-to-distal direction, along a longitudinal axis (Figs. 5, 8). The
recommended distance between each suture is approximately 0.5 cm, which is
optimal in order to avoid sutures that are too tight (a shorter distance has a lesser
plicating effect as well as increased risk of tissue ischemia) or too loose (a longer
distance with consequent formation of wide enfolding of rectal mucosa/submucosa
and increased risk of early postoperative rupture of the running suture). While
performing MP, when the “marker point” is visualized, the surgeon takes care to
make a passage of the running suture above and another below the “marker point,”
in order to entrap the hemorrhoidal artery within the running suture and
accomplish the dearterialization according to the DDD principle (Fig. 9). Each
vertical row should be spaced from the adjacent one in order to guarantee enough
blood outflow from the hemorrhoids via the venous plexus. In fact, a circumferential
obliteration of rectal tissue might create a significant obstacle for the blood and
consequently an increased risk of postoperative thrombosis. The MP running suture
is stopped at the proximal apex of the internal hemorrhoid, avoiding its inclusion in
the mucopexy. When performed this way, the THD method can effectively be
considered a hemorrhoid-sparing procedure. Finally, the suture is gently tied
(Fig. 10).

Open image in new window

Fig. 7
Fixation Z point at the proximal edge of the mucopexy continuous suture
Open image in new window
Fig. 8
Mucopexy continuous suture
Open image in new window

Fig. 9
Passages of the mucopexy continuous suture above (a) and below (b) the marker
point to entrap the hemorrhoidal artery
 Open image in new window
Fig. 10
Mucopexy suture is secured without including the hemorrhoid

Postoperative management
A diet rich in fluids (oral intake of at least 2 l of water per day) and fiber is
established, eventually supplemented by oral assumption of stool softeners. Use of
laxatives is advisable. In fact, especially in patients who underwent MP, not only
constipation but also diarrhea and increased frequency of bowel movements could
cause an early disruption of the rectal sutures and, then, possible bleeding from the
mucopexy suture(s) and early recurrence of prolapse. Scrupulous adherence to a
dietary protocol is usually recommended during the first 2–3 postoperative months,
and the patient is encouraged to continue a high residue diet after this time period.
Patients with either chronic diarrhea or irritable bowel syndrome should be put on a
very carefully controlled diet and pre-/probiotics. On the other hand, those with
either chronic inflammatory bowel disease or chronic radiation proctitis must
continue the specific therapy as prescribed; a sudden worsening of their condition
should be diagnosed early and treated.

Postoperative care should be strongly directed toward the control of pain and
tenesmus. The source of these symptoms is the surgical site (not the hemorrhoidal
cushions) and is related to the plication of the rectal mucosa/submucosa. This can
cause an inflammatory response (with edema and inflammatory reaction) associated
with relative ischemia of those tissues, which causes both pain and tenesmus. As a
consequence of the inflammatory process, MP patients can have a mucous,
sometimes bloody, anal discharge for a few days. When both piles and the sensitive
mucosa of the anal pecten are spared during MP (as described above), these are not
the source of pain and tenesmus, unless a hemorrhoidal thrombosis has developed.
The severity of pain and tenesmus could be dependent not only on the surgical
procedure but also on the patient’s tolerance level to pain; in that case, their
management of these symptoms should be specially tailored. Patients who undergo
dearterialization alone usually suffer minor pain and/or rectal discomfort, lasting
from a few hours to a few days. In these patients, anti-inflammatory drugs and/or
 analgesics can be prescribed “as needed.” Patients who had MP more frequently
report tenesmus and pain. In these patients, non-steroidal anti-inflammatory drugs
(NSAIDs) should be given around the clock for at least 3 days, and other analgesics
when requested. With these measures, in the author’s experience, both edema and
related symptoms are reduced. Usually, patients can discontinue this postoperative
regimen after a few days, and only a minority of them needs it for more than 7 days.

Urinary retention develops in about 10 % of patients, especially those who undergo

MP and males. To prevent this, restriction of excessive intravenous infusion of fluids
is advisable. Treatment should consist only in temporary bladder catheterization.

Tenesmus can be accompanied by a transient sensation of urge to defecate. This is

usually transient, with resolution within 7–10 days, and does not give rise to any
form of persistent urgency, soiling, or fecal incontinence.

Follow-up
The follow-up includes 4 different time points. At the first visit, 7–10 days after the
procedure, a digital anorectal examination is never carried out, but only an external
inspection to avoid the risk of pulling on the stitches. At this time, particular
attention is also paid to normalizing defecation with diet and laxatives. Usually,
bleeding is no longer present. In a minority of patients after MP, some bloody
mucus is referred, due to the early postoperative inflammatory process.
Inflammation can also determine mild fever along the first 2–3 postoperative days,
usually self-limited and responding to anti-inflammatory drugs. Tenesmus can be
referred after MP at this time and gradually improves. Only minority of patients still
require analgesics. The second follow-up visit is made after 1 month. The patient’s
anorectum is digitally explored and assessed. Rectal pain, discomfort, and tenesmus
should no longer be present. Persistence of these symptoms should be investigated.
In case of some hemorrhoidal prolapse is preset or reported, this is suspicious of
suture disruption, usually secondary to defecatory dysfunction. Also intermittent,
self-limited episodes of bleeding can be indicative to MP disruption. Anal
continence should be fully normal. At the 3 month follow-up visit, the patient is also
evaluated with anoscopy. At that time, when the procedure is successful, all
symptoms are resolved. Volume and appearance of hemorrhoidal cushions are that
of patients without hemorrhoidal disease. Persistent or new bleeding or prolapse
will require a closer follow-up. Thereafter, patients are contacted by telephone and
examined 1 year after surgery. A long-term annual follow-up may be established. If
any symptom related to a possible recurrence of hemorrhoidal disease is reported,
the patient undergoes digital examination and anoscopy.

Complications and management

The most common complication is tenesmus, which sometimes can turn into rectal
discomfort or pain. It can be managed with analgesics and anti-inflammatory drugs
as described above. However, these symptoms rapidly disappear. Rectal bleeding
can occur in a very limited number of patients, usually within 2 weeks after the
operation. It can be caused by trauma of the rectal mucosa involved in the surgical
procedure (especially MP) during prolonged straining, passage of hard stool, or
diarrhea. In fact, excessive suture traction can be generated and can lead to
 breakage. Moreover, the relative tissue ischemia at the level of the MP suture line
can result in a limited necrosis of the mucosa/submucosa and consequent bleeding.
In both cases, the removal of clots by saline solution lavage (performed with a soft
catheter) can usually stop the bleeding. If bleeding continues and increases in
frequency and intensity, it is necessary to perform an endoscopic or surgical
hemostasis (cauterization, endoclip, and suture).

In the author’s experience, THD, performed according to the principles outlined

above, is never followed by fecal incontinence and chronic pain. Indeed, anorectal
physiology parameters should be unaltered, and anal sphincters should not be
injured by this procedure [19].

Recurrences and their management

In case of recurrence, the treatment decision making is guided by the symptoms.
Recurrence of rectal bleeding can occur in cases where the dearterialization was not
successful in one or more rectal sectors. Severity of bleeding is usually less than in
the initial presentation and can be easily managed with medical therapy, rubber
band ligation, or new dearterialization under Doppler guidance.

In the majority of cases of recurrent prolapse, the cause seems to be the disruption
of MP suture(s) with difficult defecation early in the postoperative period or later
due to chronic straining. To prevent this occurrence, an optimal diet and fiber
supplements are necessary in case of constipation, or prompt treatment for IBS and
IBD symptoms. Patients with recurrent prolapse can be managed conservatively if
the prolapse is minimal. Re-do MP is technically possible although other strategies
such as excisional hemorrhoidectomy can also be adopted.

Conclusions
Transanal hemorrhoidal dearterialization is a valid therapeutic option in patients
with hemorrhoidal disease. It can provide effective control of symptoms in the vast
majority of patients. Accuracy in both dearterialization (using the “DDD” procedure)
and mucopexy (repositioning the prolapsing rectal mucosa and submucosa,
completely sparing the piles) seems the key to therapeutic success. However,
patients must be informed about postoperative management. The limited number
and severity of complications makes THD very safe. Finally, THD can be used in
case of recurrent disease.

Notes
Conflict of interest

The author was speaker at a number of congresses/training courses about the THD
Doppler procedure.

Supplementary material
 Supplementary material 1 (MP4 141049 kb)
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Cite this article as:
Ratto, C. Tech Coloproctol (2014) 18: 291.
https://doi.org/10.1007/s10151-013-1062-3
 DOIhttps://doi.org/10.1007/s10151-013-1062-3

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
March 2014, Volume 18, Issue 3, pp 323–324| Cite as

The first Phuket International

Symposium on Colorectal Disease:
postgraduate course of the Asia Pacific
Federation Congress 2013 of the
International College of Surgeons
 Authors
 Authors and affiliations
 E. SilvaEmail author
 M. Boutros

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1. 1.
2. 2.
Open Access
Congress Report
First Online: 07 February 2014
Download fulltext PDF

The first Biennial International Symposium on Colorectal Disease held in Phuket,

Thailand, from Dec 8 to Dec 10, 2013, was hosted by the governor of the
International College of Surgeons, assistant professor and chief of the colorectal
department of the Bangkok Hospital Phuket, Dr. Art Hiranyakas on behalf of the
International College of Surgeons, the Society of Colon and Rectal surgeons of
Thailand, Vachira Phuket Hospital and Bangkok Hospital Phuket. It was
undoubtedly a unique opportunity to hear from internationally acclaimed speakers
and experience the most exotic and exceptional Phuket beauty. The three-day
exhilarating meeting agenda focused on rectal cancer treatment and advances in
colorectal surgery. On the first day, a stimulating live surgery session, moderated by
Dr Giovanni Milito, Professor of Surgery, Tor Vergata University Hospital, Rome,
Italy, was held showcasing parallel laparoscopic and robotic low anterior resections
for distal rectal cancer performed by Drs. Steven Wexner and Seon-Hahn Kim,
respectively. The cases were followed by a live demonstration of total mesorectal
excision specimen examination and an assessment of mesorectal integrity by the
expert gastrointestinal pathologist Dr. Mariana Berho, Chairman of the Pathology
and Laboratory Medicine, Cleveland Clinic Florida. This lively and highly
informative session prompted an excellent exchange among experts and the
attendees.

The Honorary Lecture on “Colorectal Surgical Education—A Prescription for the

Future” by Steven Wexner inaugurated the second day of the conference with a
comprehensive review of colorectal surgery education and standards of training,
followed by an eye-opening exposition of the challenges and goals for future
colorectal training around the world. Dr. Steven Wexner’s lecture served as a perfect
prelude to the remainder of the day, which highlighted the complex expertise
required for state-of-the-art rectal cancer treatment. The multidisciplinary nature of
successful rectal cancer was elegantly taken into account throughout the entire
meeting with sessions that discussed the complex role of diet in colorectal
carcinogenesis, minimally invasive options and outcomes for rectal cancer surgery,
radiologic preoperative rectal cancer staging, and pathological staging after
neoadjuvant therapy. A sober discussion on sphincter preservation by Dr.
Hiranyakas topped the session with a well-balanced review of the oncologic and
functional outcomes, highlighting the advantages and disadvantages of this
approach. The controversial topic of the benefits of robotic compared to
laparoscopic low anterior resection for rectal cancer was presented by Dr. Francis
Seow-Choen and was followed by an edifying and interesting debate with excellent
audience participation. The challenges of advanced rectal cancer management were
also thoroughly discussed including presentations that reviewed the most recent
trials and outcomes for the management of stage IV disease by Yik-Hong Ho,
cytoreductive surgery and HIPEC for carcinomatosis peritonei and the liver-first
approach for metastatic rectal cancer.

The program also included a wide-ranging overview of the diagnosis and treatments
of frequent anorectal disorders including pelvic floor disorders, fecal incontinence,
and complex anal fistulas. These sessions were coupled with a hands-on endoanal
ultrasound course taught by Art Hiranyakas and a live LIFT procedure
demonstration by Arun Rojanasakul, Chulalongkorn University, Thailand, who
initially developed and reported the procedure. Hemorrhoidectomy techniques and
indications followed high-yield topics including management options for complex
anorectal fistulas and fecal incontinence. The third day of the meeting also included
updates on a potpourri of common anorectal and colorectal issues, including rectal
trauma, management of anastomotic leak, and an excellent presentation on
enhanced recovery after colorectal surgery protocols and updates, presented by Drs.
Varut Lohsiriwat, Mahidol University, Thailand, and Fabio Potenti, Cleveland Clinic
Florida, respectively. In addition, a poster walk-around session displayed scientific
research abstracts from Asia, Europe, and North and South America.

The meeting attendance surpassed expectations and absolutely fulfilled the aim of
providing an in-depth and stimulating scientific update of rectal cancer
management and advances in colorectal surgery. The world-class exchange of
knowledge and experience from international leaders in the field of colorectal
diseases and live demonstrations made this an outstanding educational meeting.
Taken together, with the fascinating natural beauty of Phuket during the most
beautiful time of the year, and the finest Thai hospitality, we are all certainly looking
forward to participating in the 2015 meeting. Anyone who did not attend in 2013
should indelibly mark the dates of December 9–11, 2015, in their calendar. Anyone
with an interest in attending a highly informative meeting and in visiting one of the
most beautiful areas in the world should plan to attend. The topics for the next
meeting include multidisciplinary approach to colorectal cancer, colorectal imaging,
histology, genetics and molecular biology, minimally invasive colorectal surgery
including robotics and laparoscopy. Controversies in the management of rectal
prolapse, advanced surgical management of fecal incontinence, constipation,
anorectal fistulas, and hemorrhoids are also a part of the agenda which includes live
surgery and hands-on workshops in surgery, imaging, and histology as well. Save
the date! (Fig. 1).
 Open image in new window
Fig. 1
From right to left Drs. Hiranyakas, Wexner, Berho, Milito, Potenti, Boutros and
Silva

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medium, provided the original author(s) and the source are credited.

About this article

Cite this article as:
Silva, E. & Boutros, M. Tech Coloproctol (2014) 18: 323.
https://doi.org/10.1007/s10151-014-1125-0
 DOIhttps://doi.org/10.1007/s10151-014-1125-0

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
March 2011, Volume 15, Issue 1, pp 67–73| Cite as
 Prospective evaluation of stapled
haemorrhoidopexy versus transanal
haemorrhoidal dearterialisation for stage
II and III haemorrhoids: three-year
outcomes
 Authors
 Authors and affiliations
 P. GiordanoEmail author
 P. Nastro
 A. Davies
 G. Gravante
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Open Access
Original Article
First Online: 12 February 2011
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Abstract
Introduction
The aim of the study was to compare short- and medium-term outcomes of
transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy
(SH) for the treatment of second- and third-degree haemorrhoids.

Methods
Patients with second- or third-degree haemorrhoids who failed conservative
treatment were randomly allocated to THD or SH. Preoperative and postoperative
symptoms, postoperative pain, time until return to normal activities, complications,
 patient satisfaction and recurrence rates were all assessed prospectively. Patients
were followed up at 2, 8 months and when the study was completed.

Results
Twenty-eight patients (43% third degree) underwent THD and 24 (38% third
degree) underwent SH. There were no significant differences in terms of
postoperative pain, expected pain and analgesia requirements, but more THD
patients returned to work within 4 days (P < 0.05). One THD patient developed a
sub-mucosal haematoma after surgery, one SH patient occlusion of the rectal lumen
and two rectal bleeding. At 8-month follow-up, two SH patients complained of
faecal urgency. At 38-month follow-up (range 33–48 months), all short-term
complications resolved. Patient satisfaction (“excellent/good outcome”, THD 89 vs.
SH 87%) and recurrence rate (THD 14 vs. SH 13%) were similar in the two groups.

Conclusions
Short-term results although similar seem to suggest SH may result in increased
morbidity while return to work is quicker after THD. Medium-term results
demonstrate that THD and SH have similar effectiveness.

Keywords
Haemorrhoids Stapled haemorrhoidopexy Procedure for prolapse and
haemorrhoids Transanal haemorrhoidal dearterialisation

Paper presented as a poster at the Association of Surgeons of Great Britain and

Ireland 2009, Association of Coloproctology of Great Britain and Ireland 2009 and
the European Society of Coloproctology 2009.

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Introduction
Conventional haemorrhoidectomy (CH) is the most widely used surgical procedure
for the treatment of symptomatic haemorrhoids and is still considered by many
surgeons as the gold-standard technique. It is very effective, relatively safe and
economic, but also notoriously painful and potentially affects the mechanism of anal
continence [1]. Over the years, alternative minimally invasive techniques have been
developed including stapled haemorrhoidopexy (SH), also known as procedure for
prolapse and haemorrhoids (PPH), and transanal haemorrhoidal dearterialisation
(THD) also known as Doppler-guided haemorrhoidal artery ligation (DGHAL). SH
consists of a transanal stapled circumferential rectal mucosectomy. The procedure
aims to lift up the mucosa and restore the normal anatomy and physiology of the
diseased haemorrhoidal tissue. Results show that the procedure is less painful and
facilitates an earlier return to normal activities than to CH [2, 3, 4, 5]. However,
data also suggest a higher recurrence rate [6] and a small risk of serious
complications [7, 8, 9, 10, 11, 12]. THD is a technique that closes, under Doppler
guidance, the distal branches of the superior rectal artery (SRA), thereby reducing
 the blood flow to the haemorrhoidal plexus [13]. The closure of the vessels is
achieved with a dedicated proctoscope that incorporates a Doppler probe. Early data
suggest a favourable comparison with CH in terms of postoperative pain and return
to normal activities. Relapse rates seem similar [14], but long-term results are
scarce [15, 16].

This prospective trial aims to compare short- and medium-term results of these two
new treatment modalities for haemorrhoids.

Materials and methods

All patients with symptomatic second- and third-degree haemorrhoidal disease that
failed a conservative treatment were offered surgical intervention in the form of
THD or SH. Patients were given an explanation of the details of both procedures and
were invited to participate to the study. Although there was no formal
randomisation, those that agreed to participate were casually allocated to either
procedure without any specific criteria for selecting one method over the other. The
surgical procedure was decided blindly by the operating surgeon on the day of
surgery just before examining the patient under anaesthesia and without being
aware of the patient’s symptoms.

All patients with fourth-degree haemorrhoids and those with a large external
component were excluded and offered CH. Furthermore, patients with complicated
haemorrhoidal disease, other concomitant anal conditions, under anticoagulation
therapy, with coagulation disorders or those who opted for one of the two
procedures thereby refusing random allocation were also excluded.

Surgical procedure and technique

All operations were performed as a day-case procedure under general anaesthesia by
the senior author (PG) or under his direct supervision by another member of the
team specifically trained in the procedure. All patients were prescribed a phosphate
enema prior to surgery. Both SH and THD procedures were carried out with the
patient in the lithotomy position. THD was performed using a specifically designed
proctoscope (THD PS02, THD Lab™, Correggio, Italy), which incorporates a side-
sensing Doppler probe and a window beyond this for suture placement. The Doppler
ultrasound transducer was used to identify the haemorrhoidal arteries at about 4 cm
above the dentate line. Once identified, the haemorrhoidal arteries were transfixed
and ligated using 2/0 absorbable Vicryl™ sutures in a figure-of-eight stitch. In
addition to that, a mucosopexy was performed at the same time using the same
stitch starting from the level of the ligation and proceeding distally towards the
dentate line, incorporating the mucosa and submucosa. The suture was stopped at
about 5 mm from the dentate line taking care not to catch the anal mucosa in order
to avoid postoperative pain.

Stapled haemorrhoidopexy was performed according to the technique described by

Longo [12] using a 2/0 polypropylene purse-string suture applied 4 cm above the
dentate line including mucosa and submucosa. The dedicated circular stapling
device (PPH 03, Ethicon Endo-Surgery™, Ohio, USA) was then used for
mucosectomy and anopexy. The excised specimen of the SH group was inspected
and sent for histological examination. Finally, an absorbable gelatine sponge
dressing was placed in the anal canal of all patients.

Anaesthesia and operative time were recorded in a computerised log. Patients were
discharged with rectal 2% lignocaine gel, oral diclofenac (50 mg tid) and co-
dydramol (paracetamol 1000 mg–dihydrocodeine 60 mg qid) to be used as required
for 10 days. Patients also received regular laxatives for 2 weeks (Hyspagula sachet
po bid and Lactulose 10 ml po bid).

Assessment and postoperative follow-up

All data were prospectively collected. Data included patients’ demographics and
relevant history. The degree of severity of haemorrhoidal symptoms was scored for
each patient using a specifically designed questionnaire assessing 5 different
parameters, each scoring from 0 to 4 with 0 corresponding to no symptoms at all
and 4 to the presence of the symptoms on a daily basis or with every bowel
movement (Table 1). A total score of 0 corresponded to the complete absence of
haemorrhoidal symptoms, while a total score of 20 corresponded to the worst
possible degree of symptoms (Table 1). Postoperative pain was assessed using a
standardised visual analogue score 0–10 (0 = no pain, 10 = the worse possible pain)
with patients asked to record the most severe episode. Patients were also asked to
record in a similar manner the expected pain from −5 to +5 VAS, with −5
corresponding to the actual pain being much better than expected, 0 as expected
and +5 much worse than expected.
Table 1
Symptom questionnaire

Never At least At least At least With every

once per once per once per bowel
year months week movement

Bleeding 0 1 2 3 4

Prolapse 0 1 2 3 4

Manual 0 1 2 3 4
reduction

Discomfort/pain 0 1 2 3 4

Impact on Not at Minimal Moderate Severe Very severe

all

QoL 0 1 2 3 4
QoL quality of life

Patients were reviewed in the outpatient clinic at 8 weeks and 8 months and
reassessed with a telephone interview at 3 years. During the interview, the
questionnaire on symptoms was completed again and unless patients were
completely asymptomatic they were recalled and evaluated in the outpatient clinic.
 Patient satisfaction was assessed at 3 years with 4 categories: excellent, good, fair
and poor.

Statistical analysis
All collected data were entered into an Excel database (Microsoft Corporation,
Redmond-Washington, USA) and analysed with the Statistical Package for the
Social Sciences Windows version 13.0 (SPSS, Chicago, Illinois, USA). Descriptive
statistics for quantitative continuous variables were the mean and standard
deviation after confirmation of normal distribution, otherwise median and range.
Descriptive statistics for qualitative categorical variables were performed using
frequencies. Comparison of groups (SH vs. THD) was performed with Student’s t-
test for continuous parametric, the Mann–Whitney test for continuous non-
parametric and the chi-square test or Fisher’s exact test for categorical variables
(Fisher’s if counts were inferior to 5). A P value of <0.05 was considered statistically
significant.

Results
Between September 2004 and December 2005, 64 consecutive patients were
evaluated. Twelve patients were excluded from this group (Fig. 1), leaving 52
patients for analysis. Demographic and preoperative clinical data are summarised in
Table 2. THD and SH groups were homogeneous for age, sex, previous
haemorrhoidal surgery, degree of prolapse and preoperative symptom score. All
patients had previously received at least one injection of sclerotherapy, 7 had
undergone haemorrhoidal banding.
Open image in new window
Fig. 1
Flow diagram of patients at each stage of treatment THD transanal haemorrhoidal
dearterialisation, SH stapled haemorrhoidopexy
Table 2
Demographic data

THD (n = 28; 54%) SH (n = 24; 46%) P

Age (years) 54 (23–73) 48 (35–78) NS

Sex (males/females) 20 M/8F 16 M/8F NS

Previous CH 1 (4%) 0 (0%) NS

Haemorrhoidal degree

Second degree 16 (57%) 15 (62%) NS

Third degree 12 (43%) 9 (38%) NS

Preoperative scoring system 13.6 (8–20) 13.3 (9–18) NS

M males, F females, CH conventional haemorrhoidectomy, THD transanal
haemorrhoidal dearterialisation, SH stapled haemorrhoidopexy

Early results
Early postoperative results are summarised in Table 3. No differences were
observed for the operative time. There was a trend towards less pain in the THD
group although this did not reach statistical significance. All patients but one in both
groups were discharged on the same day they had surgery. There was a significant
difference between the groups in terms of return to work that favoured the THD
group (Table 3).
Table 3
Early postoperative results

THD (n = 28; SH (n = 24; P

54%) 46%)

Operating time (min) 30 (20–45) 33 (18–100) NS

Postoperative pain (VAS) 2 (0–9) 3.5 (1–10) NS

Postoperative versus expected pain −2 (−5, 1) −3 (−5, 2) NS

Delayed discharge 1 (4%) 1 (4%) NS

Time required to return to normal activities 3.2 (1–11) 6.3 (4–14) <0.01
(days)

Patients with return to work or normal activities 25 (89%) 12 (50%) <0.05

at postoperative day 4

Readmissions 0 (0%) 3 (12%) NS

THD transanal haemorrhoidal dearterialisation, SH stapled haemorrhoidopexy
No significant differences were observed for the rate of postoperative surgical
complications or readmissions (Tables 3, 4). In 2 THD patients, the tip of the needle
snapped off during ligation and was not retrieved. This did not cause any symptoms
and both patients had a successful outcome. Another patient in the THD group
experienced urinary retention. He had to be catheterised overnight and was
discharged the following day. One patient in the SH group developed complete
occlusion of the rectal lumen following firing of the stapler. The complication was
successfully managed endoscopically, and the patient was discharged home 2 days
later. Again, even in this case, the haemorrhoidal symptoms resolved successfully
after surgery [17]. In the SH group, 2 patients with postoperative bleeding had to be
readmitted and managed conservatively. None of them required blood transfusions.
Another patient in the SH group also required readmission on the second
postoperative day because of severe pain (Tables 3, 4).
Table 4
Postoperative complications

THD (n = 28; 54%) SH (n = 24; 46%) P

Faecal incontinence 0 (0%) 0 (0%) NS

 THD (n = 28; 54%) SH (n = 24; 46%) P

Transient faecal urgency 0 (0%) 2 (8%) NS

Submucosal haematoma 1 (4%) 0 (0%) NS

Technical problems 2 (7%) 0 (0%) NS

Postoperative bleeding 0 (0%) 2 (8%) NS

Rectal stenosis 0 (0%) 1 (4%) NS

Urinary retention 1 (4%) 0 (0%) NS

Severe postoperative pain 0 (0%) 1 (4%) NS

Total complications 4 (14%) 6 (25%) NS

THD transanal haemorrhoidal dearterialisation, SH stapled haemorrhoidopexy

Three-year results
The overall median follow-up was 38 months (range 33–48 months). Only one
patient in the SH group was not contactable at this time. This patient was
asymptomatic when seen at 8 months.

Medium-term results are shown in Table 5. There was no significant difference in

recurrence between the groups (14 vs. 13%). Five patients (3 THDs and 2 SHs) had
prolapsed haemorrhoids and successfully proceeded to CH. Two patients, one in
each group, suffering from haemorrhoidal bleeding were happy to avoid further
intervention (Table 5). Two other patients suffered of occasional pruritus but had
no evidence of haemorrhoidal disease on clinical evaluation.
Table 5
Medium-term postoperative results

THD (n = 28; 55%) SH (n = 23; 45%) P

Postoperative scoring system 1.1 (0–7) 1.6 (0–12) NS

Total recurrences 4 (14%) 3 (13%) NS

Haemorrhoidal prolapsed 3 (11%) 2 (9%) NS

Frequent bleeding 1 (4%) 1 (4%) NS

Satisfaction rate

Excellent 19 (68%) 15 (65%) NS

Good 5 (18%) 3 (13%) NS

 THD (n = 28; 55%) SH (n = 23; 45%) P

Fair 2 (7%) 2 (9%) NS

Poor 2 (7%) 3 (13%) NS

THD transanal haemorrhoidal dearterialisation, SH stapled haemorrhoidopexy

There was no significant difference in the postoperative symptom scores between

THD and SH (Table 5; P = NS). Both techniques significantly reduced the scores
when compared to the preoperative values (P < 0.0001). As both groups had also
similar preoperative scores (Table 2), it appeared that THD and SH were associated
with a similar degree of improvement.

No differences were observed between the groups as regards patient satisfaction.

Satisfaction was excellent or good in 89% (n = 25) of patients in the THD group and
87% (n = 20) in the SH group (P = NS). Those patients that rated their satisfaction
as excellent were completely asymptomatic at the time of the interview (Table 5).

Discussion
The ideal surgical option for the treatment of symptomatic haemorrhoids is a
technique able to provide long-term relief of symptoms which is, at the same time,
economical, safe, easy to perform and well tolerated by patients. The fact that
multiple operations exist implies that no method is universally accepted as superior
to the others. The operative approach is often tailored to the individual patient.

While there is now considerable literature on SH, the data regarding THD is still
limited and mostly taken from case series, not comparative studies [15].
Furthermore, THD has progressively evolved over the years, and the technique used
in this study differs substantially from the original haemorrhoidal artery ligation
[13] since the plication of the rectal mucosa has become an integral part of the
operation. As a consequence, the postoperative changes in the anatomy of the
haemorrhoidal plexus following THD and SH are very similar, except that THD does
not involve the excision of any tissue.

THD and SH aim to correct the physiology of the haemorrhoidal plexus by restoring
normal anatomy. This may be achieved through a reduction in the arterial in-flow
(dearterialisation) or an elimination of the mucosal prolapse (mucosopexy). The
rationale behind mucosopexy is not just to reduce haemorrhoidal prolapse but also
to improve long-term outcomes. Indeed, since it has been suggested that mucosal
sliding may impair venous drainage [18], mucosopexy could perhaps improve
venous drainage from the haemorrhoidal plexus, thus reducing the recurrence rate.
Furthermore, repositioning the haemorrhoidal cushions rather than excising them
also has the advantage of restoring the physiological role of these structures in the
mechanism of anal continence. It has been demonstrated that the cushions
contribute to approximately 15–20% of the resting anal pressure [19] and perhaps
more importantly they serve as a plug ensuring complete closure of the anal canal.
With THD, dearterialisation relies on the accurate localisation and transfixion of the
terminal branches of the SRA. A plication of the rectal mucosa is also performed in
the mucosopexy. With SH, the dearterialisation and mucosopexy are obtained with
the excision of a ring of the rectal wall that transects the terminal branches of the
SRA and lifts up the mucosa at the same time. In spite of using these methods for
correcting the causes of the haemorrhoidal disease, Aigner et al. [20] recently
questioned the effectiveness of SH in achieving the dearterialisation, showing no
postinterventional changes in either arterial calibre or arterial blood flow. These
findings suggest that mucosopexy may play a more important role in SH for the
treatment of haemorrhoidal disease. The same author also demonstrated that
transmural branches of the SRA enter the rectal wall very distally, below the ligation
line of THD and the staple line of SH. These vessels might be responsible for the
recurrences observed after THD and SH [20]. However, a mucosopexy almost down
to the dentate line like the one used in our THD patients should also be able to deal
with these most distal branches.

Numerous studies clearly demonstrated the short-term advantages of SH compared

to CH especially in terms of postoperative pain and quicker recovery [3, 4, 21]. On
the contrary, only one trial compared THD to CH and showed that THD requires
less postoperative analgesia [14]. SH and THD are both performed above the
sensitive anoderm and therefore should cause less postoperative pain than to CH.
Our results confirm that both SH and THD produce minimal postoperative pain
with no significant differences among the techniques. Furthermore, we observed a
definite advantage of THD: patients returned to work earlier. It is possible that this
occurred because patients in the THD group experienced less postoperative
discomfort that was however not demonstrated due to the relatively small number of
patients included in the study. Indeed, it has been reported that when TDH is
compared to SH, postoperative pain following THD is lower during the first week
[22].

The rare but definite risk of major complications after SH has been clearly
documented [7], but no reports of major complications following THD are currently
available [15]. We believe that the risk of major complications following SH is
mainly related to the “blind” excision of the rectal wall. Since THD is a non-
excisional technique, the possibility of major problems should be virtually
eliminated. In our study, the tip of the needle snapped off during the ligation in 2
THD patients. The problem was related to a defect in the batch of needles used.
Indeed, this was the only time this unusual problem was encountered by the senior
author of this study in more than 400 procedures performed over a 7-year period. In
the SH group, postoperative pain, bleeding and one case of rectal lumen closure
after firing of the stapler accounted for the increased rates of both delayed
discharges and readmissions.

A recent meta-analysis of long-term outcomes of SH vs. CH demonstrated a

significantly higher overall rate of prolapse recurrence in the SH group [6]. The
difference was even more significant for results in patients with third- and fourth-
degree haemorrhoids. Other outcome measures including bleeding and patients
satisfaction were similar in the 2 groups. The only prospective trial available
comparing THD to CH reported a recurrence rate of 20% for THD and 16% for CH
 [14], but this study included patients with all degrees of prolapsed and the THD
technique used in this study did not include a mucosopexy. A recent review of all
published data on THD included almost 2000 patients and reported an overall
recurrence rate of 9% for prolapse and 7.8% for bleeding [15]. When those studies
with a follow-up of 1 year or more were analysed, the prolapse was present in 10.8%
of patients (46/427) and bleeding in 9.7% (49/507). Individual studies reporting
long-term results of THD for third-degree haemorrhoids have shown recurrence
rates of 12–13.5% [16, 23]. The impact of the rectal plication on recurrence rates
following THD has also been reported [24]. In a recently published prospective
trial, Khafagy et al. [25] randomised 45 patients with haemorrhoids to SH, CH and
DGHAL. The degree of haemorrhoids included is not clear since the authors first
stated that third- and fourth-degree haemorrhoids were included but then that
patients with non-reducible haemorrhoids were excluded. This study demonstrated
pain to be significantly worse following CH. While there was no significant
difference between the groups regarding improvement of symptoms such as
bleeding and pain, prolapse completely resolved following CH while it improved in
only 67 and 60% of patients following SH and DGHAL, respectively. The length of
follow-up was not stated. In another prospective trial comparing THD with
mucosopexy to SH for grades III and IV haemorrhoids, 78 and 83% (P = 0.648) of
patients had complete resolution of symptoms at 6 weeks follow-up [20]. In this
study, persistent prolapse appeared to be more common following THD (11 vs.
22%). However, more patients with fourth-degree haemorrhoids were randomised
to the THD group, which may have influenced the results [26].

The results of our study confirmed recurrence rates of 14 and 13%, respectively, for
THD and SH at three-year follow-up, well within the range of those reported in the
literature. Based on these findings, the advocates of haemorrhoidectomy might
point to the higher recurrence rates of less aggressive surgery compared to CH.
However, it is important to bear in mind that the early postoperative benefits of SH
and THD could easily overcome the higher incidence rate of late symptoms and
make these procedures much more appealing to patients.

We acknowledge that the study has a number of limitations. Equivalence of most

outcomes may reflect sample size, and there is potential for surgeon-related bias in
relation to choice of procedure for each patient. Nevertheless, it is the first to assess
directly these two procedures and provide a decent length of follow-up. These
results show that THD and SH have similar effectiveness for the treatment of
second- and third-degree haemorrhoids although THD may yield certain advantages
in terms of risk of potentially serious complications, postoperative pain and time off
work. Given its medium-term results comparable to SH in terms of recurrence rates
and patient satisfaction, we suggest that THD could be considered a valid alternative
first-line surgical option for the treatment of second- and third-degree
haemorrhoids, although larger randomised studies are needed to better establish
the definitive role of this technique.

Notes
Conflict of interest
 The senior author Pasquale Giordano is a trainer in the THD technique. The authors
Piero Nastro, Andrew Davies and Gianpiero Gravante have no conflicts of interest or
financial ties to disclose.

Open Access
This article is distributed under the terms of the Creative Commons Attribution
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reproduction in any medium, provided the original author(s) and source are
credited.

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About this article

Cite this article as:
Giordano, P., Nastro, P., Davies, A. et al. Tech Coloproctol
(2011) 15: 67. https://doi.org/10.1007/s10151-010-0667-z
 DOIhttps://doi.org/10.1007/s10151-010-0667-z

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
November 2010, Volume 14, Supplement 1, pp 9–11| Cite as

Our criteria for PPH procedure in one day

surgery practice
 Authors
 Authors and affiliations
 P. KošorokEmail author

o
1. 1.
Open Access
Article
First Online: 11 August 2010
 1Citations

Abstract
Background
The aim of this report is to analyse our results and to underline our criteria for day
surgery practice.

Patients and methods

Our patients are selected according to ASA criteria. Occasionally, the patients with
some risk factors are selected but only when their concomitant diseases are well
controlled.

Results
We have treated 673 patients with the third and early fourth degree haemorrhoids.
We have had patients with several minor problems causing no influence on the
success of the procedure. Good haemostasis, preventing postoperative bleeding, is
the most important factor.

Conclusion
Among proctological procedures in haemorrhoid treatment, the PPH technique has
firm and well-accepted position even in ambulatory surgery.

Keywords
Haemorrhoids PPH procedure Day surgery
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Introduction
The prolapsing haemorrhoids are treated surgically by means of different
procedures. The selection of patients for day surgery was made according to
proposals of ambulatory surgery practice. In day surgery, the life of patients is
minimally disturbed. Patients return to normal activities earlier, so the absence
 from work is negligible. Outpatient surgery is cheaper than hospital treatment, and
entire health expenses are reduced [1, 2, 3, 4].

Patients and methods

Between 2000 and 2010, 673 patients were treated in our day surgery unit. We are
following general selection criteria for ambulatory surgery. At the beginning, we
strictly followed the proposals, later supported with more experiences, we accepted
also patients above 60 and not only the patients from ASA group I and II, if their
health condition was generally good. However, concomitant diseases (hypertension,
diabetes) must be under control. Anticoagulant medication should be stopped at the
time of operation.

It is important that the patients maintain positive attitude towards ambulatory

surgery. The administration should be assured that the patient has home assistance
in the first 24 h. The patient’s family should be prepared to participate in the
postoperative treatment. The social circumstances should be appropriate–easy
access to bathroom and toilet is necessary.

Preparation for surgery

No laxatives and no enema are prescribed before operation. The patient is asked to
void before anaesthesia, and an i.v. access is introduced. After induction of spinal
anaesthesia, metronidazol is administered intravenously.

Surgical technique
During the operation, the patient is in gynaecological position. The operation is
performed with standard Ethicon PPH stapling device. The possible bleeding on the
staple line must be carefully controlled. Occasionally, when loose mucosa is
observed, an elastic ring ligation must be added. At the end, an obstetric tampon
infiltrated by 5 ml of saline is pushed into the anus.

Postoperative care
The communication with the patient after the procedure is very important. The
patient is given the telephone number of his surgeon. He can call him in case of
uncertainty. We also practise to call the patient in the evening on the day of surgery.
It gives the patient a very important feeling of being supervised by his surgeon. We
instruct the patient and his family not to drive a car after the surgery. In case of any
serious complications, the patient’s home should be close enough to provide
comfortable and quick access to the hospital. In case of emergency, we arrange
hospital care by ourselves, which has happened only twice.

All our patients are treated in spinal anaesthesia. After the procedure, the patient is
under control in the recovery room. Postoperative analgesia is given to the patients
according to VAS (visual analogue scale) when the pain exceeds grade II. We use
NSAID drugs (Ketoprofen, Diclofenac) or opioid analgesics (Tramadol, Metadon,
Piritramid, Morfin) on demand.
 The patients are given fluids orally. Great attention is paid to the possible bleeding.
The patient’s behaviour, general condition and secure walking are continuously
followed. It is important that the patient can urinate before leaving the unit. Average
discharge time after the operation for PPH (Longo) patients is 5 h and 8 min.

In the first week after the procedure, the painkillers are prescribed and also
Metronidazol in the first 3 days. The patient is asked to come to controls in 1 week,
and later in 6 weeks after the operation. If necessary, the patient can come back
immediately.

Results
Follow-up was 36 months. All patients were treated at home care. Only two of them
were accepted to the hospital because of the staple line bleeding, which occurred at
the beginning. Afterwards, we were very careful about this complication, and special
attention was paid to the bleeding control. Minor bleeding can be well controlled by
Foley catheter inflated into the anal canal.

Urine retention is the most common complication, specially after the use of stronger
anaesthetic drugs (bipuvacain, marcain). Urine catheter was introduced in 8% of
patients. In female patients, it is usually introduced temporarily. In case of elevated
body temperature (6%), we prescribe clindamycin. No major wound infections or
abscesses were found. Headache (6%) is connected with spinal anaesthesia. Though
the pain in PPH procedure is minor than in classic procedures, 5% of patients
suffered pain exceeding more than 7 grades on VAS scale. Sometimes (1,5%) anal
thrombosis as postoperative complication was observed.

Minor bleeding (blood on paper) on controls was seen in patients with metallic
clamps or granulomas on the staple line.

Residual mucosal folds were successfully treated by means of rubber band ligations.
Pain after defecation was present in patients with anal fissure. Urgent defecation or
occasional minor incontinence was treated by stimulation and biofeedback. In few
cases (6 patients), we found anal stenosis that was successfully treated with anal
dilators (Dilatan).

Discussion
Stapled haemorrhoidectomy is a relatively new procedure. Many randomized
controlled trials have been published, comparing the outcomes of stapled
haemorrhoidopexy to conventional haemorrhoidectomy. The trials are remarkably
consistent in the findings of a safe procedure, with less pain and disabled than the
conventional haemorrhoidectomy [1]. The stapled haemorrhoidopexy should not be
used to replace rubber band ligation but rather to be performed in patients with
prolapse. Serious or even life-threatening complications are rare in experienced
hands of a surgeon. The procedure is not painless, but when properly performed the
pain is minimal comparing to the severe pains in classical Milligan-Morgan
procedure [2]. The critical and the most difficult part of the operation is the
placement of purse-string suture. It should be in the submucosal layer, 4–5 cm
 above the dentate line. It is in the low rectum, not in the upper anal canal [3, 4].
Redundant rectal mucosa must be excised during the procedure. Prolapsed internal
haemorrhoids, fixed or immobile, are not suitable for stapled procedure. Patients
with fibrotic anal skin tags are not suitable for PPH procedure. It is suggested to
eliminate the tags later if this is indicated [5].

Stapled haemorrhoidopexy is not difficult to learn for a surgeon who is experienced

at circular stapling device and anorectal surgery [6]. There were several randomized
controlled trials assessing two or more treatment modalities for symptomatic
haemorrhoids. Stapled haemorrhoidopexy was found to be associated with
significantly less pain than conventional haemorrhoidectomy, with no significant
differences in complication rate or response to the treatment [7, 8, 9, 10, 11, 12].

Day case surgery has become an acceptable approach specially in proctology cases.
Among proctological procedures for haemorrhoid treatment even in ambulatory
surgery, PPH technique has obtained a well accepted and firm position.

Notes
Conflict of interest

The author declares that he has no conflict of interest related to the publication of
his article.

Open Access
This article is distributed under the terms of the Creative Commons Attribution
Noncommercial License which permits any noncommercial use, distribution, and
reproduction in any medium, provided the original author(s) and source are
credited.

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About this article

Cite this article as:
Košorok, P. Tech Coloproctol (2010) 14(Suppl 1): 9.
https://doi.org/10.1007/s10151-010-0634-8
 DOIhttps://doi.org/10.1007/s10151-010-0634-8

 Publisher NameSpringer Milan

 Print ISSN1123-6337
 Online ISSN1128-045X
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Techniques in Coloproctology
September 2017, Volume 21, Issue 9, pp 709–714| Cite as

Colorectal anastomotic leak: delay in

reintervention after false-negative
computed tomography scan is a reason
for concern
 Authors
 Authors and affiliations
 C. C. M. MarresEmail author
 A. W. H. van de Ven
 L. G. J. Leijssen
 P. C. M. Verbeek
 W. A. Bemelman
 C. J. Buskens

o

o
o

o

o

o

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1. 1.
2. 2.
Open Access
Original Article
First Online: 19 September 2017
 3Shares

Abstract
Background
Early detection of anastomotic leakage (AL) after colorectal surgery followed by
timely reintervention is of crucial importance. The aim of this study was to
investigate the accuracy of computed tomography (CT) imaging for AL and the
effects of delay in reintervention after a false-negative CT.

Methods
All files from patients who had colorectal surgery with primary anastomoses
between 2009 and 2014 were reviewed. The predictive value of CT scanning for AL
was determined and correlated with short-term postoperative patient outcomes. In
addition, factors predictive of false-negative scans were assessed.

Results
Six hundred and twenty-eight patient files were reviewed. In total, a CT scan was
performed in 127 patients. Overall, leakage was seen in 49 patients (7.8%). The
positive and negative predictive values were 78 and 88%, respectively. Sensitivity
was 73% and specificity 91%. In patients with a true-positive CT (n = 24),
reintervention followed after a median interval of 0 days (IQR 1), whereas this was
1 day (IQR 2) in the false-negative group (n = 11) (p < 0.05). This was associated
with a significantly increased mortality rate (1/24 = 4.2% vs 5/11 = 45.5%)
(p < 0.005), an increased length of hospital stay [median 28 days (IQR 26) vs
54 days (IQR 20) (p < 0.05)].

Conclusions
Delayed reintervention after false-negative CT scanning is associated with a high
mortality rate and a significant increase in length of hospital stay.
 Keywords
Colorectal surgery Computed tomography Anastomotic leakage Oncology
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Introduction
Anastomotic leakage (AL) is a life-threatening complication after colorectal surgery
[1]. In the literature, mortality rates after AL vary from 15 to 33%. Early detection of
AL followed by timely reintervention decreases mortality rates. In daily clinical
practice, abdominal computed tomography (CT) scanning is most frequently used to
diagnose or exclude AL after colorectal surgery [2, 3, 4]. Compared to water-soluble
contrast enema and plain X-ray, CT scan is more sensitive and is able to detect other
complications such as bleeding, perforation or abscess. At the same time, it can be
used to guide therapeutic percutaneous drainage of abscesses.

Considering how commonly CT is performed in postoperative colorectal patients,

the literature on the accuracy of CT scanning in patients with AL is scarce. The only
systematic review, performed by Kornmann et al. [5], included a total of only 221
abdominal CT scans from eight different studies. This review showed a relatively low
sensitivity of 68%, with a large range reported from these small, retrospective
studies. The technical quality of the CT scan was often suboptimal (10-mm sections,
no enteral or intravenous contrast), and the definition of AL was inconsistent.
Previous studies suggested that false-negative CT outcome may delay reintervention
[6, 7], but the clinical consequences of a false-negative CT scan were only described
in one study [8].

Recent studies by Huiberts et al. [9] and Kauv et al. [10] showed that leakage of
contrast medium was the only independent predictive factor for AL. In our
institution, abdominal CT scanning with rectal contrast enema (RCE) in cases where
there is suspicion of AL has been the standard imaging procedure for over 6 years.

The aim of this study was to investigate the accuracy of abdominal CT scanning with
RCE for anastomotic leakage and the effect of false-negative scans on delay in
therapeutic intervention and clinical outcome.

Materials and methods

Data from a prospectively maintained database of all patients who had elective or
emergency colorectal surgery with primary anastomoses for malignant or benign
disease between 2009 and 2014 were reviewed. Patient characteristics, including
age, gender and American Society of Anesthesiologists (ASA) classification, were
collated. Type of operation, complications, length of hospital stay, length of stay in
the intensive care unit (ICU), indications for abdominal CT scans, timing and
outcome of CT scans and subsequent reinterventions were also evaluated.

All colorectal resections were performed by, or under supervision of, a specialist
colorectal surgeon. Perioperatively, patients were managed according to standard
 fast-track protocol [11]. Abdominal CT was performed when patients had signs of
sepsis with clinical symptoms and/or physiological deterioration (e.g. deviations in
respiratory rate, pulse rate, blood pressure, temperature, urine production or
neurological status).

CT imaging was performed on a 16- and 64-sliced-MDCT scanner (Philips,

Netherlands), with a slice thickness of algorithm of 3–5 mm with axial and coronal
reconstructions. Scanning protocol included intravenous and rectal contrast. CT
scans were reviewed by experienced radiologists. For this study, radiology reports
were used as given at the time rather than later amendments, in order to evaluate
the effect of delay in reintervention after false-negative scans. Our radiologists
scored the following features to asses the CT scans: fluid intraabdominally, fluid
near the anastomosis, free air in the abdomen, air near the anastomosis and
contrast from the lumen. AL was graded according to the definition of the
International Study Group of Rectal Cancer [12]. Grade C was defined as a leak
requiring surgical reintervention, grade B as a leak requiring percutaneous
reintervention, and grade A as a leak requiring antibiotics at the most. Since the
indication for antibiotics was not always based on CT scan findings and it had
minimal to no clinical impact on the patients postoperative course, only grade B and
C anastomotic leaks were included in the CT accuracy analyses.

Statistical analysis
Statistical analysis was performed using SPSS software, version 22.0 (SPSS Inc,
Chicago, IL, USA). Sensitivity, specificity, positive predictive value (PPV) and
negative predictive value (NPV) were calculated with 95% confidence intervals (CI).
Categorical data are presented as frequencies and percentages compared by the Chi-
square test. The parametric and nonparametric continuous data are presented as
means and standard deviations and were analysed by the Mann–Whitney U test.
Missing data for every variable were less than 10%, and therefore there no
imputation of missing data was performed. A two-tailed p value of <0.05 was
considered statistically significant.

Results
Between 2009 and 2014, 628 patients underwent colorectal surgery with primary
anastomosis in our institution. In 127 out of 628 patients, an abdominal CT scan
was performed based on clinical symptoms and/or signs of sepsis. Of these patients,
69 (54.3%) were men and 58 (45.7%) women with a median age of 66 years (range
44–89 years).

Ninety-nine of the 127 patients undergoing CT scan for suspicion of AL were given
enteral contrast according to protocol (78%). In 85 patients (86%), the contrast
reached the anastomosis. Relevant baseline characteristics are summarised in
Table 1.
Table 1
Demographic characteristics
 a a
Variables All patients N (%) Patients with CT N (%)

Age, years

Median 66 66

Range 18–96 44–89

Sex

Female 295 (47.0) 58 (45.7)

Male 333 (53.0) 69 (54.3)

ASA class

ASA 1 or 2 489 (77.8) 92 (72.4)

ASA 3 or 4 132 (21.0) 26 (20.5)

Type of operation

Right colectomy 203 (32.3) 39 (30.7)

Left colectomy 41 (6.5) 11 (8.7)

Sigmoidectomy/LAR 310 (49.4) 53 (41.7)

Colectomy 37 (5.9) 13 (10.2)

Other 36 (5.8) 11 (8.7)

Open/laparoscopic

Open 84 (13.4) 40 (31.5)

Laparoscopic 512 (81.5) 87 (68.5)

Stoma

No stoma 413 (65.8) 88 (69.3)

Loop ileostomy 126 (20.1) 37 (29.1)

End colostomy 5 (0.8) 2 (1.6)

Urgency

Elective 508 (80.9) 93 (71.9)

Emergency 87 (13.9) 29 (22.70

 a a
Variables All patients N (%) Patients with CT N (%)

Anastomotic leak

Grade C 38 (6.1) 29 (22.8)

Grade B 6 (0.8) 6 (4.7)

Grade A 5 (1.0) 5 (3.9)

Total 628 (100) 127 (100)

CT computed tomography, ASA American Society of Anesthesiologists, LAR low
anterior resection
a
Unless stated otherwise in the first column

Anastomotic leakage
Overall leakage after surgery (grade A, B and C) was 7.8% (49 out of 628
anastomoses). Thirty-eight patients had grade C AL (6.0%), six patients (1.0%) had
grade B leakage and five patients had grade A leakage (0.8%). Leak rates were
comparable for patients with open or laparoscopic procedures and for patients with
benign or malignant disease.

In nine patients with AL, no CT was performed prior to reintervention. Six of these
patients were reoperated on within 5 days of primary resection without diagnostic
imaging because of their clinical condition. In the other three patients, a water-
soluble contrast enema with X-ray was performed, during the implementation phase
of the abdominal CT scan with contrast enema in 2009.

Predictive value of the CT scan

Twenty-four patients had a true-positive CT scan, with AL demonstrated at
reintervention. Eleven patients had a false-negative scan; there were no signs of AL
on CT scan, but a leak was confirmed afterwards during reintervention or autopsy.
Seventy-nine patients had a true-negative scan, and eight patients had a false-
positive scan. CT scans were counted as false-positive when the scan was reported as
showing signs suggestive of AL; however, either during relaparoscopy there was no
leakage detected or they had no clinical signs of AL and recovered without any
treatment (no antibiotics). In six patients, CT scan revealed too much free air or
fluid in the abdomen (based on how much free air or fluid was expected on the
corresponding day postoperatively). In one of these patients, relaparoscopy did not
show any abnormality. In two patients, minimal contrast was seen near the
anastomosis, but the clinical sign was absent and they recovered without any
treatment.

The accuracy of CT scanning for AL in this study was 85.0%. The positive and
negative predictive values were, respectively, 0.78 (CI 0.65–0.92) and 0.88 (CI
0.82–0.95). The sensitivity was 0.72 (CI 0.59–0.86) and specificity 0.91 (CI 0.85–
0.97) (Table 2). The area under the receiver operating characteristic (ROC) curve
was 0.80. This was calculated in accordance with the recommendations of Castor et
al. [13] for binary diagnostic tests.
Table 2
Sensitivity, specificity, positive and negative predictive value for anastomotic
leakage

CT Anastomotic No anastomotic Results (95% CI)

outcome leakage leakage

Positive 24 8 Sensitivity 0.69 (0.51–

0.83)

Specificity 0.91 (0.83–

0.96)

Negative 11 79 PPV 0.75 (0.56–0.87)

NPV 0.88 (0.79–0.94)

Patients with grade A anastomotic leak were excluded
Values are given as number of patients (n). Sensitivity, specificity, PPV and NPV are
given with 95% CI
CT computed tomography, PPV positive predictive value, NPV negative predictive
value

Impact on clinical outcome

The overall mortality rate after grade B and C leakage was 20.5% (9 out of 44
patients). Out of 24 patients with a true-positive CT scan, only one died (4.2%),
whereas mortality after a false-negative CT was 45.5% (5 out of 11 patients)
(p < 0.005). In patients with leakage predicted by CT, reintervention was performed
after a median interval of 0 days (IQR 1), whereas this was 1 day (IQR 2) in the false-
negative group (p < 0.05). This resulted in a significantly increased length of
hospital stay [median of 28 days (IQR 26) vs 54 days (IQR 20) (p < 0.05)]. The
median length of stay in the ICU was 3 days (IQR 10) for patients with a true-
positive CT scan versus 2 days (IQR 14) in patients with a false-negative scan
(Table 3).
Table 3
Clinical outcome of anastomotic leakage in patients with grade B and C leakage
(n = 35)

Overall N = 35 True-positive False- pvalue

CT N = 24 negative
CT N = 11

Mortality (%) 6 (17.1%) 1 (4.2%) 5 (45.5%) .003*

Length of hospital stay, 30.5 (31) 28 (26) 54 (20) .014**

median (IQR)
 Overall N = 35 True-positive False- pvalue
CT N = 24 negative
CT N = 11

Days in ICU, median 3 (10) 3 (10) 2 (14) .094**

(IQR)

Days from operation to 7 (5) 7 (4) 4 (4) .121**

CT, median (IQR)

Days from CT to 0 (1) 0 (1) 1 (2) .011**

reintervention, median
(IQR)
CT computed tomography scan, ICU intensive care unit, IQR interquartile range
* Chi-square test
** Mann–Whitney U test

To identify predictive factors influencing CT accuracy, the following variables were

analysed: anatomical site of the anastomosis, emergency surgery, whether enteral
contrast was given and if the contrast had reached the anastomosis on CT scan.

There were no statistically significant differences found in these variables between

patients with a true-positive and a false-negative scan. It is noteworthy, however,
that the contrast reached the level of the anastomosis in only 66.6% in the false-
negative group, but in 85.0% in the true-positive group (Table 4).
Table 4
Parameters predicting accuracy of CT scanning for anastomotic leakage

Overall N = 35 True-positive False-negative pvalue

CT N = 24 CT N = 11

Emergency surgery 11 (31.4%) 7 (41.2%) 4 (36.4%) .670*

Rectal anastomosis 12 (34.2%) 9 (37.5%) 3 (27.2%) .554*

Rectal contrast 29 (82.9%) 20 (83.2%) 9 (81.8%) .466*

Contrast reached 23 (79.3%) 17 (85.0%) 6 (66.6%) .874*

anastomosis
CT computed tomography
* Chi-square test

Discussion
This study demonstrated an 84% accuracy of CT scan for AL after colorectal surgery.
A leak was missed in 11/39 patients resulting in a mediocre sensitivity of 72%. False-
negative CT was associated with a significantly higher mortality.
 The sensitivity and specificity of CT scanning found in this study are in line with the
results of the systematic review of Kornmann et al. [5] and with three studies on
sensitivity of CT scanning [8, 9, 10].

Previous studies also showed that false-negative CT scan causes delay in

reintervention after AL, but numbers of patients are small in these reports.
Kornmann et al. [8] reported that mortality increased to 63% after delayed
diagnosis compared to 7% in patients with a true-positive CT outcome and
immediate intervention, which is comparable to our results (45.5 vs 4.2%).

The two most recent studies found that leakage of contrast medium was the only
independent predictive factor for AL [9, 10]. Kauv et al. [10] reported that 58
patients were scanned with RCE and 95 without. Of the 11 false-negative or
indeterminate CT scans in their study only 2 (18%) were performed with RCE.
Huiberts et al. [9] reported that RCE was given to 52 patients and 52 patients
received oral contrast only. The contrast reached the anastomosis in only 31% of the
patients. In the false-negative group, contrast was present at the site of the
anastomosis in 39% of the cases. In our study, 99 patients were given rectal
contrast. In 85 patients, the contrast reached the anastomosis (86%). The contrast
did not reach the anastomosis in 1/3 of the patients with a false-negative scan.

Although several studies mention that performing a scan too early in the course of
AL, i.e. before AL is radiologically detectable, leads to false-negative scans,
[6, 7, 14], in the present study no significant difference was found in the timing of
the CT scans of patients with a true-positive and patients with false-negative scan.

A limitation of this study is the fact that the indications for CT scanning, timing of
the intervention or “wait and see” policy are subject to a surgeon’s personal opinion
or experience. The only published prospective study on this subject to date
suggested that abdominal complications cannot be predicted by a CT scan on day 5
after laparoscopic colorectal resection and therefore it cannot be recommended for
routine use [15].

In previous studies, different definitions of clinical and radiological AL are used.

Surprisingly, there is little consensus on the definition of AL, different criteria
making interpretation of data more difficult [16, 17]. The definition and grading of
AL by the International Study Group of Rectal Cancer [18] were used in this study
and should perhaps be used as a standard in future reports.

The strength of this study is the consecutive series from a single, nonacademic,
secondary care centre, reflecting daily clinical practice of most colorectal surgeons.
To our knowledge, this is the first study with detailed information on clinical
outcome after false-negative CT scans. Furthermore, this is one of the largest studies
on accuracy of CT scanning for AL with the largest population of patients screened
with RCE.

Conclusions
 Our results indicate that a false-negative CT scan in suspected AL is associated with
a higher mortality rate and a significant prolonged length of hospital stay. CT scan is
not accurate enough to provide assurance of anastomotic integrity and should be
considered in the round with other patient parameters with a low threshold for
intervention maintained if a negative scan does not fit with symptoms, signs and
other results. Diagnostic laparoscopy despite a negative scan should still be
considered where there remains clinical suspicion of AL.

Notes
Compliance with ethical standards

Conflict of interest
The authors declare that they have no conflict of interest.

Ethical approval
This article does not contain any studies with human participants or animals
performed by the authors.

Informed consent
For this type of study formal consent is not required.

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Cite this article as:
Marres, C.C.M., van de Ven, A.W.H., Leijssen, L.G.J. et al.
Tech Coloproctol (2017) 21: 709.
https://doi.org/10.1007/s10151-017-1689-6
 DOIhttps://doi.org/10.1007/s10151-017-1689-6

 Publisher NameSpringer International Publishing

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 Online ISSN1128-045X
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