Surgical Science, 2012, 3, 542-545 doi:10.4236/ss.2012.311107 Published Online November (http://www.SciRP.org/journal/ss) Doppler-Guided Transanal Haemorrhoidal Dearterialisation is a Safe and Effective Daycase Procedure for All Grades of Symptomatic Haemorrhoids C. J. Deutsch1, K. Chan1, H. Alawattegama2, J. Sturgess2, R. J. Davies1
1Cambridge Colorectal Unit and Department of Anaesthesia, Addenbrooke’s Hospital, Cambridge, United Kingdom
2Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
Received August 7, 2012, revised September 8, 2012; accepted September 17, 2012ABSTRACT Purpose: Doppler-guided transanal haemorrhoidal dearterialisation (THD), with the addition of rectal mucopexy, has been gaining popularity as a minimally invasive haemorrhoidal treatment. The aim of this study was to assess the out- comes of THD in patients with symptomatic haemorrhoids. Methods: All consecutive patients undergoing THD by a single surgeon over a 2 year period from 1st January 2010 were included. Results: THD was performed on 58 consecu- tive patients, with 46 (79.3%) having had previous haemorrhoidal treatment(s). Haemorrhoid grades were: 1 (n = 6); 2 (n = 12); 3 (n = 32); 4 (n = 8). The median number of THD ligations was 7 (range 4 to 9) and rectal mucopexies 3 (range 1 to 3). All procedures (100%) were carried out as daycase, with 1 readmission within 30 days (anal fissure). No patients required return to theatre. After median follow-up of 10.5 weeks (range 1 to 48 weeks, 2 lost to follow-up), 53 (91%) patients reported symptomatic resolution or significant improvement. Two (3.4%) patients had post-operative complications (anal fissure). Two (3.4%) patients had further haemorrhoidal surgery following THD. Conclusions: THD is a safe daycase procedure for symptomatic haemorrhoids of all grades. It is an effective treatment in the short term, but longer-term follow-up is required to assess its symptomatic benefit more formally. Keywords: Transanal; Haemorrhoidal; Dearterialisation; Doppler; Guided; Haemorrhoid 1. Introduction
results in less post-operative pain than excisional hae- morrhoidectomy , but carries the small risk of poten-
Symptomatic haemorrhoids arise due to pathological
tially life-threatening pelvic sepsis .
swelling, engorgement and/or traumatisation of the dense
Doppler-guided THD utilises a purpose-designed dop-
vascular network supplying otherwise normal anal cu-
pler probe to identify the branches of the superior rectal
shions . This typically leads to symptoms of prolapse
artery that feed the haemorrhoidal plexus and subsequently
and bleeding, with a number of other associated pro-
ligate them . When combined with mucopexy, the hae-
blems including pruritis ani and mucus discharge. They exist as one of the commonest anal pathologies yet des-
morrhoidal tissue can be dearterialised and restored to a
pite this, treatment options are often sub-optimal.
more natural position within a single operation and with-
Traditional outpatient therapeutic strategies include
rubber-band ligation and injection sclerotherapy; surgical
Given the relative recency of the introduction of THD
interventions include stapled haemorrhoidopexy and
into mainstream practice, few studies report on outcomes
excisional haemorrhoidectomy, the latter of which is
following THD . The aim of this retrospective study
generally considered to represent the gold-standard .
of consecutive patients undergoing THD by a single sur-
More recently, doppler-guided transanal haemorrhoidal
geon over a two-year period is to expand the evidence base
dearterialisation (THD) with rectal mucopexy has been
by evaluating outcomes in terms of efficacy and safety of
gaining popularity as a minimally invasive alternative to
THD for all grades of symptomatic haemorrhoids.
more radical surgical options. This is purported to bring with it the advantages of reduced post-operative pain and
a swifter return to normal daily living than excisional
2.1. Inclusion Criteria
haemorrhoidectomy [3-5] and better success rates than rubber-band ligation . Stapled haemorrhoidopexy also
All patients having THD performed by a single surgeon
Copyright 2012 SciRes. SS
over a two-year period were included in this retros-
ing and prolapse (n = 36) was the most common com-
pective analysis. All grades of symptomatic haemor-
bination. Fifty-two (90%) patients presented with rectal
rhoids were included along with any number or type of
The median number of THD ligations required was 7
(range 4 to 9). The median number of mucopexies perfo-
2.2. Surgical Procedure
rmed was 3 (range 1 to 3). All operations (100%) were carried out as a day-case. No patients required return to
A pre-operative enema was used for all patients. All
theatre. Two patients developed an anal fissure (3.4%),
procedures were performed under general anaesthesia in
with one of these requiring subsequent readmission over-
the lithotomy position, with intravenous metronidazole
given. A pre-packaged single-use THD set (THD Ltd,
Median follow-up was 10.5 weeks (range 1 to 48
Worcester, UK) was used containing a sliding procto- scope with doppler-probe for artery identification. Arterial
weeks). Ninety-one percent of patients reported either
ligation was performed via a figure-of-eight suture. The
resolution of symptoms or symptomatic improvement.
number of ligations performed was adjusted according to
Two patients (3.4%) requested further therapy, of which
the number of doppler signals encountered. Mucopexies
one had rubber band ligation performed in the outpatient
clinic and the other a successful redo THD procedure.
2.3. Follow-Up Table 1. Frequency of grades of haemorrhoid.
Patients were followed-up clinically by the surgical team
in the outpatient clinic. They were questioned regarding any symptomatic improvement or any changes in symp-
tom profile. Any post-operative complications were re- corded and arrangements made for further follow-up if it
2.4. Data Collection
Data were obtained with the consent of the Audit Depart- ment at Addenbrooke’s Hospital, Cambridge, UK. Infor-
mation was obtained from patients’ written notes and digital records. Data parameters were patient demogra-
phics, presenting symptoms, previous treatment, the
Table 2. Frequency of symptom profiles.
number of THD ligations and mucopexies performed,
length of follow-up, documented symptomatic benefit, post-operative complications, readmission within 30 days
and whether any further haemorrhoidal therapy was re-
quired. The primary outcomes were identified as com- plication rate and symptomatic benefit.
Fifty-eight consecutive patients (43 male, 15 female) were
identified for inclusion in this study. Follow-up data
Rectal bleeding, prolapse & anorectal pain
post-operatively was available in 56/58 (96.6%) patients. Patients with all standard grades of haemorrhoid were
Rectal bleeding, prolapse & pruritis ani
included, with 55% having Grade 3 haemorrhoids (Table. 1).
The majority of patients (79%) had undergone pre-
vious therapy, often in combination. The most common
was rubber-band ligation (n = 39) but also injection
sclerotherapy (n = 14), infrared coagulation (n = 1) and
excisional haemorrhoidectomy at another institution (n =
3). The median number of previous haemorrhoidal treat- ments was 1 (range 0 to 4). Symptoms at presentation
were variable and often multiple (Table 2); rectal bleed-
Copyright 2012 SciRes. SS 4. Discussion
Patients with all grades of haemorrhoids were consi-
dered as candidates for THD in this study, although
Although first described in 1995 , THD is a relatively
guidelines recommend excisional haemorrhoidectomy
novel therapy for haemorrhoids. This study sought to
for Grade IV haemorrhoids . Our results suggest that
demonstrate that, in line with common hospital policies
THD should be considered for patients with Grade IV
for the evaluation of a new service provision, THD is
haemorrhoids . A further patient-dependent variable,
above all a safe practice. Additional data on efficacy for
the number of previous haemorrhoidal therapies, was
all grades of haemorrhoids and useful intraoperative data
also considered. No patients undergoing THD had pre-
vious stapled haemorrhoidopexy; however, 3 patients had
The majority of studies relating to THD consider ef-
a recurrence of their haemorrhoid symptoms following
ficacy over safety, however some other authors do pro-
excisional haemorrhoidectomy at other institutions. These
vide useful data on the risk of complications when using
patients were treated successfully with THD and all
THD. In common with our data, Ratto et al. found none
achieved good symptomatic benefit with no compli-
of their 170 patients complaining of chronic anal pain or
cations or recurrence. To our knowledge, the use of THD
incontinence in the follow-up period post-THD . The same study reports the only complications to be post-
following excisional haemorrhoidectomy has not previ-
operative bleeding requiring surgical haemostasis in 1.2%
of cases. In the study by Sohn et al., the complications
Despite the limitations of small sample size, limited
were thrombosed external haemorrhoid in 6% and anal
length of follow-up and potential for observer bias, this
fissure in 1.5% . This compares to our overall com-
study suggests that THD is safe and also efficacious in
plication rate of 3.4%, accounted for by 2 cases of anal
the short to medium term. The difficulty remains that
THD is not as widely practiced as excisional haemor-
The overall complication rates of THD appear similar
rhoidectomy and stapled haemorrhoidopexy, and abso-
to those of stapled haemorrhoidopexy. However, stapled
lute patient numbers are relatively low. Outcomes for
haemorrhoidopexy is associated with potential for faecal
5-year follow-up after THD are beginning to emerge, and
urgency, acute rectal obstruction, pelvic sepsis and even
suggest an increased rate of recurrence when compared
death [14-17]. When separated for early and late com-
to 1 year outcomes . It is hoped that the proposed
plications, equal rates of early complications exist be-
United Kingdom multicentre, randomized trial of THD
tween stapled haemorrhoidopexy and THD, but a greater
versus rubber band ligation in the treatment of sympto-
incidence of late complications occurs with stapled hae-
matic haemorrhoids (the HubBLe Trial ) will help to
morrhoidopexy . The potential of clinically signi-
ficant pelvic sepsis is a frequently raised criticism of stapled haemorrhoidopexy. The largest published review
on the topic has identified 40 cases in the past 12 years
THD is a safe daycase procedure, for which no life-th-
which is acknowledged as an underestimate; of these
reatening adverse outcomes have been reported to date.
cases, thirty-five required laparotomy with faecal diver-
The results from this study support these observations
sion and there were four deaths . This does not occur
and also suggest acceptable efficacy of THD over the
in conventional haemorrhoidectomy, where complica-
short to medium term. It is a useful tool in the arsenal of
tions may include bleeding, anal seepage, delayed wound
haemorrhoidal therapies and with its acceptable safety
healing and anal stricture , with overall complication
and efficacy profile and minimal post-operative discom-
rates for conventional haemorrhoidectomy and stapled
fort, it is an appropriate intervention to offer to patients
haemorrhoidopexy broadly comparable .
with any grade of haemorrhoid and after previous at-
This study suggests a success rate of THD of 91%,
tempted therapies (including previous excisional haemor-
when success is defined as a symptomatic improvement
rhoidectomy). Patients with haemorrhoids require a be-
or resolution. This correlates with other work; Giordano
spoke treatment approach, and THD appears to have a
et al. report 89% patient satisfaction rate at medium term
follow-up in a small study , and rates of 91% and 92% for prevention of recurrence of prolapse and bleeding respectively at one year . THD is frequently drawn
into comparison with stapled haemorrhoidopexy as the
 J. A. Marx, R. S. Hockberger, R. M. Walls, et al., Eds,
only other surgical alternative to excisional haemorrhoi-
“Rosen’s Emergency Medicine: Concepts and Clinical
dectomy, and data repeatedly suggest that there is no sta-
Practice,” 6th Edition, Elsevier, Philadelphia, 2006, pp.
tistically significant difference in efficacy between the
two [2-21], although data so far suggest that lifethreat-
 P. Giordano, P. Nastro, A. Davies and G. Gravante,
ening complications of THD have not yet been reported.
“Prospective Evaluation of Stapled Haemorrhoidopexy
Copyright 2012 SciRes. SS
versus Transanal Haemorrhoidal Dearterialisation for
6-Year Experience from a Single Surgical Clinic,” Tech-
Stage II and III Haemorrhoids: Three-Year Outcomes,”
niques in Coloproctology, Vol. 15, No. S1, 2011, pp.
Techniques in Coloproctology, Vol. 15, No. 1, 2011, pp.
 H. Ortiz, J. Marzo and P. Armendariz, “Randomized
 M. J. Cheetham, N. J. Mortensen, P. O. Nystrom, M. A.
Clinical Trial of Stapled Haemorrhoidopexy versus Con-
Kamm and R. K. Phillips, “Persistent Pain and Faecal
ventional Diathermy Haemorrhoidectomy,” British Jour-
Urgency after Stapled Haemorrhoidectomy,” Lancet, Vol.
nal of Surgery, Vol. 89, No. 11, 2002, pp. 1376-1381.
 N. Sohn, J. S. Aronoff, F. S. Cohen and M. A. Weinstein,
 S. Cipriani and M. Pescatori, “Acute Rectal Obstruction
“Transanal Hemorrhoidal Dearterialization Is an Alter-
after PPH Stapled Haemorrhoidectomy,” Colorectal Dis-
native to Operative Hemorrhoidectomy,” The American Journal of Surgery, Vol. 182, No. 5, 2001, pp. 515-519.
 J. E. Dowden, J. D. Stanley and R. A. Moore, “Ob-
 G. Felice, A. Privitera A, E. Ellul and M. Klaumann,
structed Defecation after Stapled Hemorrhoidopexy: A
“Doppler-Guided Hemorrhoidal Artery Ligation: An Al-
Report of Four Cases,” The American Journal of Surgery,
ternative to Hemorrhoidectomy,” Diseases of the Colon & Rectum, Vol. 48, No. 11, 2005, pp. 2090-2093.
 A. Infantino, D. F. Altomare, C. Bottini, M. Bonanno, S.
Mancini, T. Yalti, P. Giamundo, J. Hoch, A. El Gaddal
 V. Shanmugam, M. A. Thaha, K. S. Rabindranath, K. L.
and C. Pagano, “Prospective Randomized Multicentre
Campbell, R. J. Steele and M. A. Loudon, “Rubber Band
Study Comparing Stapler Haemorrhoidopexy with Dop-
Ligation versus Excisional Haemorrhoidectomy for Hae-
pler-Guided Transanal Haemorrhoid Dearterialization for
morrhoids,” Cochrane Database of Systematic Reviews,
Third-Degree Haemorrhoids,” Colorectal Disease, Vol.
 J. Burch, D. Epstein, A. B. Sari, H. Weatherly, D. Jayne,
D. Fox and N. Woolacott, “Stapled Haemorrhoidopexy
 A. Arezzo, V. Podzemny and M. Pescatori, “Surgical
for the Treatment of Haemorrhoids: A Systematic Re-
Management of Hemorrhoids. State of the Art,” Annali
viewk,” Colorectal Disease, Vol. 11, No. 3, 2009, pp.
Italiani di Chirurgia, Vol. 82, No. 2, 2011, pp. 163-172.
 I. Goulimaris, I. Kanellos, E. Christoforidis, I. Mantzoros,
 J. L. Faucheron, D. Voirin and J. Abba, “Rectal Perfora-
C. Odisseos and D. Betsis, “Stapled Haemorrhoidectomy
tion with Life-Threatening Peritonitis Following Stapled
Compared with Milligan-Morgan Excision for the Treat-
Haemorrhoidopexy,” British Journal of Surgery, Vol. 99,
ment of Prolapsing Haemorrhoids: A Prospective Study,”
European Journal of Surgery, Vol. 168, No. 11, 2002, pp.
 C. Ratto, A. Parello, L. Donisi, F. Litta, G. Zaccone and
G. B. Doglietto, “Assessment of Haemorrhoidal Artery
 M. S. Sajid, U. Parampalli, P. Whitehouse, P. Sains, M. R.
Network Using Colour Duplex Imaging and Clinical Im-
McFall and M. K. Baig, “A Systematic Review Compar-
plications,” British Journal of Surgery, Vol. 99, No. 1,
ing Transanal Haemorrhoidal De-Arterialisation to Sta-
pled Haemorrhoidopexy in the Management of Haemor-
 P. Giordano, J. Overton, F. Madeddu, S. Zaman and G.
rhoidal Disease,” Techniques in Coloproctology, Vol. 16,
Gravante, “Transanal Hemorrhoidal Dearterialization: A
Systematic Review,” Diseases of the Colon & Rectum,
 A. G. Acheson and J. H. Scholefield, “Management of
Haemorrhoids,” British Medical Journal, Vol. 336, No.
 K. Morinaga, K. Hasuda and T. Ikeda, “A Novel Therapy
for Internal Hemorrhoids: Ligation of the Hemorrhoidal
Artery with a Newly Devised Instrument (Moricorn) in
 J. L. Faucheron, G. Poncet, D. Voirin, B. Badic and Y.
Conjunction with a Doppler Flowmeter,” The American
Gangner, “Doppler-Guided Hemorrhoidal Artery Ligation
Journal of Gastroenterology, Vol. 90, No. 4, 1995, pp.
and Rectoanal Repair (HAL-RAR) for the Treatment of
Grade IV Hemorrhoids: Long-Term Results in 100 Con-
 C. Ratto, L. Donisi, A. Parello, F. Litta and G. B. Dogli-
secutive Patients,” Diseases of the Colon & Rectum, Vol.
etto, “Evaluation of Transanal Hemorrhoidal Dearteriali-
zation as a Minimally Invasive Therapeutic Approach to
Hemorrhoids,” Diseases of the Colon & Rectum, Vol. 53,
 S. Avital, R. Inbar, E. Karin and R. Greenberg,
“Five-Year Follow-Up of Doppler-Guided Hemorrhoidal
Artery Ligation,” Techniques in Coloproctology, Vol. 16,
 SPSS, SPSS version 16, SPSS Inc., Chicago, 2007.
 P. Grigoropoulos, V. Kalles, I. Papapanagiotou, A. Mek-
 The HubBLe Trial: Haemorrhoidal Artery Ligation (HAL)
ras, A. Argyrou, K. Papgeorgiou and A. Derian, “Early
versus Rubber Band Ligation (RBL) for haemorrhoids.
and Late Complications of Stapled Haemorrhoidopexy: A
Copyright 2012 SciRes. SS
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