Australian people can buy antibiotics in Australia online here: No prescription required and cheap price!

Surgical Science, 2012, 3, 542-545
doi:10.4236/ss.2012.311107 Published Online November (
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 Email: Received August 7, 2012, revised September 8, 2012; accepted September 17, 2012 ABSTRACT
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 [7], but carries the small risk of poten- Symptomatic haemorrhoids arise due to pathological tially life-threatening pelvic sepsis [8]. 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 [1]. 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 [9]. 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 [10]. The aim of this retrospective study generally considered to represent the gold-standard [2]. 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 2. Methods
a swifter return to normal daily living than excisional 2.1. Inclusion Criteria
haemorrhoidectomy [3-5] and better success rates than rubber-band ligation [6]. 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. 3. Results
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.
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 [11], THD is a relatively guidelines recommend excisional haemorrhoidectomy novel therapy for haemorrhoids. This study sought to for Grade IV haemorrhoids [22]. 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 [23]. 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 [12]. 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% [13]. 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 [24]. 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 [25]) will help to morrhoidopexy [18]. The potential of clinically signi- ficant pelvic sepsis is a frequently raised criticism of stapled haemorrhoidopexy. The largest published review 5. Conclusions
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 [8]. 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 [19], 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 [20]. 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 [2], and rates of 91% and 92% for prevention of recurrence of prolapse and bleeding respectively at one year [11]. THD is frequently drawn REFERENCES
into comparison with stapled haemorrhoidopexy as the [1] 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- [2] 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. [3] H. Ortiz, J. Marzo and P. Armendariz, “Randomized [15] 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. [4] N. Sohn, J. S. Aronoff, F. S. Cohen and M. A. Weinstein, [16] 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. [17] J. E. Dowden, J. D. Stanley and R. A. Moore, “Ob- [5] 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. [18] A. Infantino, D. F. Altomare, C. Bottini, M. Bonanno, S. Mancini, T. Yalti, P. Giamundo, J. Hoch, A. El Gaddal [6] 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. [7] J. Burch, D. Epstein, A. B. Sari, H. Weatherly, D. Jayne, D. Fox and N. Woolacott, “Stapled Haemorrhoidopexy [19] 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. [20] I. Goulimaris, I. Kanellos, E. Christoforidis, I. Mantzoros, [8] 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. [9] C. Ratto, A. Parello, L. Donisi, F. Litta, G. Zaccone and G. B. Doglietto, “Assessment of Haemorrhoidal Artery [21] 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- [10] 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, [22] A. G. Acheson and J. H. Scholefield, “Management of Haemorrhoids,” British Medical Journal, Vol. 336, No. [11] 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 [23] 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- [12] 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, [24] S. Avital, R. Inbar, E. Karin and R. Greenberg, “Five-Year Follow-Up of Doppler-Guided Hemorrhoidal Artery Ligation,” Techniques in Coloproctology, Vol. 16, [13] SPSS, SPSS version 16, SPSS Inc., Chicago, 2007. [14] P. Grigoropoulos, V. Kalles, I. Papapanagiotou, A. Mek- [25] 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


Microsoft word - band trip emergency form-chaperone

RIVER FALLS HIGH SCHOOL BAND CHAPERONE 2010-2011 Emergency Information Please Print Chaperone’s Name: _______________________________________________________________ Home Address: __________________________________________________________________ Home Address:____________________________________________________________________ Spouse/Significant Other’s Name: ________________

Abstract Spam has grown to become a major threat for email positives are more dangerous by far, in a business environment communication. Although spam filters' degree of sophistication a false positive might have been a customer ordering a has increased ever since, they still produce huge amounts of false product. Failing to notice this message due to an overacting positives and fals

Copyright © 2010-2014 Find Medical Article