Literature Review on Dearterialization of Hemorrhoids and Mucopexy
This chapter gives a revision of the literature on dearterialization of hemorrhoids combined with mucopexy for treatment of hemorrhoidal disease, in order to present its evolution, safety, and efficacy of the technique, to define its indications, as well as to show advantages, disadvantages, and modalities of surgical treatment.
Performing a literature search in PubMed, Livivo, and Cochrane, one has to use multiple terms, including different combinations and variations of “transanal hemorrhoidal dearterialization (THD),” “Doppler-guided hemorrhoidal artery ligation (DGHAL),” “dearterialization of hemorrhoids,” “mucopexy,” “anopexy,” “suture mucosal pexy,” and “recto anal repair.”
In addition, references of selected articles were looked on to find more studies in this field.
Included were articles available in English or German.
An overall of 51 articles including 5315 patients were identified concerning dearterialization of hemorrhoids combined with mucopexy, beginning in the year 2007 up to today.
The overall quality was poor with recurrence rates ranging between 0% and 40%, highest in patients with fourth degree hemorrhoidal disease. The overall complication rate was low, nearly all minor complications, without life threatening or deadly complications.
One to 16 ligations were performed with a number of pexies from one up to nine.
Reintervention rates were stated between cero and 29%.
Operation times differ from 10 min up to 1 h.
The overall patient satisfaction, as far as specified, was 75% up to 99%, mainly around 90%.
Doppler-guided hemorrhoid artery ligation combined with mucopexy is safe and especially in second and third degree hemorrhoidal disease efficacious, with a moderate complication rate and the absence of life-threatening incidents.
The learning curve seems to be flatter than expected with acceptable recurrence rates in experienced hands. The question whether Doppler guidance is needed or not cannot be answered with absolute certainty so far.
- Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L, Pratschke J, Peer S, Gruber H (2016) Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of grade III haemorrhoids: a prospective randomized controlled trial. Colorectal Dis 18:710–716. https://doi.org/10.1111/codi.13280CrossRefPubMedGoogle Scholar
- Baker H (2006) Hemorrhoids. In: Gale encyclopedia of medicine, 3rd edn. Gale, Detroit, pp 1766–1769Google Scholar
- Béliard A, Labbé F, de Faucal D, Fabreguette J-M, Pouderoux P, Borie F (2014) A prospective and comparative study between stapled hemorrhoidopexy and hemorrhoidal artery ligation with mucopexy. J Visc Surg 151:257–262. https://doi.org/10.1016/j.jviscsurg.2014.03.009CrossRefPubMedPubMedCentralGoogle Scholar
- Bjelanovic Z, Draskovic M, Veljovic M, Lekovic I, Karanikolas M, Stamenkovic D (2016) Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. Cir Esp. https://doi.org/10.1016/j.ciresp.2016.07.002
- Brown SR, Tiernan JP, Watson AJM, Biggs K, Shephard N, Wailoo AJ, Bradburn M, Alshreef A, Hind D (2016) Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet 388:356–364. https://doi.org/10.1016/S0140-6736(16)30584-0CrossRefPubMedPubMedCentralGoogle Scholar
- Bursics A, Morvay K, Kupcsulik P, Flautner L (2004) Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study. Int J Colorectal Dis 19:176–180. https://doi.org/10.1007/s00384-003-0517-9CrossRefPubMedPubMedCentralGoogle Scholar
- Cavazzoni E, Bugiantella W, Graziosi L, Silvia Franceschini M, Cantarella F, Rosati E, Donini A (2013) Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding. Colorectal Dis 15:e89–e92. https://doi.org/10.1111/codi.12053CrossRefPubMedGoogle Scholar
- Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196. https://doi.org/10.1097/SLA.0b013e3181b13ca2CrossRefPubMedGoogle Scholar
- Dal Monte PP, Tagariello C, Sarago M, Giordano P, Shafi A, Cudazzo E, Franzini M (2007) Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease. Tech Coloproctol 11:333–338, 339. https://doi.org/10.1007/s10151-007-0376-4CrossRefPubMedGoogle Scholar
- De Nardi P, Capretti G, Corsaro A, Staudacher C (2014) A prospective, randomized trial comparing the short- and long-term results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids. Dis Colon Rectum 57:348–353. https://doi.org/10.1097/DCR.0000000000000085CrossRefPubMedPubMedCentralGoogle Scholar
- Denoya PI, Fakhoury M, Chang K, Fakhoury J, Bergamaschi R (2013) Dearterialization with mucopexy versus haemorrhoidectomy for grade III or IV haemorrhoids: short-term results of a double-blind randomized controlled trial. Colorectal Dis 15:1281–1288. https://doi.org/10.1111/codi.12303CrossRefPubMedGoogle Scholar
- Deutsch CJ, Chan K, Alawattegama H, Sturgess J, Davies RJ (2012) Doppler-guided transanal haemorrhoidal dearterialisation is a safe and effective daycase procedure for all grades of symptomatic haemorrhoids. Surg Sci 3(11):542–545. https://doi.org/10.4236/ss.2012.311107
- Digestive Diseases Statistics for the United States. https://www.niddk.nih.gov/health-information/health-statistics/Pages/digestive-diseases-statistics-for-the-united-states.aspx. Accessed 11 Jan 2017
- Faucheron J-L, Poncet G, Voirin D, Badic B, Gangner Y (2011) Doppler-guided hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) for the treatment of grade IV hemorrhoids: long-term results in 100 consecutive patients. Dis Colon Rectum 54:226–231. https://doi.org/10.1007/DCR.0b013e318201d31cCrossRefPubMedPubMedCentralGoogle Scholar
- Festen S, van Hoogstraten MJ, van Geloven AAW, Gerhards MF (2009) Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results. Int J Colorectal Dis 24:1401–1405. https://doi.org/10.1007/s00384-009-0803-2CrossRefPubMedGoogle Scholar
- Giordano P, Nastro P, Davies A, Gravante G (2011) Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes. Tech Coloproctol 15:67–73. https://doi.org/10.1007/s10151-010-0667-zCrossRefPubMedPubMedCentralGoogle Scholar
- Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB (2010) Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum 53:47–52. https://doi.org/10.1007/DCR.0b013e3181bbfc89CrossRefPubMedGoogle Scholar
- Hoyuela C, Carvajal F, Juvany M, Troyano D, Trias M, Martrat A, Ardid J, Obiols J (2016) HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up. Int J Surg 28:39–44. https://doi.org/10.1016/j.ijsu.2016.02.030CrossRefPubMedGoogle Scholar
- Infantino A, Bellomo R, Dal Monte PP, Salafia C, Tagariello C, Tonizzo CA, Spazzafumo L, Romano G, Altomare DF (2010) Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study. Colorectal Dis 12:804–809. https://doi.org/10.1111/j.1463-1318.2009.01915.xCrossRefPubMedGoogle Scholar
- Infantino A, Altomare DF, Bottini C, Bonanno M, Mancini S, THD Group of the SICCR (Italian Society of Colorectal Surgery), Yalti T, Giamundo P, Hoch J, El Gaddal A, Pagano C (2012) Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids. Colorectal Dis 14:205–211. https://doi.org/10.1111/j.1463-1318.2011.02628.xCrossRefPubMedGoogle Scholar
- Khafagy W, El Nakeeb A, Fouda E, Omar W, Elhak NG, Farid M, Elshobaky M (2009) Conventional haemorrhoidectomy, stapled haemorrhoidectomy, Doppler guided haemorrhoidectomy artery ligation; post operative pain and anorectal manometric assessment. Hepatogastroenterology 56:1010–1015PubMedGoogle Scholar
- Leardi S, Pessia B, Mascio M, Piccione F, Schietroma M, Pietroletti R (2016) Doppler-guided transanal hemorrhoidal dearterialization (DG-THD) versus stapled hemorrhoidopexy (SH) in the treatment of third-degree hemorrhoids: clinical results at short and long-term follow-up. J Gastrointest Surg 20:1886–1890. https://doi.org/10.1007/s11605-016-3220-1CrossRefPubMedPubMedCentralGoogle Scholar
- Lehur PA, Didnée AS, Faucheron J-L, Meurette G, Zerbib P, Siproudhis L, Vinson-Bonnet B, Dubois A, Casa C, Hardouin J-B, Durand-Zaleski I, LigaLongo Study Group (2016) Cost-effectiveness of new surgical treatments for hemorrhoidal disease: a multicentre randomized controlled trial comparing transanal Doppler-guided hemorrhoidal artery ligation with mucopexy and circular stapled hemorrhoidopexy. Ann Surg 264:710–716. https://doi.org/10.1097/SLA.0000000000001770CrossRefPubMedPubMedCentralGoogle Scholar
- Lucarelli R, Picchio M, Caporossi M, De Angelis F, Di Filippo A, Stipa F, Spaziani E (2013) Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up. Ann R Coll Surg Engl 95:246–251. https://doi.org/10.1308/003588413X13511609958136CrossRefPubMedPubMedCentralGoogle Scholar
- NICE (2010) Haemorrhoidal artery ligation|1-guidance|Guidance and guidelines|NICE. https://www.nice.org.uk/guidance/ipg342/chapter/1-Guidance. Accessed 6 Nov 2016
- Noguerales F, Díaz R, Salim B, Piniella F, Landaluce A, Garcea A, de Mata López Pérez J (2015) Treatment of haemorrhoids by transanal haemorrhoidal dearterialization. Experience of several specialized units. Cir Esp 93:236–240. https://doi.org/10.1016/j.ciresp.2014.04.012CrossRefPubMedGoogle Scholar
- Piccinini P (2016) Tratamiento no resectivo de la enfermedad hemorroidal: HAL RAR ¿Una alternativa?Google Scholar
- Ratto C, Donisi L, Parello A, Litta F, Zaccone G, De Simone V (2012a) “Distal Doppler-guided dearterialization” is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization. Colorectal Dis 14:e786–e789. https://doi.org/10.1111/j.1463-1318.2012.03146.xCrossRefPubMedGoogle Scholar
- Ratto C, Parello A, Veronese E, Cudazzo E, D’Agostino E, Pagano C, Cavazzoni E, Brugnano L, Litta F (2015) Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis 17:O10–O19. https://doi.org/10.1111/codi.12779CrossRefPubMedGoogle Scholar
- Roka S, Gold D, Walega P, Lancee S, Zagriadsky E, Testa A, Kukreja AN, Salat A (2013) DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study. Eur Surg 45:26–30. https://doi.org/10.1007/s10353-012-0182-8CrossRefPubMedPubMedCentralGoogle Scholar
- Sajid MS, Parampalli U, Whitehouse P, Sains P, McFall MR, Baig MK (2012) A systematic review comparing transanal haemorrhoidal de-arterialisation to stapled haemorrhoidopexy in the management of haemorrhoidal disease. Tech Coloproctol 16:1–8. https://doi.org/10.1007/s10151-011-0796-zCrossRefPubMedPubMedCentralGoogle Scholar
- Satzinger U, Feil W, Glaser K (2009) Recto anal repair (RAR): a viable new treatment option for high-grade hemorrhoids. One year results of a prospective study. Pelviperineology 28:37–42Google Scholar
- Scheyer M, Antonietti E, Rollinger G, Arnold S (2008) Doppler-guided RAR – a combination of HAL and transanal rectal mucopexy for a minimally treatment of hemorrhoidal disease – all grades. JCD 23:17–21Google Scholar
- Shelygin IA, Titov AI, Veselov VV, Kanametov MK (2003) Results of ligature of distal branches of the upper rectal artery in chronic hemorrhoid with the assistance of Doppler ultrasonography. Khirurgiia (Mosk) (1):39–44Google Scholar
- Simillis C, Thoukididou SN, Slesser AAP, Rasheed S, Tan E, Tekkis PP (2015) Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg 102:1603–1618. https://doi.org/10.1002/bjs.9913CrossRefPubMedPubMedCentralGoogle Scholar
- Tempel MB, Pearson EG, Page M, Pollock D, Gilmore-Lynch K, Peche W, Sklow B, Snyder M (2014) Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings. Tech Coloproctol 18:607–610. https://doi.org/10.1007/s10151-013-1104-xCrossRefPubMedPubMedCentralGoogle Scholar
- Theodoropoulos GE, Sevrisarianos N, Papaconstantinou J, Panoussopoulos SG, Dardamanis D, Stamopoulos P, Bramis K, Spiliotis J, Datsis A, Leandros E (2010) Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III–IV haemorrhoids: a multicenter prospective study of safety and efficacy. Colorectal Dis 12:125–134. https://doi.org/10.1111/j.1463-1318.2008.01739.xCrossRefPubMedGoogle Scholar
- Theodoropoulos GE, Michalopoulos NV, Linardoutsos D, Stamopoulos P, Flessas I, Tsamis D, Zografos GC (2012) Rectoanal repair versus suture haemorrhoidopexy: a comparative study on suture mucopexy procedures for high-grade haemorrhoids. Tech Coloproctol 16:237–241. https://doi.org/10.1007/s10151-012-0822-9CrossRefPubMedGoogle Scholar
- Titov AY, Abritsova MV, Mudrov AA (2016) Comparison of Doppler-assisted dearterialization with mucopexy and hemorrhoidectomy. Khirurgiia (Sofiia) 24–32Google Scholar
- Tsang YP, Fok KLB, Cheung YSH, Li KWM, Tang CN (2014) Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Tech Coloproctol 18:1017–1022. https://doi.org/10.1007/s10151-014-1170-8CrossRefPubMedPubMedCentralGoogle Scholar
- von Roon AC, Reese GE, Tekkis PP (2009) Haemorrhoids: haemorrhoidal artery ligation. BMJ Clin Evid 2009:0415Google Scholar
- Walega P, Romaniszyn M, Kenig J, Herman R, Nowak W (2012) Doppler-guided hemorrhoid artery ligation with recto-anal-repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease. Sci World J. https://doi.org/10.1100/2012/324040
- Wallis de Vries BM, van der Beek ESJ, de Wijkerslooth LRH, van der Zwet WC, van der Hoeven JAB, Eeftinck Schattenkerk M, Eddes EH (2007) Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation. Dig Surg 24:436–440. https://doi.org/10.1159/000108326CrossRefPubMedGoogle Scholar
- Xu L, Chen H, Lin G, Ge Q, Qi H, He X (2016) Transanal hemorrhoidal dearterialization with mucopexy versus open hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials. Tech Coloproctol 20:825–833. https://doi.org/10.1007/s10151-016-1551-2CrossRefPubMedPubMedCentralGoogle Scholar
- Yamoul R, Attolou G, Njoumi N, Alkandry S, Tahiri MEH (2013) The effectiveness of Doppler controlled hemorrhoidal artery ligation based on preliminaries results. Pan Afr Med J. https://doi.org/10.11604/pamj.2013.15.159.2190
- Zagryadskiy EA, Gorelov SI (2008) Transanal doppler-guided hemorrhoidal artery ligation/recto anal repair (HAL-RAR®) for treatment of grade 3–4 hemorrhoids: a new mini-invasive technology. Pelviperineology 27:151–155Google Scholar
- Zagryadskiy EA, Gorelov SI (2011) Transanal Doppler-guided hemorrhoidal artery ligation and recto anal repair vs closed hemorrhoidectomy for treatment of grade III–IV hemorrhoids. A randomized trial. Pelviperineology 30:107–112Google Scholar
- Zampieri N, Castellani R, Andreoli R, Geccherle A (2012) Long-term results and quality of life in patients treated with hemorrhoidectomy using two different techniques: Ligasure versus transanal hemorrhoidal dearterialization. Am J Surg 204:684–688. https://doi.org/10.1016/j.amjsurg.2012.01.014CrossRefPubMedPubMedCentralGoogle Scholar