Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids

Abstract

Background

Traditional treatment of fourth-degree haemorrhoidal disease (HD) is conventional haemorrhoidectomy and is frequently associated with significant pain and morbidity. In recent years, the use of transanal haemorrhoidal dearterialization (THD) for the treatment of HD has increased. The procedure aims to decrease the arterial blood flow to the haemorrhoids. Moreover, since a rectal mucopexy to treat the prolapsing component has become part of the THD technique, this treatment is also indicated for more advanced HD. The aim of this study was to assess the possible role of THD in the treatment of fourth-degree HD.

Methods

All patients with non-fibrotic fourth-degree HD were offered the THD procedure with mucopexy. Excision of skin tags was added to THD and mucopexy, when needed. A specific score was used to assess HD severity, ranging from 0 (no HD) to 20 (worst HD). The mean preoperative score was 18.1 ± 1.8.

Results

Thirty-five consecutive patients (mean age 50.4 ± 13.8 years; 19 men) with fourth-degree HD were prospectively enroled. An average of 6 arteries were identified and transfixed. Mucopexy was achieved with a 3–6 sector plication of rectal mucosa. Mean operating time was 33 ± 12 min. No intraoperative complications were recorded. Postoperative morbidity included 3 (8.6%) haemorrhoidal thromboses (1 requiring surgery) and 2 (5.7%) episodes of bleeding (1 requiring surgical haemostasis). Five patients (14.3%) had urinary retention requiring catheterization. At a median follow-up of 10 months (range 2–28 months), symptoms had resolved or significantly improved in 33 (94%) patients. Nine patients (25.7%) reported irregular bleeding, 3 patients (8.6%) mild anal pain, 4 patients (11.4%) transient anal burning and 4 patients (11.4%) tenesmus. Ten patients (28.6%) experienced some degree of residual prolapse, significant only in 2 (5.7%) who required further surgery. There was no anorectal stenosis, and no faecal incontinence was reported. At a median follow-up of 10 months, the symptomatic score was 2.5 ± 2.5 (P < 0.005).

Conclusion

Transanal haemorrhoidal dearterialization seems to be a safe and effective treatment for fourth-degree HD providing a significant improvement of symptoms for the majority of patients. When present, persisting symptoms are mostly transient, occasional or limited in severity, and only a very few patients require further intervention. Larger series and longer follow-up to further assess the role of THD in this challenging group of pts.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. 1.

    Maeda Y, Phillips RKS (2009) Open hemorrhoidectomy. In: Khubchandani I, Paonessa N, Khawaja A (eds) Surgical treatment of hemorrhoids. Springer, London, pp 71–76

    Google Scholar 

  2. 2.

    Metcalf DR, Senagore AJ (2010) Hemorrhoidal surgery. In: Whitlow CB, Beck DE, Margolin DA, Hicks TC, Timmcke AE (eds) Improved outcomes in colon and rectal surgery. Informa Healthcare, Colchester, pp 168–177

    Google Scholar 

  3. 3.

    Sohn N, Aronoff JS, Cohen FS, Weinstein MA (2001) Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy. Am J Surg 182:515–519

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    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

    PubMed  Article  Google Scholar 

  5. 5.

    Dal Monte PP, Tagariello C, Sarago M et al (2007) Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease. Tech Coloproctol 11:333–338

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Giordano P, Overton J, Madeddu F, Zaman S, Gravante G (2009) Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum 52:1665–1671

    PubMed  Article  Google Scholar 

  7. 7.

    Morinaga K, Hasuda K, Ikeda T (1995) 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 90:610–613

    PubMed  CAS  Google Scholar 

  8. 8.

    Aigner F, Bodner G, Conrad F et al (2004) The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am J Surg 187:102–108

    PubMed  Article  Google Scholar 

  9. 9.

    Ratto C, Donisi L, Parello A, Litta F, Doglietto GB (2010) Evaluation of transanal hemorrhoidal dearterialization as a minimally invasive therapeutic approach to hemorrhoids. Dis Colon Rectum 53:803–811

    PubMed  Article  Google Scholar 

  10. 10.

    Goligher JC, Leacock AG, Brossy JJ (1955) The surgical anatomy of the anal canal. Br J Surg 43:51–61

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG (1992) Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum 35:477–481

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Arbman G, Krook H, Haapaniemi S (2000) Closed vs. open hemorrhoidectomy–is there any difference? Dis Colon Rectum 43:31–34

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Sayfan J (2001) Complications of Milligan-Morgan hemorrhoidectomy. Dig Surg 18:131–133

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Yano T, Matsuda Y, Asano M et al (2009) The outcome of postoperative hemorrhaging following a hemorrhoidectomy. Surg Today 39:866–869

    PubMed  Article  Google Scholar 

  15. 15.

    Chen JS, You JF (2010) Current status of surgical treatment for hemorrhoids–systematic review and meta-analysis. Chang Gung Med J 33:488–500

    PubMed  Google Scholar 

  16. 16.

    Stolfi VM, Sileri P, Micossi C et al (2008) Treatment of hemorrhoids in day surgery: stapled hemorrhoidopexy vs Milligan-Morgan hemorrhoidectomy. J Gastrointest Surg 12:795–801

    PubMed  Article  Google Scholar 

  17. 17.

    Altomare DF (2009) Stapled hemorrhoidopexy. In: Khubchandani I, Paonessa N, Khawaja A (eds) Surgical treatment of hemorrhoids. Springer, London, pp 87–94

    Google Scholar 

  18. 18.

    Ravo B, Amato A, Bianco V et al (2002) Complications after stapled hemorrhoidopexy: can they be prevented? Tech Coloproctol 6:83–88

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Ripetti V, Caricato M, Arullani A (2002) Rectal perforation, retropneumoperitoneum, and pneumomediastinum after stapling procedure for prolapsed hemorrhoids: report of a case and subsequent considerations. Dis Colon Rectum 45:268–270

    PubMed  Article  Google Scholar 

  20. 20.

    Blouhos K, Vasiliadis K, Tsalis K et al (2007) Uncontrollable intra-abdominal bleeding necessitating low anterior resection of the rectum after stapled hemorrhoidopexy: report of a case. Surg Today 37:254–257

    PubMed  Article  Google Scholar 

  21. 21.

    Pescatori M, Gagliardi G (2008) Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 12:7–19

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    van Wensen RJ, van Leuken MH, Bosscha K (2008) Pelvic sepsis after stapled hemorrhoidopexy. World J Gastroenterol 14:5924–5926

    PubMed  Article  Google Scholar 

  23. 23.

    Cirocco WC (2008) Life threatening sepsis and mortality following stapled hemorrhoidopexy. Surgery 143:824–829

    PubMed  Article  Google Scholar 

  24. 24.

    Augustin G, Smud D, Kinda E et al (2009) Intra-abdominal bleeding from a seromuscular tear of an ascending rectosigmoid intramural hematoma after stapled hemorrhoidopexy. Can J Surg 52:E14–E15

    PubMed  Google Scholar 

  25. 25.

    Dowden JE, Stanley JD, Moore RA (2010) Obstructed defecation after stapled hemorrhoidopexy: a report of four cases. Am Surg 76:622–625

    PubMed  Google Scholar 

  26. 26.

    Jayaraman S, Colquhoun PH, Malthaner RA (2007) Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum 50:1297–1305

    PubMed  Article  Google Scholar 

  27. 27.

    Tjandra JJ, Chan MK (2007) Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 50:878–892

    PubMed  Article  Google Scholar 

  28. 28.

    Giordano P, Gravante G, Sorge R, Ovens L, Nastro P (2009) Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch Surg 144:266–272

    PubMed  Article  Google Scholar 

  29. 29.

    Zacharakis E, Kanellos D, Pramateftakis MG et al (2007) Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years. Tech Coloproct 11:144–147

    Article  CAS  Google Scholar 

  30. 30.

    Ceci F, Picchio M, Palimento D et al (2006) Long-term outcome of stapled hemorrhoidectomy for Grade III and Grade IV hemorrhoids. Dis Colon Rectum 21:166–171

    Google Scholar 

  31. 31.

    Ortiz H, Marzo J, Armendariz P (2002) Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg 89:1376–1381

    PubMed  Article  CAS  Google Scholar 

  32. 32.

    Ortiz H, Marzo J, Armendariz P et al (2005) Stapled haemorrhoidopexy vs. diathermy excision for fourth-degree hemorrhoids: a randomized, clinical trial and review of the literature. Dis Colon Rectum 48:809–815

    PubMed  Article  Google Scholar 

  33. 33.

    Boccasanta P, Capretti PG, Venturi M et al (2001) Randomised controlled trial between stapled circumferential mucosectomy and conventional circular haemorrhoidectomy in advanced haemorrhoids with external mucosal prolapse. Am J Surg 182:64–68

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Infantino A, Bellomo R, Dal Monte PP et al (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

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to C. Ratto.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Ratto, C., Giordano, P., Donisi, L. et al. Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids. Tech Coloproctol 15, 191 (2011). https://doi.org/10.1007/s10151-011-0689-1

Download citation

Keywords

  • Haemorrhoids
  • Transanal haemorrhoidal dearterialization
  • Doppler
  • Mucopexy
  • Complications