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.  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 . 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.  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.  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.  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.  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.