The most important finding of this study is that the Doppler-guided THD procedure is not inferior to conventional excisional hemorrhoidectomy for advanced hemorrhoidal disease in terms of postoperative complications and long-term symptom recurrence.
The major strength of this study is that only patients with grade III and IV hemorrhoids were included. Short- and long-term follow-up was performed by the same surgical team during the study period, and recurrence or persistence of hemorrhoid symptoms was evaluated using a symptomatic score that takes into account bleeding, prolapse, pain and impact of hemorrhoidal disease on quality of life. Clinical evaluation using only the Goligher grade could cause confusion regarding true symptomatic recurrence or symptom persistence, the elimination of which must be considered the real goal of surgery for hemorrhoids.
The study has some limitations. First, the number of patients included was relatively small due to the restricted inclusion criteria, which may be responsible for a power error. Nevertheless, these were consecutively enrolled patients, and there were no differences in demographics and disease grade between the 2 groups. Second, a classic well-known surgical technique (hemorrhoid excision) was compared with Doppler-guided THD which is a relatively new procedure. This could introduce a bias in the analysis of the results. Actually, as recently observed , the number of complications can decrease with increasing surgeon experience. To reduce this error, before starting the inclusion of patients for the study, the Doppler-guided THD procedure was performed on 15 patients. Moreover, it was performed only by 1 surgeon. Another weakness of the present study is that postoperative pain has not been studied. Considering that most of the published studies aim to analyze the relationship between type of procedure and postoperative pain, we focussed our analysis on early complications and long-term results. In addition, postoperative pain is a difficult point to study outside of a targeted randomized trial, because it depends on many variables which are not directly related to the surgical technique such as pain medication protocol, anesthesia and scales used to record the pain. In a recent double-blind randomized controlled trial comparing 20 patients who underwent Doppler-guided THD with mucopexy with 20 patients who underwent conventional hemorrhoidectomy, the authors found that the dearterialization led to less postoperative pain . Other authors found that pain was similar after both surgical techniques [11, 13].
As reported in others studies [11,12,13, 25], we did not find statistical differences in overall postoperative morbidity between the two techniques. Nevertheless, a higher number of acute urinary retention occurred after Doppler-guided THD. This is not a major complication and all the cases were effectively treated by a temporary bladder catheterization removed the same day or the day after surgery. However, frequently this mild complication implied a delay in hospital discharge. Four patients experienced acute internal hemorrhoid thrombosis during the first 30 days after Doppler-guided THD. All cases were treated successfully by thrombectomy under local anesthesia with immediate relief of pain. While uncommon after excisional hemorrhoidectomy, thrombosis needs to be suspected when a patient presents acute anal pain in the first weeks after a THD procedure.
A recent meta-analysis including 316 patients from 4 randomized controlled trials, which evaluate the surgical and postoperative outcomes of Doppler-guided THD procedure versus open conventional hemorrhoidectomy, finds no differences in terms of recurring disease between the surgical procedures . These results are in line with our findings in which long-term symptom recurrence or persistence was similar in the 2 groups. However, when a separate analysis was performed for different grades of hemorrhoids, for grade III the Doppler-guided THD procedure appears to be more effective in long-term symptom control compared to excisional hemorrhoidectomy, although this result did not reach statistical significance. This could be explained by a minor effect of the mucopexy on grade IV hemorrhoids in which the chronic prolapsed piles are often epithelialized making fibrosis less effective in maintaining the piles in the anal canal. The same trend was observed by Denoya et al. in a recent randomized double-blinded trial comparing Doppler-guided THD with excisional hemorrhoidectomy, in which all patients who experienced recurrence in either arms had grade IV hemorrhoids .
Analyzing separately the symptoms included in the Giordano score, no differences between the 2 groups were observed in terms of persistence of symptoms. Although the rate of persistence of symptoms is apparently high, in most patients, symptoms were occasional and therefore had a low clinical impact. Actually, only 3 patients included in the study have been considered for further surgical treatment.
Long-term chronic complications such as anal stricture, nonhealing wounds and fecal incontinence as consequence of sphincter lesions have been reported after conventional excisional hemorrhoidectomy but not after Doppler-guided THD [16, 17]. In the present study, we did not observe any anal stricture or chronic nonhealing wounds, but 2 patients reported fecal incontinence after excisional hemorrhoidectomy. One of these patients had previous mild continence impairment that worsened after surgery. Due to the fact that sphincter lesions are only anecdotal after Doppler-guided THD, this surgical technique should be preferred for patients at high risk of fecal incontinence.
Operation time was not analyzed in the present study. As reported in several publications, the operation time for the Doppler-guided THD procedure is longer than for excisional hemorrhoidectomy [13, 25]. This disadvantage must be balanced with the fact that Doppler-guided THD is less invasive than conventional hemorrhoidectomy because no wounds are created and there is no risk of sphincter damage. Another potential advantage of Doppler-guided THD, though time-demanding, is that it can correct the physiology of the hemorrhoidal plexus by of the arterial blood flow to the hemorrhoidal cushions through dearterialization and eliminate the mucosal prolapse by mucopexy in 6 different points of the anal canal [22, 26, 27].