Doppler-Guided Hemorrhoidal Artery Ligation: The Experience of a Single Institution

Szmulowicz, Ursula M.; Gurland, Brooke; Garofalo, Thomas E.; Zutshi, Massarat

doi:10.1007/s11605-011-1460-7

Cited by 27 publications

(14 citation statements)

References 21 publications

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“…This method, comparable to the elastic band ligations performed blind for several decades, is effective in internal hemorrhoidal disease where there is no prolapse. Several descriptive studies [20][21][22][23][24][25] have reported a shortterm efficacy rate of 90 %, and long-term efficacy of 70-92 %. Post-operative pain was present in 1-6 % of cases.…”

Section: Discussionmentioning

confidence: 99%

Emborrhoid: A New Concept for the Treatment of Hemorrhoids with Arterial Embolization: The First 14 Cases

Vidal

Sapoval

Sielezneff

et al. 2014

Cardiovasc Intervent Radiol

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Section: Discussionmentioning

confidence: 99%

Emborrhoid: A New Concept for the Treatment of Hemorrhoids with Arterial Embolization: The First 14 Cases

Vidal

Sapoval

Sielezneff

et al. 2014

Cardiovasc Intervent Radiol

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“…Another advantage is that this can be an outpatient procedure. Recurrence rates have been reported at 6-21% in short-term follow-up 103,104) , but there is no evidence based on long-term follow-up.…”

Section: ) Other Techniquesmentioning

confidence: 99%

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

Yamana

2017

J Anus Rectum Colon

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The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.

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“…Pucher et al 19 pointed out that many case series include the particular centre's initial experience and describe a poorer outcome in the early patients. 66,105 Our trial required that surgeons had to have carried out at least five mentored cases and an additional five procedures prior to delivering the study intervention. This was based on manufacturers' recommendations, with no data to indicate that this was adequate to have reached the top of the learning curve for competence.…”

Section: Learning Curvementioning

confidence: 99%

The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

Brown

Tiernan

Biggs

et al. 2016

Health Technol Assess

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BackgroundOptimal surgical intervention for low-grade haemorrhoids is unknown. Rubber band ligation (RBL) is probably the most common intervention. Haemorrhoidal artery ligation (HAL) is a novel alternative that may be more efficacious.ObjectiveThe comparison of HAL with RBL for the treatment of grade II/III haemorrhoids.DesignA multicentre, parallel-group randomised controlled trial.PerspectiveUK NHS and Personal Social Services.Setting17 NHS Trusts.ParticipantsPatients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL.InterventionsHAL with Doppler probe compared with RBL.OutcomesPrimary outcome – recurrence at 1 year post procedure; secondary outcomes – recurrence at 6 weeks; haemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness.ResultsA total of 370 participants entered the trial. At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [adjusted odds ratio (OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51;p = 0.0005]. The main reason for the difference was the number of extra procedures required to achieve improvement/cure. If a single HAL is compared with multiple RBLs then only 37.5% recurred in the RBL arm (adjusted OR 1.35, 95% CI 0.85 to 2.15;p = 0.20). Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL), suggesting significant deterioration in both groups over the year. Symptom score, EQ-5D-5L and Vaizey score improved in both groups compared with baseline, but there was no difference between interventions. Pain was less severe and of shorter duration in the RBL group; most of the HAL group who had pain had mild to moderate pain, resolving by 3 weeks. Complications were low frequency and not significantly different between groups. It appeared that HAL was not cost-effective compared with RBL. In the base-case analysis, the difference in mean total costs was £1027 higher for HAL. Quality-adjusted life-years (QALYs) were higher for HAL; however, the difference was very small (0.01) resulting in an incremental cost-effectiveness ratio of £104,427 per additional QALY.ConclusionsAt 1 year, although HAL resulted in fewer recurrences, recurrence was similar to repeat RBL. Symptom scores, complications, EQ-5D-5L and continence score were no different, and patients had more pain in the early postoperative period after HAL. HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY.LimitationsBlinding of participants and site staff was not possible.Future workThe incidence of recurrence may continue to increase with time. Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness. The polysymptomatic nature of haemorrhoidal disease requires a validated scoring system, and the data from this trial will allow further assessment of validity of such a system. These data add to the literature regarding treatment of grade II/III haemorrhoids. The results dovetail with results from the eTHoS study [Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A,et al.Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial.Lancet2016, in press.] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy. Combined results will allow expansion of analysis, allowing surgeons to tailor their treatment options to individual patients.Trial registrationCurrent Controlled Trials ISRCTN41394716.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 88. See the NIHR Journals Library website for further project information.

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Doppler-Guided Hemorrhoidal Artery Ligation: The Experience of a Single Institution

Abstract: DG-HAL is a simple procedure with a low complication rate. Recurrences are more frequent during the learning curve. Patients with large, circumferential internal hemorrhoids should be counseled about a possible higher rate of recurrence. DG-HAL can be effectively repeated for recurrences.

Cited by 27 publications

References 21 publications

Emborrhoid: A New Concept for the Treatment of Hemorrhoids with Arterial Embolization: The First 14 Cases

Emborrhoid: A New Concept for the Treatment of Hemorrhoids with Arterial Embolization: The First 14 Cases

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

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