The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk

Abstract

The Emborrhoid is an innovative non-surgical technique for the treatment of severe hemorrhoidal bleeding. Patient selection and the impact on quality of life have not been fully investigated. This prospective observational study aims to evaluate the clinical outcomes after Emborrhoid in patients with high surgical risk. All patients with high surgical risk and anemia due to hemorrhoids were enrolled. Clinical data and previous blood transfusions were collected. The Hemorrhoidal Disease Symptom Score and Short Health Scala were completed before the procedure and during the follow-up visits at 1, 6 and 12 months. Transfusions and serum hemoglobin level variations were registered. Perioperative complications and the recurrence of bleeding were assessed. Trans-radial/femoral embolization of superior rectal artery, and/or middle rectal artery was performed with Interlock and Detachable Embolization Coils. From September 2020 to February 2022, 21 patients underwent a superselective embolization of all branches of the superior rectal artery. The transradial approach was most frequently performed compared to transfemoral access. After the procedure, no signs of ischemia were identified; three minor complications were observed. The mean follow-up was 18.5 ± 6.0 months. At the last follow-up, the mean increase of hemoglobin for patients was 1.2 ± 1.6 g/dL. Three patients needed transfusions during follow-up for recurrent hemorrhoidal bleeding. The Hemorrhoidal Disease Symptom Score and Short Health Scala decreased from 11.1 ± 4.2 to 4.7 ± 4.6 (p < 0.0001) and from 18.8 ± 4.8 to 10.2 ± 4.9 (p < 0.0001), respectively. Patients who had given up on their daily activities due to anemia have returned to their previous lifestyle. Emborrhoid seems to be a safe and effective option for the treatment of bleeding hemorrhoids in frail patients. The low complication rate and the significant reduction of post-defecation bleeding episodes are related to the improvement of the hemorrhoidal symptoms and patients’ quality of life.

Prevalent Technique and Results of Hemorrhoidal Embolization

“…Embolization of bilateral posterior and lateral branches can be performed with 2-3 mm pushable coils, such as Nester ® (Cook Medical; Bloomington, IN, USA), or detachable coils, such as Target ® (Stryker; Cork, Ireland) or Interlock (Boston Scientific; Marlborough, MA, USA). Some authors report bigger coil sizes of 4 to 7 mm with similar results [25,30]. Coils are the most often documented embolic material; regardless, the usage of particles and coils is preferred by some working groups.…”

“…Once fasting and adequate hemostasis are confirmed, the procedure is performed under aseptic conditions in a room equipped with a digital angiography. Conscious sedation is used, and local anesthetic is injected at the puncture site, which most commonly is the right femoral artery [25][26][27][28][29][30].…”

“…Compared to surgery, the endovascular approach avoids rectal manipulation, eliminating the risk of rectal trauma, allowing the preservation of anal continence. Coil and particle embolization of the SRA has been found to be a well-tolerated, effective, and safe technique [23][24][25][26][27][28].…”

“…Some studies have analyzed the impact of HE on frail patients with severe cardiovascular, pulmonary, or neurological disease, which usually contraindicates the use of general anesthesia, finding excellent modifications in hemorrhoid bleeding, anemia, and patient's quality of life after the endovascular procedure [23]. Patients with congenital or acquired bleeding disorders have shown good responses to HE, even without suspending antiplatelet or anticoagulant therapy [24,25]. Inflammatory bowel disease stays controversial as it appears as a particular indication or contraindication in the different literature [23,25,26].…”

“…Patients with congenital or acquired bleeding disorders have shown good responses to HE, even without suspending antiplatelet or anticoagulant therapy [24,25]. Inflammatory bowel disease stays controversial as it appears as a particular indication or contraindication in the different literature [23,25,26]. Nowadays, it is also a suitable procedure for young surgical candidates who are averse to direct rectal manipulation [27].…”