Hybrid digitally guided hemorrhoidal artery ligation with laser hemorrhoidoplasty: our experience with a new approach to hemorrhoidal disease
Keywords:Hemorrhoidal disease, Hemorrhoidal artery ligation, Laser hemorrhoidoplasty
Background: Minimally invasive surgeries are currently advocated in hemorrhoidal disease for better patient satisfaction. The aim of our study is to assess the feasibility, efficacy and safety of a hybrid hemorrhoidal artery ligation under digital guidance with laser hemorrhoidoplasty (Hybrid HAL-LHP) in patients with grade II to III hemorrhoids.
Methods: In a prospective clinical study, hybrid HAL-LHP was performed in 75 consecutive patients between May 2018 to February 2020 with grade II to III hemorrhoids. Hemorrhoidal artery ligation was done by digital palpation followed by laser hemorrhoidoplasty using a 1470 nm diode laser. Postoperative pain and bleeding, return to work, resolution of symptoms, recurrence and reoperation was assessed on a follow up upto 1 year.
Results: Postoperative pain assessed on Visual analog score (VAS) was 2.82 on 3rd day, 1.28 on 7th day and till 14th day was extremely low. None of the patients had significant intraoperative or spontaneous postoperative bleeding. Most of the patients had some degree of post defecation bleeding till 7th to 14 days which resolved after 2 weeks. After a mean follow up of 16.6 months, we reported a suspected recurrence rate of 5.33%.
Conclusions: Postoperative pain assessed on Visual analog score (VAS) was 2.82 on 3rd day, 1.28 on 7th day and till 14th day was extremely low. None of the patients had significant intraoperative or spontaneous postoperative bleeding. Most of the patients had some degree of post defecation bleeding till 7 to 14 days which resolved after 2 weeks. After a mean follow up of 16.6 months we reported a suspected recurrence rate of 5.33%.
Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Haemorrhoids: Pathology, pathophysiology and aetiology. Br J Surg. 1994;(7):946-54.
Maloku H, Gashi Z, Lazovic R, Islami H, Juniku–Shkololli A. Laser Hemorrhoidoplasty procedure vs open surgical hemorrhoidectomy: a trial comparing 2 treatments for hemorrhoids of third and fourth degree. Acta Inform Med. 2014;(6):365-7.
Goligher J. Surgery of the anus, rectum and colon. 4th ed. London, UK, Balliere Tindall: 1980.
Van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, et al. European society of ColoProctology: Guideline for hemorrhoidal disease. Color Dis, 2020;22(6):650-62.
MacRae HM, McLeod RS. Comparison of Hemorrhoidal Treatment Modalities. A meta-analysis. Dis Colon Rectum 1995;38(7):687–94.
Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. 6th World Congress of Endoscopic Surgery, Rome, Bologne. 1998;3-4:777-84.
Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flow meter. Am J Gastroenterol. 1995;90(4):610-3.
Karahaliloglu A. First results after laser obliteration of first and second-degree hemorrhoids. Coloproctology. 2007;29:327–36.
Salfi R. A new technique for ambulatory hemorrhoidal treatment. Coloproctology 2009;31(2):99–103.
Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L. et al. Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial. Colorectal Dis. 2016;18:710–6.
Schuurman JP, Rinke I, Borel HM, Peter MN. Hemorrhoidal Artery Ligation Procedure with or Without Doppler Transducer in Grade II and III Hemorrhoidal Disease A Blinded Randomized Clinical Trial. Ann of Surg. 2012;255(5):840-5.
Gupta PJ, Kalaskar S, Taori S, Heda PS. Doppler-guided hemorrhoidal artery ligation does not offer any advantage over suture ligation of grade 3 symptomatic hemorrhoids. Tech Coloproctol. 2011;15(4):439-44.
Shmuel Avital, R Inbar, E Karin, R Greenberg. Is Doppler ultrasonography essential for hemorrhoidal artery ligation? Techniques in Coloproctology. 2012;16(4):291-4.
Knight JS, Senapati A, Lamparelli MJ. National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland. Colorectal Dis 2003;10:440–5.
Brown SR, Tiernan JP, Watson AJ Biggs K, Shephard N, Wailoo AJ, et al. HubBLe Study team. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. The Lancet. 2016;388(10042):356-64.
Zagryadskiy E, Goreloc SI. Transanal doppler-guided hemorrhoidal artery ligation and recto anal repair vs closed hemorrhoidectomy for treatment of grade III-IV hemorrhoids. a randomized trial. Pelviperineology 201;30:107-2.
Jeong WJ, Cho SW, Noh KT, Chung SS. One year follow-up result of Doppler-guided hemorrhoidal artery ligation and recto-anal repair in 97 consecutive patients. Journal of the Korean Society of Coloproctology. 2011;27(6):298-302.
Daniil M, Inna T, Tatiana G, Mikhai B, Aftandil A, et al. Hemorrhoidal artery ligation with Doppler guidance vs digital guidance for grade II-III hemorrhoidal disease treatment. Study protocol clinical trial (SPIRIT Compliant). Medicine 2020;99(15):e19424.
Plapler H, Hage R, Duarte J, Lopes N, Masson I, Cazarini C, et al. A new method for hemorrhoidsurgery: intrahemorrhoidal diode laser, does it work? Photomed Laser Surg. 2009;27:819-23.
Maloku H, Gashi Z, Lazovic R, Islami H, Juniku-Shkololli A, et al. Laser hemorrhoidoplasty procedure vs open surgical hemorrhoidectomy: a trial comparing 2 treatments for hemorrhoids of third and fourth degree. Acta Inform Med. 2014;22:365–7.
Naderan M, Shoar S, Nazari M, Elsayed A, Mahmoodzadeh H, Khorgami Z, et al. A randomized controlled trial comparing laser intra-hemorrhoidal coagulation and Milligan–Morgan hemorrhoidectomy. J Invest Surg. 2017;30:325–31.
Jahanshahi A, Mashhadizadeh E, Sarmast MH. Diode laser for treatment of symptomatic hemorrhoid: a short term clinical result of a mini invasive treatment, and one year follow up. Pol Przegl Chir. 2012;84(7):329–32.
Brusciano L, Gambardella C, Terracciano G, Gualtieri G, di Visconte MS, et al. Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids. Updates Surg. 2020;72(3):851-7.
Deeba S, Mokalled I, Jaafar RF, Habib S, Doughan S. Hybrid Hemorrhoid Artery Ligation: A Novice Technique to Treat Non Reducing Hemorrhoids. Journal of Surgical Techniques and Procedures. 2019;3(1):1026.
Ramírez JA, Aguilella V, Elía M, Gracia JA, Martínez M. Doppler-guided hemorrhoidal artery ligation in the management of symptomatic hemorrhoids. Rev Esp Enferm Dig. 2005;97:97-103.
Giordano P, Overton J, Madeddu F. Transanal Hemorrhoidal Dearterialization: A Systematic Review. Diseases Colon Rectum. 2009;52(9):1665-71.
Yilmaz I, Sücüllü I, Karakaş DO, Özdemir Y, Yücel E, Akin ML. Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up. Am Surg. 2012;78(3):344-8.
Giamundo P, Salfi R, Tibaldi MGL, Murru L, Valente M. The hemorrhoid laser procedure technique vs rubber band ligation: a randomized trial comparing 2 mini-invasive treatments for second- and third-degree hemorrhoids. Dis Colon Rectum. 2011;54(6):693-8.
Ferhatoglu MF, Kıvılcım T, Ekici U, Kebudi A. Laser hemorrhoidoplasty procedure for grade two and three hemorrhoidal disease. A retrospectively prospective study, analysis of forty-seven patients. OSP J Surg. 2019;1:101.