Other Haemorrhoid Operations

Mo Saeed

Consultant Surgeon Stepping Hill Hospital Stockport

Other Haemorrhoid Operations

• Doppler Guided Haemorrhoid Artery Ligation (DG- HAL) Morinaga et al Am J Gastroenterology 1995; 90:610-3

• Ligasure Haemorrhoidectomy (LH) sayfan et al Ann Surg;2001:234:21-24)

DG-HAL

• Embolisation of superior rectal artery and its branches results in effective treatment of bleeding from chronic haemorrhoids (Galkin et al VRS 1994;4:52-56)

• Morinaga et al Am J Gastroenterology 1995; 90:610-3

DG-HAL

• The bases of this treatment underlies the arterial blood flow to the haemorrhoids

• The anal cushions or corpus cavernosus recti (CCR) are arterio-venous anastomosis which lies above the dentate line

• The functional effect of changes in arterial flow into the CCR results in a gas tight seal of the anal canal

DG-HAL

• Primary aim is to specifically locate & ligate terminal branches of the Superior rectal artery

• Reduction in haemorrhoidal arterial blood flow resulting in shrinkage of haemorrhoidal mass

• Fixate the mucosa with interruption of blood supply results in pulling up the prolapse

DG-HAL

• 116 patients treated for symptoms of pain, prolapse & bleeding

• 1 month follow up: treatment effect observed in 96% of patients with

pain 78% with prolapse95% with

bleeding

What Degree of Haemorrhoids ?

• Can be used for grade II-IV

• Symptoms include : BleedingPain

Prolapse

• Procedure performed under sedation

DG-HAL

• Recent longer term outcome data

• Felice et al DCR 2005; 48: 2090-2093

• Greenberg et al DCR 2006; 49: 485-489

DG- HAL

• Felice et al 68 consecutive patients with grade III haemorrhoids treated with DG-HAL. Mean F/U 11 months (3-18) :

pain completely resolve in 8/11 & improved in the remaining 3 bleeding completely resolved in 51/56 (91%)prolapse resolved in 64/68 (94%)

Complications: 5 persistent pain > 2 day in 2 patients2 patients had thrombosis of 1 haemorrhoid1 patient developed 20 haemorrhage

DG-HAL

• Greenberg et al DCR 2006; 49: 485-489 Treated 100 patients with grade II (19) or III (81) haemorrhoids 42 males 58 females. F/U 3,6 & 12 months:

95 discharged after 2-4 hours 96 patients completed 1 year f/u & 85 were asymptomatic 11 patients had persistent bleeding &

required further treatment

DG- HAL

• Anopexy- Changes to the design of the proctoscope now allows placement of a suture to lift the prolapsing tissue.

• This will improve results for prolapse but may be associated with patient discomfort

DG-HAL

• Effective minimally invasive treatment for haemorrhoids

• Can be performed under sedation

• Randomised controlled trial vs other treatments needed

• Longer term F/U

Ligasure Haemorrhoidectomy

• The underlying principle of ligasure haemorrhoidectomy is the same as that for the standard Ferguson method with the only difference being the choice of diathermy

• Ligasure is a bipolar diathermy that provides energy and pressure to seals vessels and tissue bundles

• It produces minimal sticking,charring or thermal spread to adjacent tissues

Ligasure Haemorrhoidectomy (LH)

• First described by sayfan et al Ann Surg;2001:234:21-24)

• Several randomised controlled trials comparing LigasureTM haemorrhoidectomy with conventional diathermy haemorrhoidectomy

Ligasure Haemorrhoidectomy

• Franklin et al DCR 2003; 46:1380-1383compared ligasure with

conventional diatherny haemorrhoidectomy: Main findings were reduced

1. operating time (6vs11mins) 2. post op pain at days 1 & 14

In the ligasure group

Ligasure Haemorrhoidectomy

• Palazzo et al BJS 2002;89:154-157Ligasure haemorrhoidectomy

reduced operating time and analgesic requirements but the postoperative pain was similar to that with conventional diathermy haemorrhoidectomy

Ligasure Haemorrhoidectomy

• Jayne et al BJS 2002: 89;428-32Demonstrated reduced blood loss, shortened operating time & reduced pain for ligasure compared to conventional diathermy haemorrhoidectomy facilitating sameday discharge

Ligasure Haemorrhoidectomy

• Kraemer et al DCR 2005;48:1517-1522Prospective randomised study

comparing PPH with Ligasure haemorrhoidectomy 50 patients

• No differences in post op pain, patient satisfaction or length of operation between the two techniques

Ligasure Haemorrhoidectomy

• Ligasure haemorrhoidectomy is safe & effective technique for the treatment of grade 3 & 4 haemorrhoids

• Cost of the equipment can be offset by daycase treatment of patients