Transanal hemorrhoid dearterialization and mucopexy: a minimal invasive approach for prolapsed hemorrhoids. Four cases report.
Hemorrhoids are cushions of submucosal tissue containing venules, arterioles and smooth-muscle fibers that are normally located in the anal canal and contribute toward maintaining fecal continence and the entire continence mechanism . When hemorrhoids are associated with bleeding, pruritus, mucous discharge per rectum or prolapse, they are referred as symptomatic and in the presence of symptom associations they are referred to as "hemorrhoidal disease" [2-4]. Even though they are probably one of the most common causes of anal pathology, the true prevalence of hemorrhoids is difficult to establish, because many patients don't seek medical care. Increased abdominal pressure (obesity, pregnancy), constipation and prolonged straining are believed to be the main causes for prolapse of hemorrhoidal tissue .
There are mainly three therapy choices for hemorrhoidal disease: (1) medical management and diet, (2) office-based procedures and (3) surgical therapy . Symptomatic first and second degree hemorrhoids are best managed with diet and decrease in straining (high-fiber diet, regular exercise, stool softeners) and with medical therapy (topical ointments, creams, suppositories) [7, 8]. Office-based procedures (rubber band ligation, sclerotherapy, infrared photocoagulation, and cryotherapy) are a suitable tool for persistent first and second degree hemorrhoids and for selected third degree cases [1, 2, 8, 9]. Surgical therapy is reserved for patients who fail non-operative management techniques and for advanced prolapsed third and fourth degree hemorrhoids [10, 11].
Transanal Hemorrhoid Dearterialization (THD) and mucopexy is the newest addition to a surgeon's repertoire. It was first described by Morinaga et al.  and since then the technique and the operative equipment have been improved. THD procedure involves ligation of the hemorrhoidal arteries under Doppler guidance resulting in reduced inflow that facilitates reduction in size of hemorrhoids, while suture mucopexy addresses the prolapsed mucosa . Kjaer et al.  reported a low success rate (64%) after a median follow-up periods of nine months in patients with three and fourth degree hemorrhoids who underwent THD and mucopexy, while other authors described THD as a safe one-day procedure for patients with hemorrhoids [14-16].
Herein we report four cases of advanced prolapsed hemorrhoids, which were treated with THD and mucopexy. We emphasize that THD is an effective procedure with minimal postoperative pain and early return to normal activity.
Four patients (three male, one female) diagnosed with 4th degree hemorrhoids underwent operative management using THD and mucopexy procedure at Naas General Hospital, Naas, Co. Kildare, Ireland. Main complaints were pruritus ani and long standing rectal bleeding. These patients underwent colonoscopy as part of their pre-operative work-up. Preoperatively phosphate enema was prescribed and Digital Rectal Examination was performed to assess any other concomitant anal or/and rectal pathologies. Procedures were performed under general anesthesia and patients were placed into lithotomy position.
THD device consists of an anoscope equipped on the superior surface with a Doppler sensor and a light source. After digital examination with lubricant, the anoscope was inserted with the Doppler sensor placed at different clock positions (1, 3, 5, 7, 9, 11) (Figure1) and at each position the Doppler value was noted in order to localize the hemorrhoidal arteries. Once identified, all six arteries were ligated with a 2-0 absorbable suture (Figures 2 and 3). The suturing equipment is also specially designed: the needle holder is longer and has a marked line at the tip where the needle should be placed; the needle is 5/8 of a circle, so that it perfectly fits in the suturing groove. When the artery was identified, the needle holder was inserted inside the anoscope with the tip placed into groove at the end of the inside surface of the anoscope and with circular motions of the needle-holder an "8-figure" suture was placed to ligate each artery. All arteries were ligated.
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Anal packing was done using a cylindrical sponge soaked in anesthetic and antiseptic gel (Figure 5).
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THD procedure ligates the arteries and decreases the arterial blood flow. In order to lift the prolapsed mucosa, mucopexy was necessary. With the anoscope inserted, using the technique described above, multiple running sutures were placed above the dentate line, in order to avoid the anoderm and tied at the proximal end of the hemorrhoid (Figure 4).
The mean operative time was approx. 45 min. The procedure was successful in all patients without any intra-operative and postoperative complications. Photographs taken, before and after the procedure, show an impressive reduction of the prolapsed hemorrhoids (Figures 6-13).
On ward follow-up patients did not have major symptomatic complaints, except mild nausea, presumably anesthetic related. All patients were discharged in the same day and were prescribed Lactulose 15mg/twice daily, Flagyl[R] (metronidazole) 400mg/three times daily, Acetaminophen 1g/three times daily and Difene[R] (diclofenac) 50mg/twice daily (each for 5 days).
Patients were referred back to their general practitioners and were scheduled in the outpatient department for reassessment.
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The purpose of this article is to prove the effectiveness of THD in reducing 4th degree prolapsed hemorrhoids as a safe one-day procedure with minimal-to-none pain and other early, hemorrhoidectomy--associated, postoperative symptoms. While the results presented herein prove better outcomes for THD in the first 24 h post-op, further research is needed to assess the feasibility of this procedure in the long-run. In this case report, there is no data regarding long-term follow up, therefore it is early and beyond this article's reach to say that THD has superior long-term outcomes when compared to other surgical alternatives for 4th degree hemorrhoids. For patients with second and third degree hemorrhoids, Giordano et al.  thoroughly evaluated, in a prospective study, the three years outcomes of THD in comparison with stapled hemorrhoidopexy and their results show higher patient satisfaction rates and promising complication rates for THD.
Milligan-Morgan (open) and Ferguson (closed) hemorrhoidectomy techniques are still considered the gold-standard for the operative management of advanced hemorrhoids . However, these procedures are associated with postoperative complications including infection, ano-rectal stenosis, incontinence, urinary retention, severe rectal bleeding and postoperative pain [4, 6, 18].
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Firstly described by Milligan and Morgan in 1937 , the open hemorrhoidectomy involves a full-thickness excision of the affected mucosa and submucosa: the hemorrhoid is grasped using a forceps and an ellipsoidal incision is made at its base; scissors are used to dissect the remaining hemorrhoid. At the end of the procedure the wound is left open, hence the name "open hemorrhoidectomy". If the mucosa is closed with an absorbable running suture, the procedure is named Ferguson's closed hemorrhoidectomy  (Figure 14).
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In order to minimize complications and postoperative pain, several less invasive procedures have been described and two of them are reported with promising results: PPH/stapled hemorrhoidopexy and Transanal Hemorrhoid Dearterialization (THD)/Doplerguided hemorrhoidal artery ligation (DGHAL). In the past years, stapled hemorrhoidopexy became less popular even though early postoperative pain is not as severe as after hemorrhoidectomy . Various studies have shown that PPH is associated with a greater recurrence rate , higher stenosis rate  when compared with the standard hemorrhoidectomy and it is related with other unusual complications (chronic proctalgia, bleeding granulomatous polyps due to retained staples, rectovaginal fistulae etc.) which are not described after Ferguson or Milligan-Morgan approach .
Associated with mucopexy, THD appears to be an effective technique for the management of advanced fourth degree hemorrhoids and offers immediate results as seen in the cases presented above. It is a relatively new procedure developed as an alternative to excisional hemorrhoidectomy and it is increasingly being embraced by surgeons for its better outcomes, higher patient satisfaction and fewer postoperative complications [23-26]. For II and III degree hemorrhoids, THD is a widely accepted therapeutic choice, but there is little information of the results of THD for grade IV hemorrhoids .
Milligan-Morgan (open)/Ferguson (closed) hemorrhoidectomy techniques withstood over the years because of their efficacy, but the notorious postoperative pain pushed researchers in developing less invasive treatments. THD is a non-excisional operative technique that spares the anoderm; therefore it is associated with less postoperative pain when compared to the excisional approaches. Popo et al.  published a comparison between THD and two excisional procedures: Milligan-Morgan and Whitehead hemorrhoidectomy; they found that THD is linked with shorter hospital stay, less discomfort in postoperative period and an excellent aesthetic effect. Another famous less invasive treatment for hemorrhoidal disease that offers superior results to the classic procedures is stapled hemorrhoidopexy (PPH). Several studies comparing THD and PPH [29, 30] described that both procedures seem an effective and safe treatment for hemorrhoids, but THD seems to be superior when it comes to pain score and return to normal daily activities. Verre et al.  report better results in terms of pain and postoperative complications after THD surgery, while Lucarelli et al.  describe a higher recurrence rate after THD and similar long-term follow-up results regarding symptom control and patient satisfaction.
The approach and equipment used in the cases presented above are relatively new, being described by Ratto in 2014 .
Since its first report, the THD procedure has been constantly modified and improved. THD is a promising minimal invasive technique and it offers major advantages such as higher patient satisfaction, fewer complications, less pain and earlier return to normal daily activities. Even so, many surgeons do not embrace this procedure as the standard of care for grade III-IV hemorrhoids mainly because of high recurrence rate, expensive equipment and lack of success in reducing severe prolapsed mucosa. These patients had severe mucosal prolapse and, as seen in pictures, ligation of all arteries accompanied by a continuous suture placed above the dentate line can effectively reduce and fix even prolapsed hemorrhoids. We believe that THD with mucopexy can be safely used in advanced fourth degree hemorrhoids as a safe one-day procedure with immediate visible results. Without proper equipment, finding and ligating the arteries is technically demanding and can lead to poor results. Even though it is expensive, this new THD equipment provides standardization, reduces recurrence rate and it may become cost-effective, because postoperative hospitalization costs are kept at a minimum. Further research is needed to establish which of the two well-known less invasive procedures (PPH and THD) is the treatment of choice for IV degree hemorrhoids.
This article was designed and written with special contributions from Mr. Emmanuel Eguare and his operative team. The cases presented in this manuscript are patients treated by Mr. Emmanuel Eguare at Naas General Hospital and the paper was conducted during my (S. Morarasu) summer elective clinical clerkship in Mr. Eguare's clinic. The corresponding author would like to express his deepest gratitude to all the staff at Naas General Hospital, Naas, Co. Kildare, Ireland.
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Stefan Morarasu *, (1), Emmanuel Eguare (2), Yasir Bashir (2), Qurat ul Ain (2), Anca Bradu (1)
(1)"Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania, (2) Allen Ward, Naas General Hospital, Naas, Co. Kildare, Ireland
Received: September 2015; Accepted after review: March 2016; Published: March 2016.
* Corresponding author: Stefan Morarasu, MD, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania.
Table. 1. Comparison between open and closed hemorrhoidectomies and THD. THD is associated with a significant shorter hospital stay. Open Closed THD and Hemorrhoidectomy hemorrhoidectomy mucopexy   Mean operative approx. 25 min. approx. 31 min. approx. time 45 min. Hospital days 3-5 days 2-4 days one-day case
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|Author:||Morarasu, Stefan; Eguare, Emmanuel; Bashir, Yasir; Ain, Qurat ul; Bradu, Anca|
|Publication:||Archive of Clinical Cases|
|Article Type:||Clinical report|
|Date:||Mar 1, 2016|
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