RAR) FOR TREATMENT HEMORRHOID III-IV IV GRADE : A NEW MINI-INVASIVE INVASIVE TECHNOLOLOGY

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1 TRANSANAL DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION / RECTO ANAL REPAIR (HAL-RAR RAR) FOR TREATMENT HEMORRHOID III-IV IV GRADE : A NEW MINI-INVASIVE INVASIVE TECHNOLOLOGY Author: : Zagryadskiy Eugeny MD. Medical center «ON CLINIC».. Moscow, Russia proctolog52@ rambler.ru

2 INTRODUCTION PURPOSE: : Postoperative pain is the main adverse effect of formal hemorrhoidectomy. A new technique based on Doppler-guided guided ligation of the terminal branches of the su-perior hemorrhoidal artery with ligation- mucopexy as an alternative to hemorrhoidectomy. METHODS: 85 consecutive patients (mean age, 44 years; range, years) with Grade 3 and 4 hemorrhoids were treated. Through a special proctoscope the arteries leading to the hemorrhoidal cushions are e located in the pain-free rectum under Doppler guidance and suture ligated. The new device and modificated proctoscope allow to execute mucosal lifting and fixation of the hemorrhoidal plexus. Early results of DGHAL with ligation-mucopexy in 85 patients are presented. RESULTS: Time of operation ranged: (32±5.21) minutes. Postoperative discomfort was measured by a Visual Analog Scale (1-10)( 10) and resulted in a mean score of 33, 2 ± 0,52mm (range, 20-50mm) in first day and 16, 5 ± 0, 10 mm (0-4 4 mm) in five days. Patients were examined at 1 week, 1 month, 3 months and 6 months thereafter. Bleeding re-solved in 96,5 percent of patients, prolapse in 91,8 percent. Secondary hemorrhage is not recorded. The complication rate was low. CON-CLUSION CLUSION: : Doppler-guided ligation of the hemorrhoidal ar-tery with ligation-mucopexy is a safe and effective alternative to hemorrhoidectomy and is associated with minimal discomfort and low risk of complications. cations. [Key words: Hemorrhoids; Hemorrhoidec-tomy; Doppler; Prolapse; Rectal bleeding]

3 URGENCY OF THE PROBLEM Hemorrhoids are very common and affect more than 4 percent of the population. [Bleday[ R, et.a 1992]. Surgical hemorrhoidectomy is a notoriously painful procedure. Much research over the last two decades has concentrated on reducing posthemorrhoidectomy rhoidectomy pain resulting from these surgical incisions The complication rate after standard hemorrhoidectomy is approxi-mately 10 percent (pain, bleeding, infection, fissure, abscess, fistula, anal a stenosis, soiling) with postopera-tive tive pain reported in scores up to 8 on the visual analog scale and anal incontinence in up to 33 per cent of cases. [ Shalaby R, Desoky A. 2001]. Moreover, it is unsuitable as an outpa-tient tient procedure because the mean hospital stay is ap-proximately proximately two days. Modifications of the original technique (Ferguson's or diathermy hemorrhoidectomy) have not shown significant advantages.[ Cheetham MJ, Phillips RK. 2001]. HAL-RAR RAR- is new mini invasive technologic is treatment hemorrhoid

4 Surgical hemorrhoidectomy is a notoriously painful procedure 23-34% 34% patients, who underwent hemorrhoidectomy, had significant postoperative pain, which required multiple administration of opioid![blagodarny L.A., 1999; Wexner S., 2001; Orrom W., 2002; Madoff R., 2004]. WHAT alternative hemorrhoidectomy?

5 CLASSIFICATION of METHODS of TREATMENT of the HEMORRHOIDS I. Conservative of treatment (grade-i). (dietary dietary management with adequate fluid and fiber intake, micronized flavonoids, rectal suppositories, ointments),i. MINI-INVASIVE INVASIVE TECHNOLOLOGY infrared coagulation (grade I-II I II ).) Injection sclerotherapy (grade-i-ii II ). RBL- (grade-ii-iiiiii ). DHAL (grade-ii-iii) III) III. Operative Treatments Stapled Haemorrhoidopexy of Longo (grade-ii II-IV IV ) Haemorrhoidectomy- Milligan-Morgan Morgan, (grade-iii III-IV IV ). Haemorrhoidectomy- Ferguson, Parcs

6 Any of existing ways mini-invasive invasive [infrared coagulation, injection sclerotherapy, RBL] treatments does not influence pathogenetic mechanisms of disease

7 FACTORS of DEVELOPMENT of the HEMORRHOIDS Stelzner F, et.al.962; Kapuler L.L.1974; 1974;Thomson W H F. 1975; Vorobyov G.I. et. al. (2002) The dysfunction of vessels caused Increase of diameter of an artery and amplification to inflow arterial Blood and reduction of outflow on cavernosum to veins In the general longitudinal muscle submucos a layer and sheaf Parcs holding cavernosum the texture in anal canal results dystrophic processes in displacement hemorrhoid plexus Destruction of a fibrosno-muscular skeleton internal hemorrhoids the units holding them in anal canal is higher anorectal than a line, in a combination to amplification of arterial inflow of blood, results in increase of the sizes hemorrhoids, their displacement in distal a direction and finally loss from anal canal.

8 Character of blood circulation in system hemorrhoidal plexus in norm and at a hemorrhoids Normal hemodynamic in system hemorrhoidal plexus Increased arterial supply and impaired venous drainage (anal spasm, increased intraabdominal pressure) cause hyperplasia of the corpus cavernosum. Bright blood comes from mucosal tears during defecation

9 Morinaga K., Hasuda K., IkedaT Have introduced technology TRANSANAL DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION (HAL) FOR TREATMENT HEMORRHOIDAL DISEASE Efficiency of treatment grade-ii-93-95% 95% [Felice G et al;2004; Scheyer M, 2006]. Efficiency of treatment- grade-iii-iviv Residual prolaps after performance DHAL grade-iii in 8%-13% grade-iv in-50% 50%-60% [Narro JL,2004 Scheyer M, 2006]. ].

10 Ahmed M. Hussein, (2001) Ligation-Anopexy for Treatment ofadvanced Hemorrhoidal Disease Dis Colon Rectum Vol. 44, No

11 THE PURPOSES of RESEARCH To estimate efficiency of treatment at patients with hemorrhoids grade III-IV IV To reveal a degree and duration and expressiveness of a painful syndrome To estimate duration of the rahabilitation period

12 MATERIALS AND METHODS Since November 2003 technique is introduced into treatment HEMORRHOIDAL DISEASE of a grade II-IV. IV. It is executed 627 operations about application of technology DHAL Since January 2007 till April, 2008 in the Medical centre Moscow treatment to 85 patients with a internal hemorrhoids grade-iii/iv In the age of from 27 till 68 years (mean age 44,78±9,02 year), Male - 57 (67,1 %) Female-28 (32,9 %). Duration of disease - from 2до2 20 (8,02±3,83) year

13 Patient Demographics and study variables (N= N=85) Variables Age age Gender Grade HAL-RAR Mean±st.dev (44,8±9.02) age male 57 67,1% female 28 32,9% III 61 71,7 IV 24 28,3 Last diseases ( 8,028,02±3,83)

14 Distribution of patients on a floor and stages of disease GENDER male female III- grade frequency percent IV- стадия frequency percent frequency Total percent 45 73, , , ,9 Asymp. Sig. (2-sided) P=0,066

15 HAL-RAR RESULTS of TREATMENT (January April-2008) 2008)-N= N=85 III-grade 61-71,7 % IV- grade 24-28,2% Distribution of patients on a floor and stages of disease

16 Clinical displays of disease Symptoms of disease frequency percent Prolaps bleeding Pan after defecatio (pruritus /unease) Moderate 32 37,6 Severe ,4 Light 21 24,7 Moderate 34 40,0 Severe 18 21,2 Light ,3 Light 24 28,2 Moderate 1 1,2

17 Symptoms of disease Symptoms of disease Grade-III (n= n=61) Grade-IV (n=24) Total (n=85) Prolaps bleeding Pan after defecatio Itching/discharge

18 The following conditions were excluded 1. patients with acute thrombosed hemorrhoids; 2. patients with external hemorrhoids or other concomitant anal diseases (fissure, fistula, or abscess, etc.); 3. patients with inflammatory bowel disease or hematological disorders; 4. patients on anticoagulants; 5. patients with a previous history of anorectal surgery, including 6 previous hemorrhoidectomy or fistula surgery. 7.Patients with neurologic deficit (paraplegia or previous cerebrovascular accident) 8.patients already taking narcotic analgesics were also excluded.

19 Statistical analysis Statistical analysis The analysis is lead with use of program SPSS (v.11., Chicago, IL). The figures adequating to normal distribution, are presented as averages with a standard deviation. For comparison of results of treatment test Wilcoxon for two dependent elections is used. The test considered statistically significant at Р <0,005

20 Volume of preoperative inspection and preparation for operation Anoscopy Proctosigmoscopy-examination Colonoscopy (among patients over 45 y.o Laboratory inspection Patients are prepare by having fluids only by mouth from midday before the procedure and by using two Microlax enemas (Kabi Pharmacia AB). One the night before, and the other two hours before the procedure. RW, HIV, Hbs-Ag Anti-HCV the Estimation of the status on scale ASA

21 The equipment for performance DHAL-RAR A.M.I.. (Feldkirch( Feldkirch, Austria)-II rar-2013 Anoscop-rar-2011

22 Technique OPERATIONS 1.stage-DHAL The arteries (3 and 5; and 7 and 9) are ligated together with a double figure of eight suture on each side. The anterior arteries (11 and 1) are ligated separately, also with figure eight sutures 2.stage-RAR

23 DHAL-RAR 1). Search and ligatio distal branches hemorrhoidal arteries under the control dopplerometria 2-lifting+mucopexsia

24 Results of operation Kind of anesthesia sedated with intravenous (Propofol 1%)+ local anesthesia for Nystrem) Time of operation Time of stay in a hospital min-24 max-45 мin min-16 max-23 hours 32±5,21 min 19,3±2,17 hoursh Time of returning to work min- 2 max-4 day (2,79±0,81) day

25 Character postoperative Complications (n=85) Character complications frequency percent Urinary retention 0 0 Secondary hemorrhage 0 0 Perianal thrombosis 7 0,3 hyperthermia 1 0,2 Total 17 3,6

26 Expressiveness of a painful syndrome and quantity of consumption analgesics Day after operation (n=85) Expressiveness of a painful syndrome on a scale VAS in (mm). Mean±st st.dev. Consumption analgesics «Ketarolac trometamin» (мg). Mean±st st.dev. 1-day 33,2 ±0 0,52 mm 31,6 ± 0,45 mg 2-day 30,4 ± 0,61 mm 28,7 ± 0,52 mg 3-day 22,3 ± 0,98 mm 17,4 ± 0,10 mg 4-day 19,2 ± 0,10 mm 14,4 ± 0,10 mg 5-day 16,5 ± 0,10 mm 13,3 ± 0,93 mg 6-day 14,2 ± 0,79 mm 0 7-day 11,7 ± 0,81 mm 0

27 Expressiveness of a painful syndrome on a scale VAS in (mm) ,2 HAL-RAR 30 30,4 Pain (VAS 0,0-100,0 mm) ,1 23,3 19,2 16,5 14,1 11,7 5 0 pro oper 1-day 2-day 3-day 4-day 5-day 6-day 7-day Day after operacio

28 Consumption analgesics «Ketarolac trometamin» (мg). "Ketarolac trometamin" mg day 2-day 3-day 4-day 5-day 6-day 7-day DAY AFTER OPERACIO

29 Necessity of consumption analgesics the ambassador HAL-RAR (n=85) Day after operation frequency with analgesics percent Without analgesics frequency percent 1-day day 83 97,6 2 2,4 3-day 40 47, ,9 4-day 27 31, ,2 5-day 24 28, ,8 6-day 9 10, ,4 7-day 7 8, ,8

30 Functional results of operation DHAL-RAR For an estimation of results of treatment questionnaire used for an estimation of result hemorrhoiectomy is used [Guenin M-O, Rosenthal R, et. al Dis. Colon. Rectum. 2005] Symptoms of disease Before operation frequency percent After operation frequency percent P prolapss Bleeding after defecatio Pain after defecatio Thrombosis internal hemorhoid Not present ,8 moderate 32 37,6 6 7,1 severe 53 62,4 1 1,2 Not present 12 14, ,5 light 21 24,7 3 3,5 moderate 34 40,0 severe 18 21,2 0,000 Not present 21 24,7 0,000 light 64 75,3 Not present 78 91, Thrombosis 7 8,3 0,000

31 Functional results of operation DHAL-RAR For an estimation of results of treatment questionnaire used for an estimation of result hemorrhoiectomy is used [Guenin Guenin M-O, Rosenthal R, et. al Dis. Colon. Rectum. 2005] loss of feces (soiling ) Symptoms of disease Hygienic problems (pruritus/unease) Additional operations Estimation of patients results of operation Before operation After operation Абс. % Абс. % Not present 63 74, ,3 light 21 24,7 4 4,7 moderate 1 1,2 Not present 12 14, ,5 light 21 24,7 3 3,5 moderate 34 40,0 severe 18 21,2 Excision external hemorrhoid 5 5,9 Excellent 72 84,7 good 12 14,1 moderate 1 1,2 P 0,000 0,000

32 THE CONCLUSION Transanal Doppler-guided hemorrhoidal artery ligation / RECTO ANAL REPAIR (HAL-RAR) - the method effectively influences the basic pathogenetic factors of development of a hemorrhoids, not demanding removal internal hemorrhoidal plexus (HAL-RAR - the accessible method of treatment hemorrhoidal disease, can be used as in out-patient, so in conditions of a hospital of one day conditions Well bearableness patients Differs small number of complications The method allows to restore work capacity of the patient in short terms

33 I thank for attention NEW TECHNOLOGIES SOLVE OLD PROBLEMS

34 Result HAL-RAR Ds: hemorrhoid grade III-IV IV. The patient К.. 47 year г. Before operation After operation

35 Result HAL-RAR Ds: hemorrhoid grade IV. The patient L.. 44 year г. Before operation After operation

36 Results of operation Ds: hemorrhoid grade III-IV IV L.. 54 year г. Befor operatoin After operation

37 Difficult a case of treatment HEMORRHOIDAL DISEASE Ds: hemorrhoid grade III-IV IV Л.. 53 year г. DHAL-RAR with excision external hemorrhoid Before operation After operation 39-day after operation

38 Difficult a case of treatment HEMORRHOIDAL DISEASE It is possible to combine HAL- RAR with excision external hemorrhoid Cases where it is shown hemorrhoidectomy