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Doppler-guided hemorrhoidal artery ligation
(DG-HAL): a safe treatment of II-III degree
hemorrhoids for all patients.
Could it be potentially also good prophylaxis?
Aim. Doppler-guided hemorrhoidal artery lig-
Department of Surgery, S. Peter Hospital
ation (HAL Doppler) is an innovative hemor-
rhoid treatment mainly utilised for II-III degree
where bleeding is a predominant symptom.
This procedure aims at dearterialization of the
internal hemorrhoidal plexus by ligation of
®FBF, Rome, Italy
2Pediatric Surgery Unit, G. Salesi
Children’s Hospital, Ancona, Italy
the terminal branches of the superior rectal
artery detected using a special proctoscope and
ultrasound system; the procedure is performed A
which are a contraindication to the usual sur-
ely above the dentate line, so it is gen-
gical treatments. Moreover, they suppose the
uinely painless. The aim of this study was to
use of HAL Doppler in low degree hemorrhoids
evaluate the efficacy, safety and invasivity of
as a therapeutic and also prophylactic rule of
HAL Doppler technique to treat II and III degree
Methods. The authors treated 148 patients, from
Key words: Doppler - Hemorrhoids - Hemor-
May 2002 to December 2007, principally affect-
rhage - Vascular factor.
ed by II-III degree hemorrhoids characterized
by bleeding and pain at evacuation. These
patients were examined in a retrospective
observational study of 128 patients, 86% of the
group. Follow-up varied from 5 up to 72
gains interest. This is due to diffusion in
months with an average observation time of
the population and to a constant search for
more effective, less traumatic methods prin-
Results. Success was registered in 90% of
cipally free of risk of early or later complica-
patients affected by II-III degree hemorrhoids
tions. Some postoperative complications are
and the absence of major complications (hem-
orrhage, incontinence, stenosis, perforation,
disease symptomatology as described in lit-
The authors suggest the safety, effi-
erature. Further, these complications are often
cacy and low invasity of HAL Doppler for treat-
difficult to resolve: cases of fatalities were
ment of II-III degree hemorrhoids, which also
found in the literature, and highlight its use in
Considering this it is easy to understand
treating patients with unhealthy conditions
the recent tendency to seek methods of oper-ation which treat the early stages of hemor-
Received on September 30, 2009.
Accepted for publication on June 1, 2010.
rhoidal disease where, the hygienic-behav-ioral therapy together with pharmacologicalsupport are ineffective with the symptoma-
Corresponding author: A. Testa, MD, via Cassia 987, 00189
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
TABLE I.—Total cases inserted in follow-up: 128.
brilliant, distinctly innovative invention for
Morinaga;4 he described the experience of
patients affected by hemorrhoids with bleed-
ing on a 1995 publication. Morinaga was ableto detect the branches of the upper and medi-an hemorrhoidal arteries in those patients,
TABLE II.—Preoperative symptoms.
using Doppler technology applied to a proc-toscope. He then performed sutures on the
vessels with absorbable stitches verifying the
TABLE III.—Number of vessels stitched for surgical ses-
immediate and significant. The result, visi-
ble to the patient, was a drastic reduction or
indeed disappearance of the bleeding symp-
tom from the early postoperative days.
Diverse interesting publications appeared
about the encouraging results obtained in
several series of cases in North American 5
and European centers,6-10 as described in the
literature of the recent years. This aspect, A
One-hundred and four patients (81%) had
together with the persuasion that the vascu-
preoperative pain at evacuation, 120 (94%)
lar aspect is definitely the core factor in hem-
had bleeding and 100 patients (78%) had a
orrhoidal pathogenesis, led us to use HAL
prolapse of III and IV degree (Table II).
Doppler for selected patients, obtaining total-
The aim of this study was to evaluate the
efficacy, safety and invasivity of HAL Doppler
ed in 106 cases, and local anesthetic was
technique to treat II and III degree hemor-
used in 14 cases (11%), using a 33% Naropin
solution (perineal procedure sec. Marti) withsedation (propofol or ipnovel). The durationof the operation varied from 25 to 45 minutes.
Materials and methods
As to the number of ligatures performed, 4
to 6 ligatures were inserted in 16 cases (13%),
The study enrolled 148 patients who under-
6 to 8 ligatures in 100 cases (78%), and 8 to
10 ligatures in 12 cases (9%) (Table III).
December 2007: 128 (86%) were included in
The patients were discharged on the day of
our retrospective observational study; they
the operation (at least 6 hours after the oper-
ation) in 20 cases (16%), and the morning
females), and heterogeneous by age (25 to 78
after in the other 108 cases (84%) with refer-
ence “one day surgery” procedure.
rhoids, 92 (72%) showed III degree hemor-
were performed simultaneous to the DGHAL;
rhoids (sec. Goligher). A total of 116 out of
8 due to the presence of anal fissure (fissure
128 cases treated were primitive hemorrhoids
excision and minimal internal sphincteroto-
and 12 were relapses (8 cases after multiple
my) while 8 were due to the presence of a
sessions of rubber band ligation and 4 after
polypus in the anal canal (excision).
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
TABLE IV.—Postoperative pain analysis at one week.
TABLE VI.—Total recurrences and its distribution.
TABLE V.—Return to normal daily activity after sur-
TABLE VII.—Disappearance of preoperative bleeding
and, performed as follows: the first check
There was pain up to the seventh day in 8
was performed 12 hours after the operationfirst verifying pain and post-operative bleed-ing or hematoma via
Painkiller consumption was analysed (Ketoro-lac 30 mg e.v.), urinary function, and the
patients (6%) and beyond the seventh dayfor a further 8 patients (6%) with additionalprocedures who took a daily 30 mg dose of
examination of changes in preoperative A
Of the 104 patients with preoperative pain,
96 indicated a complete absence of pain after
the HAL Doppler procedure after the firstweek (P<0.001).
symptoms, especially for bleeding, and con-
sidering postoperative symptomatology con-
As to a return to daily activities, the team
Further follow-up visits were effected up to
noticed that 56 patients (44%) returned to
their regular activities within three days of
the operation, 44 patients (34%) by the sev-
contacted in May 2008, and asked a set of
enth day, and 28 patients (22%) returned to
their regular activities after a week (Table V).
pain, prolapse, and their degree of satisfaction
All relapses in the group, 20 patients (16%)
were registered at the six-month follow-up.
patients in the IV degree hemorrhoids group
A statistical evaluation of the results was
(100%), 12 patients in the III degree hemor-
rhoids group (13%), no patients with II degree
hemorrhoids had a relapse (Table VI).
operatively in 120 patients disappeared com-
pletely at the six month check in 100 patients
of urinary retention were recorded at the ini-
(P<0.001); 50% disappearance of bleeding
tial postoperative visits within 12 hours of
was observed in eight patients (7%), and per-
the operation. Analysis of postoperative pain
sistent bleeding in 12 patients (10%) (Table
indicated an absence of pain in 96 of 128
patients after one week; while 16 patients
(12%) reported pain in the first three days
patients, 92 cases of III degree prolapse were
required a daily 10 mg dose of Ketorolac.
examined: total resolution was registered in
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
TABLE VIII.—Resolution of III degree prolapse after HAL
evaluation of the HAL Doppler, is the degree
of satisfaction expressed by patients. Eighty-four (66%) stated that they were satisfied, 24
(19%) reasonably satisfied, four patients (3%)
not particularly satisfied while 16 patients(12%) said they were dissatisfied (Table X).
months, was observed during the annualcheck up.
TABLE IX.—Postoperative complications.
Hemorrhoidal pathology is an area in con-
description and treatment, aiming at achiev-
ing better, more concrete, lasting results using
increasingly less traumatic techniques. At pre-
TABLE X.—Degree of satisfaction.
of controversy. On the one hand there is a
24/128 (19%) A
theory which recognizes alteration of theParks ligament, the support frame of the inter-nal hemorrhoidal plexus, as the “primum
movens” of hemorrhoidal prolapse, which is
responsible for the symptomatology sequel in
On the other, several studies regarding the
vascular anatomy of the rectal anal canal
60 patients (P<0.001), a 50% reduction in 20
support a different theory. The most inter-esting of these is the work carried out by
Aigner in 2006.13, 14 He subjected a group of
patients (13%) (Table VIII). There was relapse
patients with the four different degrees of
research of the distant branches of the upper
haemorrhoidal artery. Aigner compared them
postoperative fissures was observed in eight
with a group of patients who were included
in the check, not affected with the patholo-
(excision), the other four with anal dilata-
gy. The study highlighted a structural alter-
ation in the branches examined. In the first
were observed in certain patients who used
mented calibre and were bearers of greater
arterial flow to the entire haemorrhoidal
plexus. The factor examined is called “vas-
Further, four cases of proctitis were record-
cular” and it becomes increasingly impor-
ed and were treated with topical antinflam-
tant in direct proportion to the degree of the
illness studied. In Aigner’s paper, the values
It can be stated that other complications as
of both calibre and of arterial flow were
rectal anal stenosis, incontinence, abscesses,
iatrogenic perforation of the rectum, were
not present in our cases (Table IX).
We are persuaded that the vascular factor
In our opinion, a significant parameter for
is determinant for hemorrhoidal pathogene-
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
sis and that the prolapsing character is an
ence manoeuvre into the rectal anal canal
effect of the volumetric increase with the rel-
above the ano-rectal line not only at the lev-
ative encumbrance of the haemorrhoidal piles
el of the principal hemorrhoidal piles, which
into the anal canal at the internal plexus lev-
occupy those positions at hours 3, 7, 11, in
el. Problems at evacuation impact all those
the gynecological position, but also at the
factors: even the tone alteration at rest of the
terminal vessels level, which can be detect-
ed in the interposed seats. Thus treatment of
those sectors which are generally left as dur-
We, therefore, think that precise suture of
ing an hemorrhoidectomy for the integrity
ever, cause relapse is also effected.
line and thus over the internal hemorrhoidal
plexus (the technique is extensively described
cessfully in some cases of relapse (4 cases
of Milligan-Morgan); the patients complained
to the reader),16, 17 may be the moment for
of renewed bleeding after evacuation, due
patients when the initial pathogenic hemor-
to congested hemorrhoidal piles. Significant
rhoidal process is finally terminated. Rapid
improvement was rapidly obtained after the
ultrasound verification of the suturing per-
formed assures the result of treatment of thevascular factor.
The present study indicates that it is pos-
sible to obtain far more satisfying results in
In analysing the cases studied by our team,
consistent with those described in the litera-ture, it is clear that the eventual complica-
patients affected by II and III degree hemor-
rhoids with bleeding as the principal symp-
tom. Indeed, the degree of satisfaction was A
tions and relapses recorded in our study allappeared within the first six months of our
follow-up. The results registered after this
assume a favorable predictory value if pro-
reduced to a minimum (disappearance of all
jected into a longer observation time.
symptoms linked with the procedure in 88%
after the third day, postoperatively); a return
the operation and the almost total absence of
to normal daily activities was registered by
complications, lead to possible treatment of
seventh day after operation, in some 80% of
patients with severe pathology types which
are disabling. Hemorrhoidal problems ren-
der their quality of life worse, with painful
seemed the total absence of early or later
complications, by contrast with other con-
patients, patients already incontinent due to
Milligan Morgan procedures): postoperative
prior surgical operation or trauma, patients
hemorrhoidal stenosis, damage to anal con-
with hepatic or hematological problems. The
tinence, postoperative pain, urinary reten-
extant illness is, in these cases, an effective
contraindication for the demolishing manoeu-
vres of surgical resection at the level of the
remains totally intact after the HAL Doppler
rectal anal canal for excision of hemorrhoids,
procedure; any eventual future operation in
as the case of hemorrhoidectomy or stapled
this anatomic site will not find any scar defor-
repeated in the future given the absence of
surgical trauma, in the case of complete or
upper hemorrhoidal artery blocks arterial
flow to the internal hemorrhoidal plexus.
It is interesting to notice that HAL Doppler
development of the events which lead unre-
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
lentingly to the most advanced stages of hem-
the most precocious degree of haemorrhoidal
orrhoidal illness. That is true and evident in
illness. With this technique both a therapeu-
patients with structural alterations character-
tic procedure and prophylaxis of the most
ized by augmented calibre and flow which is
advanced degree of hemorrhoidal illness may
Eventually, when a group of at risk patients
is recognized by simple transperineal ultra-
sound study (as demonstrated by Aigner),our team considers treatment with the HAL
Legatura Doppler-guidata delle arterie emorroidarie
Doppler technique proper and suitable for
(DG-HAL): un trattamento sicuro del II-III grado emor-
those patients, since there is absence of sur-
roidario per tutti i pazienti. Potrebbe potenzialmen-
gical trauma and total absence of major com-
te avere anche un ruolo nella profilassi?
plications. This HAL Doppler treatment not
La legatura Doppler-guidata delle arte-
only assumes therapeutic significance but it
rie emorroidarie (hemorrhoidal artery ligation
Doppler) rappresenta un trattamento innovativo perla patologia emorroidaria ed è principalmente utiliz-
the more advanced stages of the illness. The
zata per le emorroidi di II e III grado associate a san-
question of hemorrhoidal prolapse is differ-
guinamento. Questa tecnica mira alla dearterializza-
ent as it requires treatment capable of direct-
zione del plesso emorroidario interno mediante la
ly correcting the prolapse, especially in III
legatura dei rami terminali dell’arteria rettale superiore
advanced degree or IV degree cases; the ver-
utilizzando uno speciale proctoscopio ad ultrasuo-
ification effected by our team indicates that
ni. Tale procedura è eseguita interamente al di sopradella linea pettinata e pertanto non provoca dolore.
hemorrhoidal prolapse only partially benefits
Scopo di questo studio è valutare la sicurezza, l’effi-
from arterial ligation and only in the initial
cacia e la bassa invasività di questa tecnica nel trat-
postoperative period, whence it reappears
tamento delle emorroidi di II-III grado.
albeit with minor improvement in the symp- A
Gli autori hanno trattato 148 pazienti, da
maggio 2002 a dicembre 2007, affetti principalmen-
te da emorroidi di II-III grado, caratterizzate da san-guinamento e dolore all’evacuazione. Questi pazien-
ti sono stati inclusi in uno studio osservazionale retro-spettivo; tale studio ha riguardato 128 pazienti pari
The results of our study definitely appeared
all’86% dei casi trattati. Il follow-up varia da 5 a 72
coherent with the data reported in the liter-
mesi con un tempo medio di osservazione di 36,5
È stato registrato un successo del 90%
nei pazienti affetti da emorroidi di II-III grado con
easy to perform; in our opinion, it is a first
assenza di complicazioni maggiori (emorragia, incon-
choice treatment in the therapy of II and III
tinenza, stenosi, perforazione, sepsi).
degree hemorrhoids characterised by bleed-
Gli autori indicano, come dimostra-
ing. Indeed, it surpasses the surgical alterna-
to in letteratura, un ruolo efficace, sicuro e poco inva-
tives (hemorrhoidectomy or prolassectomy)
so dell’HAL Doppler nel trattamento delle emorroididi II-III grado e ne sottolineano un opportuno impie-
with reference to operative trauma, compli-
go nei pazienti affetti da patologia associate per le
cations and postoperative comfort, obtain-
quali è controindicato il trattamento chirurgico stan-
dard. Infine, gli autori ipotizzano nelle emorroidi di
Moreover, we believe that it is important to
basso grado un ruolo, per HAL Doppler, oltre che
extend the indication for this technique, espe-
terapeutico, anche profilattico, dei gradi più avanza-
cially due to its low invasiveness, even to
patients with neurological, hepatic and hema-
Parole chiavi: HAL Doppler - Emorroidi - Emorragia -
tological problems, who are often excluded
from conventional treatments due to the highrisk of complications.
the absence of complications justify the use
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retropneumoperitoneum, and pneumomediastinum
of HAL Doppler also in patients affected by
after stapling procedure for prolapsed hemorrhoids:
DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION
report of a case and subsequent considerations. Dis
12. Haas PA, Fox TA Jr, Haas GP. The pathogenesis of
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2. Wong LY, Jiang JK, Chang SC, Lin JK. Rectal perforation:
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a life-threatening complication of stapled hemor-
Fritsch H. The superior rectal artery and its branching
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tomy. J Am Coll Surg 2005;200:983; author reply 983.
14. Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H,
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Margreiter R et al
. The vascular nature of hemorrhoids.
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Six-month Depression Relapse Rates among Women Treated with Acupuncture SUBMITTED FOR REVIEW—PLEASE DO NOT CITE OR DISTRIBUTE Department or institution to which the work should be attributed: Department of Psychology University of Arizona, PO Box 210068 Tucson, AZ 85721-0068 Until June 30, 2001 After July 1, 2001 the published version of this manuscript) Phone, FAX, and email a
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