Dr. Angelo Parello Catholic University, Rome, Italy

T H D

THD

• Transanal • Through the anus into the rectum

• Only mild stretch of anal sphincters

• Hemorrhoidal • … arteries, not cushions, identified by Doppler

• Dearterialization • ligation of main hemorrhoidal arteries

• reduction of overflow

THD

Sphincter hypertone

Anal cushions hypertension

(overflow)

Venous drainage impairment

Increased cushions pressure

Stress on connective tissue

Abnormally high anal pressure

Increased straining during defecation

Increased congestion and slippage of the

anal cushions

Degeneration of connective

tissue

Pathophysiology

THD

Dearterialization

THD

Mucopexy

Pathophysiology

- Higher artery caliber

- Increased arterial flow

- Incresed arterial flow velocity

- Lower arterial resistivity index

Echo-color Doppler features in

Hemorrhoidal Disease

Aigner et al. 2006

Aigner et al. 2009

Aigner et al. 2010

Ratto et al. 2007

Healthy volunteers

Patients with hemorrhoidal disease

Hemorrhoidal Arteries

Assessment of hemorrhoidal arteries location within the rectum using endorectal ultrasound and echo-color Doppler

• 50 pts.

• Evaluation at 6 sectors

• At 1, 2, 3, 4, 5, 6 cm above

ano-rectal junction (ARJ)

Ratto et al. – Br J Surg. 2012;99:112-8

Ano-Rectal

Junction (ARJ)

Endorectal

Echo-color

Doppler Probe

• Are there always arteries?

• Relation to the rectal wall?

• Deepness of arteries?

Right Antero-Lateral

Right

Right Postero-Lateral

Left Antero-Lateral

Left

Left Postero-Lateral

BK Medical - 8848

F F

F-M M-SM

M-SM SM

Echo-color Doppler of

Hemorrhoidal Arteries

(HAs)

Ratto et al.

Br J Surg. 2012;99:112-8

- in almost all 6 sectors there are arteries (99.3 – 99.7 %)

- the arteries are into the submucosa (98.3 – 100 %)

- the arteries are very superficial (2.4-1.9 mm)

Close to the Ano-Rectal Junction (within 2 cm):

Assessment of hemorrhoidal arteries location within the rectum using endorectal ultrasound and echo-color Doppler

Ratto et al. – Br J Surg. 2012;99:112-8

THE DOPPLER SIGNAL

IS NOT

HOMOGENEOUS

Between 1 and 2 cm

the Doppler signal

is

more intense

Distal Doppler-guided Dearterialization

THD

Distal Doppler-guided Dearterialization

& Structured Hemorrhoid-sparing Mucopexy

500 patients:

301 male

199 female

mean age: 48.0 ± 12.8 yrs (range: 20-87)

Goligher’s classification:

II degree: 92 pts (18.4%) - resistant to medical treatment

III degree: 343 pts (68.6%)

IV degree: 65 pts (13.0%)

Associated anal fissure 47 pts (9.4%)

July 2005 – June 2011

Update Results

Intraoperative Data

Dearterialization alone 110(22.0%)

Dearterialization + Mucopexy 390 (78%)

Dearterialization 6 arteries in ALL patients

Operation time 20±5 min dearterialization

30±10 min dearterialization + mucopexy

27 pts. 41 pts. 57 pts. 375 pts.

1st year 2nd year 3rd year 4-6th years

Traditional

proctoscope THD Surgy THD Slide

THD instruments over the time

Post-operative Symptoms

SYMPTOMS EARLY (< 10 days) LATE (30 days)

Dearterializ.

alone

Dearterializ.

+ Pexy

Dearterializ.

alone

Dearterializ.

+ Pexy

n. % n. % n. % n. %

Tenesmus - - 123 31.5 - - - -

Significant bleeding

• Surgery - -

15

5

3.8

1.3 - - - -

Fecal Incontinence - - - - - - - -

Anorectal pain

• Prolonged analgesics

5

-

4.5

-

46

16

11.8

4.1 - - - -

Urinary retention 6 5.5 44 11.3 - - - -

Thrombosis 2 1.8 8 2.1 - - - -

Follow up

Recurrences 58 pts (11.6%)

Symptoms

Bleeding 0 pts

Prolapse 36 pts (7.2%)

Bleeding + Prolapse 22 pts (4.4%)

Mean Follow-up: 10.3±9.4 months (range 3-57)

Schedule: 2 weeks, 1 and 3 months, once a year after operation

Follow up

%

Recurrences

Bleeding Recurrence

Follow up %

Dearterialization with “intention to treat”

Bleeding Recurrence

20 / 461 cases (4.3%)

Follow up %

6.3% 2.8%

Follow up %

Mucopexy with “intention to treat”

Prolapse Recurrence

48 / 388 cases (12.4%)

22.8% 7.3%

Follow up %

Mucopexy with “intention to treat”

Prolapse Recurrence

48 / 388 cases (12.4%)

28.6% 26.8% 10.3%

Mucopexy with “intention to treat”

Prolapse Recurrence

48 / 388 cases (12.4%)

Follow up %

28.6% 26.8% 20.3% 7.3%

Re-operation 26 pts (5.2%) THD 16 pts (3.2%) Prolapse 13 pts (2.6%) Bleeding + Prolapse 3 pts (0.6%) MM 10 pts Prolapse 6 pts (1.2%) Bleeding + Prolapse 4 pts (0.8%)

Follow up

• Locations of arteries are not always the same

• Find the best ! Be selective !

• Not time-expensive

• Precision and reliability are of great value

Why Doppler ?

• To “modulate” the treatment of prolapse

• No any resection

• Save the hemorrhoids ! Away from the pecten !

• Safe procedure (no major complications)

Why Mucopexy ?

Why would a surgeon want to utilize this technique ?

SUMMARY

Together

A reliable method to treat hemorrhoidal disease