Other Haemorrhoid Operations

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Other Haemorrhoid Operations

• Mo Saeed
• Consultant Surgeon Stepping Hill Hospital
  Stockport

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Other Haemorrhoid Operations

• Doppler Guided Haemorrhoid Artery Ligation (DG-
  HAL) Morinaga et al Am J Gastroenterology 1995
  90610-3
• Ligasure Haemorrhoidectomy (LH) sayfan et al Ann
  Surg200123421-24)

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DG-HAL

• Embolisation of superior rectal artery and its
  branches results in effective treatment of
  bleeding from chronic haemorrhoids (Galkin et al
  VRS 1994452-56)
• Morinaga et al Am J Gastroenterology 1995
  90610-3

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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

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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

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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
  prolapse 95 with bleeding

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What Degree of Haemorrhoids ?

• Can be used for grade II-IV
• Symptoms include Bleeding Pain Prol
  apse
• Procedure performed under sedation

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DG-HAL

• Recent longer term outcome data
• Felice et al DCR 2005 48 2090-2093
• Greenberg et al DCR 2006 49 485-489

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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 gt 2 day in 2
  patients 2 patients had thrombosis of 1
  haemorrhoid 1 patient developed 20 haemorrhage

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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

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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

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DG-HAL

• Effective minimally invasive treatment for
  haemorrhoids
• Can be performed under sedation
• Randomised controlled trial vs other treatments
  needed
• Longer term F/U

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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

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Ligasure Haemorrhoidectomy (LH)

• First described by sayfan et al Ann
  Surg200123421-24)
• Several randomised controlled trials comparing
  LigasureTM haemorrhoidectomy with conventional
  diathermy haemorrhoidectomy

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Ligasure Haemorrhoidectomy

• Franklin et al DCR 2003 461380-1383 compared
  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

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Ligasure Haemorrhoidectomy

• Palazzo et al BJS 200289154-157 Ligasure
  haemorrhoidectomy reduced operating time and
  analgesic requirements but the postoperative
  pain was similar to that with conventional
  diathermy haemorrhoidectomy

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Ligasure Haemorrhoidectomy

• Jayne et al BJS 2002 89428-32 Demonstrated
  reduced blood loss, shortened operating time
  reduced pain for ligasure compared to
  conventional diathermy haemorrhoidectomy
  facilitating sameday discharge

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Ligasure Haemorrhoidectomy

• Kraemer et al DCR 2005481517-1522 Prospective
  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

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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