Transanal desarterialization guided by Doppler associated to anorectal repair in hemorrhoids: THD technic

Abstracts

INTRODUÇÃO: O tratamento cirúrgico para hemorroidas deve ter indicação individual e baseia-se no sintoma predominante (sangramento ou prolapso), na gravidade da doença e na presença ou ausência de componente externo (plicoma). Cabe ao cirurgião conhecer as mais variadas técnicas para que possa encontrar o tratamento mais adequado caso a caso. TÉCNICA: O procedimento THD consiste na ligadura alta seletiva e guiada por Doppler de até seis ramos arteriais submucosos que irrigam as hemorroidas, levando à sua desarterialização, associada à correção do prolapso (reparo anorretal ou lifting). Utiliza equipamento e kit especiais. CONCLUSÃO: A técnica do THD tem mostrado bons resultados iniciais. Por ser técnica cirúrgica em que se respeita a anatomia, ela age diretamente sobre a fisiopatologia da afecção e corrige suas principais consequências, ela parece bastante promissora. Sua aplicação inicial pode ser nos pacientes com doença hemorroidária de II grau, que tenham indicação de tratamento cirúrgico, e de III e IV graus, nestes últimos, podendo ser associada à ressecção de plicomas.

Cirurgia; Hemorroidas; Técnica

TECHNIQUE

Transanal desarterialization guided by doppler associated to anorectal repair in hemorrhoids: THD technic

Carlos Walter Sobrado-Junior; José Américo Bacchi Hora

Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, SP, Brazil

Correspondence

ABSTRACT

INTRODUCTION: Surgical treatment for hemorrhoids should be indicated individually and is based on the predominant symptom (bleeding or prolapse), severity of disease and the presence or absence of external component (plicoma). Surgeons must choose among varied techniques the one suitable for each case.

TECHNIC: The THD procedure consists of Doppler guided high ligation, selective to up six submucosal arterial branches that supply the hemorrhoids, leading to its desarterialization associated with prolapse repair (anorectal repair or lifting). It uses special equipment and kit.

CONCLUSION: THD technique has shown good initial results. Because surgical technique respects the anatomy, it acts directly on the pathophysiology of the disease and corrects its principal consequences; it looks quite promising. Its initial application may be in patients with hemorrhoids grade II, which have surgical indication, grades III and IV, the latter being associated with resection of plicomas.

Headings: Surgery. Hemorrhoids. Technique

INTRODUCTION

The search for the optimal surgical treatment of hemorrhoidal disease dates back to historical times, currently being necessary in only 10-20% of symptomatic patients first³. In the last century, many techniques have been developed, but few have signed up such as those proposed by Milligan-Morgan²¹, Parks²⁴ and Ferguson⁸ , which can still be considered the gold standard in surgical treatment of this disease. In order to simplify the therapeutic process, were developed outpatient treatment modalities, such as sclerotherapy¹², variceal ligation², cryotherapy¹⁹ and photocoagulation²³. Arriving to the era of minimally invasive surgery, were created methods of mechanical anopexia²⁰and, more recently, Doppler-guided hemorrhoidal desarterialization, or THD (Transanal hemorrhoidal dearterialization) object of this text. Therapy must be instituted individually, based on predominant symptom (bleeding or prolapse), severity of disease and the presence or absence of external component (plicoma). Surgeons face themselves with varied techniques, so they can find the most suitable treatment in each case.

Anatomophysiological bases of the technique

The length of the anal canal varies from 2.5 to 4 cm above the anal verge. Inferiorly it is limited to the perianal skin, highly innervated and sensitive area. Has its epithelial lining divided by dentate line in two areas: the cranial, less sensitive to pain with visceral innervation and distal, more sensitive. The blood supply to the rectum and the anal canal is supplied by three arteries: the superior rectal artery, a branch of the inferior mesenteric artery, middle rectal artery, a branch of the internal iliac artery, and inferior rectal artery, a branch of the internal pudendal artery.The internal hemorrhoidal plexus, also called the corpus cavernosum of the rectum, appears histologically as a cavernous venous network with arteriovenous shunts, surrounded by connective tissue, within or below the rectal mucosa. This plexus receives its blood supply exclusively from the terminal branches of the superior rectal artery.

According to Aigner¹ , in healthy individuals, the mean diameter of the terminal branches of the upper rectal artery is 0.92 mm with average flow of 11.9 cm / sec and in patients suffering from hemorrhoidal diseases, both the diameter, as the flow increases, being the mean diameter of 1.87 mm with average flow of 33.9 cm / sec. Recent studies²⁸ , with endoanal ultrasound Doppler (360° - rotating ltrasonographic endoprobe) demonstrated that in the circumference of the wall of the distal rectum, 6 cm above the anal verge, is generally identified six arterial branches located in positions 1, 3, 5, 7, 9 and 11 hours in individuals with or without hemorrhoids. In the same study showed that in patients with hemorrhoidal disease, there is increased arterial blood flow velocity and decrease in venous resistance.

In theory, arterial blood hyperflow going to the hemorrhoids in higher speed leads to congestion and venous injury, which causes stasis, edema and prolapsed nipples. Hypertension by overflow, also contributes to the degeneration of the connective tissue. The increased force during defecation further impairs venous drainage. All this stress on connective tissue leads, with time, to degeneration and the onset of symptoms of prolapse, bleeding, discomfort, burning, mucous secretion, pain and itching.

Historical evolution

Treatment for Doppler-guided hemorrhoidal desarterialization for hemorrhoidal disease - HAL (only desarterialization) was first described in Japan in 1995 by Morinaga et al.,²² , who reported good results in 116 patients evaluated for pain, bleeding and prolapse after a month of monitoring. A northamerican group in 2001, after operating on 60 patients, considered it an option to hemorrhoidectomy, in most cases³². Since then, both the technique HAL and anorectal repair equipment have been improved. Data collected from case series, increasingly bigger, and with longer follow-up have been published, mainly in Europe⁶. Currently, the technique THD (desarterialization associated to hemorrhoidopexia) have been indicated for refractory hemorrhoidal disease 2nd degree, 3rd degree and selected cases of 4th degree.

TECHNIC

The procedure consists of selective high ligation, Doppler guided, up to six submucosal arterial branches that supply the hemorrhoids, leading to its desarterialization associated with prolapse repair (anorectal repair or lifting).

Was developed a special anoscope coupled on the side of its tip to a Doppler sensor, which allows to listen to the submucosa arterial pulse sound, locating the artery. After soft digital examination with anesthetic gel or lubricant, anoscope is introduced. By means of the sound, the arterial branches are identified with great precision and its ligature is made with absorbable 00 (polyglycolic acid) to approximately 6 cm above the dentate line, through a side window on the instrument. This initial desarterialization already reduces the engorgement of the hemorrhoidal tissue, facilitating its reduction, suspension and fixation (Figure 1).

Later, there will be a simple continuous running suture with the same thread in craniocaudal direction to place about 1.0 cm above the dentate line, which tied after the starting point, lead to pexia of mucosal tissue prolapsed, which return to their anatomical position. At this stage, it must avoided deep sutures involving the anal sphincter, because hinder lifting of prolapsed tissue, and also increase postoperative pain. This procedure should be conducted in six arterial branches located in positions 1, 3, 5, 7, 9 and 11 hours. Finally, hemostasis is reviewed and a dressing is positioned with the introduction of a hemostat, as part of kit THD (Figures 2 and 3).

So, the interruption of blood flow is added to the mucosal pexia and hemorrhoids, directing treatment to the resolution of the two main symptoms of hemorrhoids: bleeding and prolapse. Because there is no tissue resection and the entire procedure take place above the dentate line, is expected to reduce postoperative pain, compared to hemorrhoidectomy procedures. Antibiotics are used as prophylaxis routine (Figures 4 and 5).

Commercial fibers (plantago ovata, psillium, methylcellulose) are prescribed routinely and, as analgesics, dipyrone and antiinflammatories (ketoprofen). All patients were examined weekly for four weeks, when they are questioned about pain, stool frequency, stool appearance, bleeding, satisfaction with the procedure and return to work.

DISCUSSION

In 2009, in a review of 1996 cases published in the literature, it was concluded that the treatment is safe for hemorrhoids grades II and III, and that further studies about its efficacy are necessary in more advanced cases and in longer follow-up. In 2011, a French group, in an uncontrolled study with 100 patients with grade IV hemorrhoids, obtained good results with median follow-up of 34 months 16. In the same year, Ratto et al. published the results of the procedure in 35 consecutive patients with more advanced hemorrhoidal disease, obtaining similar data²⁹, which suggests that the technique has potential use for the majority of cases with surgical indication^28,29,30,33. Since then, initial experiments in several countries^{5,13,25,27,34}, have been published, with good results, the procedure being isolated or associated with other techniques. Brazil has gaining adherents in recent years, measured by conferences, presentations and publications on initial experience^16,31; it showed good results and low complication rates at two years follow-up.

Were found six publications of comparative studies using hemorrhoidal desarterialization. Four of them were comparing it to the mechanic anopexia, showing similar results in the medium term, with one of them observing a lower incidence of early complications and faster return to work for groups of desarterialization¹⁰, and other two, slight reduction of pain in the early postoperative^9,17. A Chinese desarterialization group of patients has been very favorable for the early complications and postoperatively pain²⁶. In comparative paper with closed hemorrhoidectomy and TDH technique, showed less pain and earlier recovery, with similar results in a year⁴. Indian study found no differences between simple desarterialization and Doppler-guided ligation of hemorrhoids within one year of follow-up¹⁴. Egyptian study already showed that hemorrhoidectomy is superior to PPH and to desarterialization in advanced cases, where there anal plicomas, and is similar in the other aspects¹⁵.

CONCLUSIONS

The THD technique has shown good initial results. It respects the anatomy, acts directly on the pathophysiology of the disease and corrects its principal consequences. So, THD seems quite promising. Its initial application may be in patients with second-degree hemorrhoids, with surgical indication, and also in grades III and IV, the latter associated with plicomas resection

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Publication Dates

• Publication in this collection
  07 Feb 2013
• Date of issue
  Dec 2012

History

• Received
  25 June 2012
• Accepted
  13 Aug 2012