Summaries by PT Dian Langgeng Pratama, Fahrenheit

Medical Team, 2014.

 Patients Recruitment
Inclusion Criteria :
Exclusion criteria :




Any prolapse which could be reduced was classified as concomitant anal disease (acute thrombosed
grade III hemorrhoidal disease.
hemorrhoids,fissure, abscess, fistula, incontinence,

inflammatory bowel disease), previous anal surgery,
Permanently prolapsed anal cushion that prolapse ongoing treatment with oral anticoagulants, disease or
immediately after replacement were classified as grade IV.
hematological disorders.




Other underlying pathologies were excluded by barium The patients were classified in category I-II of the ASA
enema or colonoscopy where necessary. score (American Society of Anesthesiologists).

Diagnosis & staging of the disease using rigid sigmoidoscopy & Anoscopy

Randomization
n= 135 (grade III-IV hemorrhoids)

Closed Hemorrhoidectomy HAL-RAR

n= 70 n= 65
RESULT
 RESULT

Conclusion: HAL-RAR appears to cause less postoperative pain and results in better patient-satisfaction in the early postoperative
period than closed hemorrhoidectomy. Doppler-guided hemorrhoidal artery ligation fulfills the requirements of minimally invasive
surgery and appears to be ideal for 1-day surgery
 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?
A. Testa, G. Torino.
Department of Surgery, S. Peter Hospital FBF, Rome, Italy
Pediatric Surgery Unit, G. Salesi Children’s Hospital, Ancona, Italy.

Aim of the study : To evaluate the efficacy, safety and invasivity of

Hal Doppler technique to treat II and III degree
hemorrhoids.

Methods : Retrospective observational study of 128 patients with

II-III degree hemorrhoids then follow up was performed
from 5 up to 72 months (average observation 36.5
months).
12 Hours & 7 Days Post Surgery Follow up
6 Months & Annual Post Surgery Follow up
 Conclusion

•  The HAL Doppler Technique is safe and easy to perform.

•  Might be considered as the first choice treatment in the therapy of II and III degree hemorrhoids
characterized by bleeding.
•  The HAL Doppler Technique surpasses the surgical alternatives (hemorrhoidectomy or prolassectomy)
with reference to operative trauma, complications and post operative discomfort, obtaining satisfying
result.
•  The HAL Doppler Technique due to its low invasiveness can be done to patients with neurological, hepatic
and hematologic problems who are often excluded from conventional treatments due to high risk of
complications.
•  Low discomfort during the operation and the absence of complications justify the use of HAL Doppler also in
patients affected by the most precocious degree of haemorhoidal illness.
•  The HAL Doppler Technique both therapeutical procedur and prophylaxis of the most advance degree of
haemorrhoidal illness may be performed at the same time.
•  The aim of the study : To review several technical aspects and analyze 1-year results of this method (DG-HAL/RAR) in
terms of recurrence of prolapse and symptoms other than prolapse.

•  Patients & Method : Prospective Observational Study, multicenter (7 proctologic institution)

•  Inclusion criteria : Patients aged 18-80 years with symptomatic grade III and IV haemorrhoidal
disease according to Goligher classification.

•  Exclusion criteria : Patients with a history of prior anal surgery and those considered unfit for surgery pregnant
woman and those in puerpureum.
 Patients Data & Surgical Procedure
Pa#ents  profile   Surgical  Procedure      

n   184   Median  of  Liga#on   6(2-­‐11)  

male   120  (65%)   Prolapse-­‐reduc#on  sutures  (PRSs)   3(1-­‐9)  
Female   64  (35%)   %  pa#ents  with  6  or  more  liga#on   80%  
Median  Age  (years)   46.8  (23-­‐76)  
%  pa#ents  with  3  or  more  PRSs   80%  
III  Degree  Hemorrhoids   107(58%)  
Surgery  under  general  anesthesia  (Ptn)   132  (72%)  
IV  Degree  Hemorrhoids   77(42%)  
Surgery  under  spinal  anesthesia  (Ptn)   45(25%)  
Surgery  under  local  Anesthesia  (Ptn)   7(4%)  
Preopera#ve  symptoms   Mean  Opera#ng  #me  (minute)   35(13-­‐75)  
Instance  of  significant  bleeding  (Ptn)   3  (2%)  
Post  opera#ve  complica#on  (Ptn)   14(8%)  
Pain     136/184  (74%)   Bleeding  which  required  opera#ve  revision  (Ptn)   2(1%)  
Perianal  thromboses  (Ptn)   11(7%)  
Itching   139/184  (76%)   Unspecified  proc##s  (ptn)   1(1%)  
Mean  Hospital  stays  (Days)   2.3  
Bleeding   174/184  (95%)  
Post Operative Follow up
 Conclusion

•  HAR-HAR proved to be safe & effective

•  Showing acceptable prolapse RR of 11% after 12 months for high grade haemorrhoid patients (59% grade
III, 41% grade IV)
•  Symptom control & high patients satisfaction (9 of 10 patients staying symptom free and satisfied 1 year
after surgery.
•  Low perioperative complication, primarily cases of perianal thrombosis and post operative bleeding.
Objective : To describe our experience with this combined procedure in the treatment of grade IV hemorrhoids

Design : Prospective Observational Study

Setting : Outpatients Colorectal Surgery Unit

Patients : Consecutive patients with grade IV hemorrhoids treated from April 2006 to December 2008

Intervention : Hemorrhoidal Artery Ligation-Rectoanal Repair (HAL-RAR)

Main Outcome Measures : Operating time, Number of Ligation, Number of mucopexies and associated procedures and post operative
symptoms were recorded. Pain was graded on a visual analog scale, follow up was at 2,6 and 12 months
after surgery and then annually.
 Result

Surgical  Procedure      
        Complica#ons      
Median  of  Liga#on   9(4-­‐14)  
Surgery  under  general  anesthesia  (Ptn)   29   Dyschezia  las#ng  for  31  months   1  
Mean  Opera#ng  #me  (minute)   35(17-­‐60)  
n  Pa#ents  discharge  aXer  opera#on   84   Anal  Incon#nence  at  4  months   1  
n  pa#ents  remained  hospitaliza#on  for  2  days   11  
n  pa#ents  remained  hospitaliza#on  for  3  days   3   Thrombosis  of  residual  piles  at  4  months   1  
n  pa#ents  remained  hospitaliza#on  for  4  days   2  
The  mean  follow  up   34(14-­‐42)   Anal  Fissure  at  12  months   1  
CONCLUSION

Doppler-guided HAL-RAR is safe, easy to perform and can be tailored to suit each individual case. This
procedure shoul be considered as an effective treatment option for grade IV hemorrhoids
Aim of the study: To observe the outcome of a series of consecutive DG HAL-RAR procedures

Method : Seventy seven consecutive patients (49 male) underwent DG-HALRAR for symptomatic
hemorrhoids and were reviewed for 6 months post surgery.
 Pre-Operative & Surgical Procedure
Pa#ents  profile  
80 Patients perform n   77  
HAL-RAR surgery male   49  
Female   28  
Median  Age  (years)   50  
Mean  Follow  up  (Months)   13.21(6-­‐21)  
II  Degree  Hemorrhoids   12  
III  Degree  Hemorrhoids   65  
6 Month Post Prolapse+Bleeding  symptoms   57  (74%)  
Surgery Follow up

Surgical  Procedure      

Median  of  Liga#on   6(1-­‐9)  

Patients not
followed up 6 Median  No.  of  RARs  performed   2(1-­‐5)  
months : 3
Surgery  under  general  anesthesia  (Ptn)   55  

Surgery  received  seda#on  and  pa#ents  controlled  analgesia   22  

n  Pa#ents  discharge  aXer  opera#on   74(96.1%)  

Patients Followed up n  pa#ents  stay  overnight   2(2.5%)  

for 6 months : 77
n  pa#ents  stayed  for  3  days   1(1.2%)  
 Post-operative & Follow up

Conclusion:
•  DG-HAL-RAR is safe and effective minimally invasive technique that can be used for symptomatic haemorrhoids.
•  DG-HAL-RAR can be performed as a day case procedure, under sedation.
•  DG-HAL-RAR is easy to learn and although more painfull than DGHAL alone is well tolerated with high patients
satisfaction rates.
•  The addition of RAR appears to improve the outcome of DGHAL in improving the outcome for patients suffering
prolapse as a prominent symptom.
•  Recurrent symptoms following DGHAL-RAR can be treated by repeate DGHAL-RAR or any other form of
therapeutic intervention, however it is rarely necessary to perform conventional, painful and potentially
dangerous excisional procedures.
 §  n = 83 (43% female, 57% male) I II III IV
§  Mean age = 56 years (range 20-83)) Grade: 90% 10%
§  Follow-up was carried out at 1 week, and then at 1, 3, 6 and 12 months, whereby
clinically relevant parameters such as hemorrhoidal symptoms and re-prolapse were
recorded and the spatial distribution of treated arteries analysed
§  Observation time: 12 months

§  Results:
§  The number of patients showing relief of hemorrhoidal symptoms at 12-month follow-up was
high.
§  Patient satisfaction was consistently high (>90%) at all follow-up intervals and the
complication rate was low.

Criteria resolved Results

Bleeding 89%
Itching 95 %
Burning & Soiling in 100%
No Re-prolapse 89%

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