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FIGURE4-8Anulcerationfromastitchthatwastoodeep,
justbelowthedentateline,causinganulcerandthedentate linetoflipupwithswellingandobviouslypoorpexy.
Essentially,thepexyshouldbeanchoredintherectum,pullingdown onthehemorrhoidaltissueandnotanchoredinthesphinctercomplex pullingupontherectum.
Theauthor’spersonalpreferenceisnottoexciseexternaltagsatthe timeofTHDbecauseexcisionincreasesthepainandcanconfusethe issueoftheetiologyofpostoperativeswelling.Inaddition,theauthor doesnotremoveanytissuefromtheanalcanalexceptforhypertrophied papillae.
Withtheexceptionofpain,earlycomplicationsarecomparableto thoseassociatedwithothermethodsofoperativehemorrhoid management.Postoperativeurinaryretentionhasbeenreportedin anywherefrom0.7%to8.4%ofpatients,andexternalthrombosed hemorrhoidsin1.8–2.4%ofpatients.Othercomplicationssuchasanal fissures,fistulas,proctitis,andfecalimpactionhavebeenreported<1%of thetime.

RESULTS

Amixtureofrandomizedcontroltrialsandprospectiveandretrospective studieshaveanalyzedtheoutcomesofTHDcomparedwiththoseof excisionalhemorrhoidectomyandPPH.Thedataaredifficulttocompare becausesomestudiesdonotdifferentiatepatientswhounderwent concomitantmucopexyinadditiontotheTHDprocedure;moreover, resultsareoftennotstratifiedbythehemorrhoidgrade.
Long-termpostoperativecomplicationsincluderecurrenceof hemorrhoidalprolapse.Therangeofthishasbeenreportedtobe anywherefrom8.4%to14.3%,whichishigherthanthatfollowingPPHor excisionalhemorrhoidectomy.
Rattoetal.presentedtheirdataon170patientswhounderwentTHD withorwithoutmucopexy.TheyincludedpatientswithgradesIItoIV hemorrhoids.Ofthese,patientswithgradesIIIandIVhemorrhoidsalso underwentmucopexy.Resultsindicate5.9%oftheirpatientsdevelopeda transienthematomaatthesuturestransfixationpoint.Theyalsoreported thatwhereas15.9%oftheirpatientsreportedpain,only4.7%(8patients) requiredanarcoticmedication.Duringamedian11-monthfollow-up,50 patients(29.5%)reportedarecurrenceofprolapse.However,thiswas detectedinonly18patients(10.5%)onexamination.
Giordanoetal.reviewed17publicationsonTHD,totaling1,996 patients.ThereviewincludedpatientswhounderwentTHDwithor withoutmucopexy.Theynotedthattheoverallqualityofthestudieswas eitherloworverylow.Hemorrhoidrecurrenceratesat1yearof10.8%for prolapseand9.8%forbleedingwerereported.GradeIVhemorrhoidshad thehighestrecurrencerateinthissystemicreview.
Anumberofstudieshavealsocompareddifferentsurgicalmethodsof hemorrhoidmanagement.Infantinoetal.comparedpatientsundergoing THDwiththoseundergoingPPH.Theyfoundlowcomplicationsinboth thegroups,withnosignificantdifferenceinperioperativecomplications. Intheirpopulation,PPHdidexhibitmoreoverallcomplicationsinterms ofpain,fecalurgency,andabscesswhenlookingatoutcomesbeyond30 days.Verreetal.reported63patientsundergoingPPHand59 undergoingTHDwithgradeIIIorIVhemorrhoids.Itisnotstated whetherthepatientsalsounderwentmucopexy.Patientsundergoing THDhadsignificantlylesspainat1week,1month,and3monthsbothat restandwithbowelmovements.THDpatientsalsoreturnedtoworkan averageof2daysearlier(3.5days).

CONCLUSIONS

THDwasintroducedanddescribedbyMorinagaetal.in1995.In2002, DalMonteaddedmucopexyforprolapsetothisprocedure.Short-and long-termoutcomesforthisprocedurehavebeenpublished,showinga lowriskofcomplicationswithanincreasedriskofrecurrence,especially forgradeIVhemorrhoids.Atpresent,THDwithmucopexyremainsan optionforhemorrhoidmanagementforpatientswithgradeIIorIII hemorrhoidsandselectedgradeIV(Figs.4-9and4-10).Itspotential benefitsincludedecreasedpainwhencomparedwiththatassociatedwith excisionalmethods.Itmayalsobeusefulforpatientswithhemorrhoidal diseasewhocannotstoptheirtherapeuticanticoagulation.Thereisalso anopportunitytotreatolderandyoungerpatientsalikewith hemorrhoidalsymptomsonaselectivebasis.
FIGURE4-9GradeIVpre-THD.
FIGURE4-10GradeIVpost-THD.
RECOMMENDEDREFERENCESAND READINGS
DalMontePP,TagarielloC,SaragoM,etal.Transanalhaemorrhoidaldearterialisation:
nonexcisonalsurgeryforthetreatmentofhaemorrhoidaldisease.TechColoproctol
2007;11:333–8;discussion338–9. ElmerSE,NygrenJO,LenanderCE.Arandomizedtrialoftransanalhemorrhoidal
dearterializationwithanopexycomparedwithopenhemorrhoidectomyinthetreatmentof
hemorrhoids.DisColonRectum2013;56(4):484–90. GiordanoP,NastroP,DaviesA,GravanteG.Prospectiveevaluationofstapledhaemorrhoidopexy
versustransanalhaemorrhoidaldearterializationforstageIIandIIIhaemorrhoids;threeyear
outcomes.TechColoproctol2011;15:67–73. GiordanoP,OvertonJ,MadedduF,ZamanS,GravanteG.Transanalhemorrrhoidal
dearterialization:asystemicreview.DisColonRectum2009;52:1665–71. InfantinoA,AltomareF,BottinC;THDgroupoftheSICCR.Prospectiverandomizedmulticenter
studycomparingstaplerhaemorrhoidopexywithDoppler-guidedtransanalhaemorrhoid
dearterializationforthirddegreehaemorrhoids.ColorectalDis2012;14(2):205–11. InfantinoA,BellomoR,DalMontePP,etal.Transanalhaemorrhoidalarteryechodopplerligation
andanopexy(THD)iseffectiveforIIandIIIdegreehaemorrhoids:aprospectivemulticentric
study.ColorectalDis2010;12(8):804–9. MorinagaK,HasudaK,IkedaT.Anoveltherapyforinternalhemorrhoids:ligationofthe
hemorrhoidalarterywithanewlydevisedinstrument(Moricorn)inconjunctionwitha
Dopplerflowmeter.AmJGastroenterol1995;90:610–3. O’DonovanS,FerraraA,LarachS,WilliamsonP.IntraoperativeuseofToradolfascilatates
outpatienthemorrhoidectomy.DisColonRectum1994;37(8)793–9. RattoC,DonisiL,ParelloA,LittaF,DogliettoGB.Evaluationoftransanalhemorrhoidal
dearterializationasaminimallyinvasivetherapeuticapproachtohemorrhoids.DisColon
Rectum2010;53(5):803–11. RattoC,ParelloA,VeroneseE,etal.Doppler-guidedtransanalhaemorrhoidaldearterialization
forhaemorrhoids:resultsfromamulticentertrial.ColonrectalDis2015;17(1):O10–O19. RivadeneiraDE,SteeleSR,TernentC,ChalasaniS,BuieWD,RaffertyJL;StandardsPracticeTask
ForceoftheAmericanSocietyofColonandRectalSurgeons.Practiceparametersforthe
managementofhemorrhoids(revised2010).DisColonRectum2011;54(9):1059–64. TsangYP,FokKL,CheungYS,LiKW,TangCN.Comparisonoftransanalhaemorrhoidal
dearterializationandstapledhaemorrhoidopexyinmanagementofhaemorrhoidaldisease:a
retrospectivestudyandliteraturereview.TechColoproctol2014;18:1017–22. VerreL,RossiR,GaggelliI,DiBellaC,TironeA,PiccolominiA.PPHversusTHD:acomparisonof
twotechniquesforIIIandIVdegreehaemorrhoids.Personalexperience.MinerraChir
2013;68:543–50.
Chapter5
RubberBandLigation
MitchellA.Bernstein,AlexisL.Grucela,and
MichaelJ.Grieco

INDICATIONS/CONTRAINDICATIONS

Internalhemorrhoidscanpresentwithbleeding,prolapse,and/or discomfort.Afocusedhistoryandphysicalexaminationwithselective endoscopyisimportanttoexcludeothercommonpathologiessuchas tumors,infection,fissure,inflammatoryboweldisease,radiation, proctitis,trauma,orcondyloma.
First-linetherapyforinternalhemorrhoidsinvolvesreducing constipation;limitingtimestrainingonthetoilet;andincreasingwater intake,fibersupplementation,andlaxatives.Fiberhasbeenshownina meta-analysisofsevenrandomizedtrialstodecreasetheriskofbleeding inpatientswithinternalhemorrhoidsby50%.Internalhemorrhoidsare classifiedintogradeI—prominenthemorrhoidalvesselsbutnoprolapse; gradeII—prolapsewithValsalvaandspontaneousreduction;gradeIII— prolapsewithValsalvarequiresmanualreduction;andgradeIV— chronicallyprolapsedmanualreductionineffective.
Rubberbandligation(RBL)canbeofferedtopatientswhoremain symptomaticdespitemedicaltherapyforgradesI,II,andselectgradeIII internalhemorrhoids.
Contraindications
(includingwarfarinandheparin),antiplatelettherapysuchas clopidogrel
topic,althoughaseriesof11HIVpatientswithameanThelpercountof
400(200–1,000)wereshowntoundergoRBLwithoutcomplications
PREOPERATIVEPLANNING
BeforeproceedingwithRBL,patientsshouldbeinformedaboutthe possibleneedforfollow-upproceduresinadditiontotheriskof complications.Partoftheplanninginvolvesthedecisiontoperform multipleversussinglehemorrhoidbandinginasinglesetting,asmultiple bandinghasthepotentialforfasterresolutionofsymptoms,butagreater post-proceduraldiscomfort.Theprocedureisgenerallywelltoleratedand canalmostalwaysbeperformedinanofficesettingwithoutanyneedof anesthesia,antibiotics,orenemas.

SURGERY

Positioning
RBLcanbeperformedwithadequatelightingeitherinpronejack-knife positionorSims’leftlateraldecubitusposition.TheSims’positionis preferredintheabsenceofspecializedtilttableortheinabilityofthe patienttotolerateakneelingposition.
Technique
Eithersuctionorforcepssystemscanbeusedtoapplytherubberband. Someserieshavesuggestedthatsuctionelasticbandligationissuperior toforcepsligationrelativetopostprocedurepain,postprocedure analgesiarequired,andintraprocedurebleeding.
identifythelargestinternalhemorrhoid
transitionzonethathasvaryinglevelsofpainreceptors)(seeFig.5-1A)
FIGURE5-1Rubberbandligationofinternal
hemorrhoids.A.Hemorrhoidgraspedbytheclamp andpulledthroughthedrumsoftheinstrument.B. Innerdrumretractedtoreleasethebandsontothe baseofthehemorrhoid.C.Retroflexedcolonoscopic viewofrubberbandedinternalhemorrhoid.
thehemorrhoidsuction/forcepsattheproximalaspectofthe
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