Doppler Guided
Hemorrhoid Artery Ligation

Assoc. Prof.  Karl Miller, MD

Head of the Surgical Department

A.ö. Krankenhaus Hallein, Bürgermeisterstr. 34, A-5400 Hallein

Tel: ++43 . 6245-799-360   Fax: ++43 . 6245-799-361

E-Mail: Chirurgie@kh-hallein.at

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Summary

We recommend this new technique for treating hemorrhoids.  It has proven to be a safe and effective alternative to operative hemorrhoidectomy.  It is an office procedure and postoperative pain is usually minimal to mild.  Normal activities and work can usually be resumed within 48 hours. Nevertheless, this is a new procedure and all considerations regarding a new procedure apply here.


In 1995, a Japanese surgeon, Kazumasa Morinaga, conceived of a novel way to treat hemorrhoids.  He identified the hemorrhoidal arteries by means of a Doppler (ultrasound) technique.  He designed a special instrument, which contained a Doppler transducer and a window, which permitted the surgeon to identify and ligate the hemorrhoidal arteries by placing a suture (stitch) around them.  This is a simple maneuver, which produced prompt resolution of most of the hemorrhoidal symptoms of bleeding and protrusion. When we first became aware of the paper we were impressed with the concept of ligating the hemorrhoidal arteries, as a therapy for hemorrhoids, and that this had never been tried.  We were skeptical as to how effective this would be in eliminating hemorrhoidal symptoms.  By now several thousand patients, mostly in Japan, Australia and Southeast Asia have been treated with this technique. 

The results continue to be impressive. In one study of 1,415 patients, the treatment was successful in 93.2% and unsuccessful in 6.8% in a follow-up of 5-24 months.  Since the procedure is only been done for a little over four years, longer-term results are not known.

Technique

Across the world variations in techniques for Doppler Guided Hemorrhoid Artery Ligation are evolving.  At this time, we prefer giving the patient intravenous anesthesia using Propofol (Diprivan) administered by a board certified anesthesiologist.We then introduce rectal local anesthesia by a series of injections about the anus and rectum with. Because of the intravenous anesthesia, this step is painless.  We have performed thousands of rectal operations with this technique and are skilled with it and very comfortable with it.  No preparation is necessary aside from 1-2 Fleet enemas shortly before the procedure.  The specially designed proctoscope is then inserted into the rectum. The hemorrhoidal arteries are identified and suture ligated. It is interesting to note that traditionally it had been felt that most patients had 3 hemorrhoidal arteries.  The new Doppler technique indicates that people have up to six such vessels.  An effort is made during surgery to eliminate all of those vessels. 

The patient can go home and resume his/her usual activities after the sedation wears off. There is often a feeling of a desire to defecate after the procedure, which can last for 12-24 hours.  Most patients are back to work within 24-48 hours.  There is usually little or no bleeding in the immediate postoperative period.  There is a rare risk of late bleeding 1-3 weeks after the procedure.  The use of aspirin predisposes to that complication and you are advised to avoid aspirin for 5-7 days prior to and 3 weeks after the procedure.

 

 

Indications

 What is the optimum place for this procedure?  We initially offered this new procedure to patients who required an operative hemorrhoidectomy and in whom for various reasons this could not be performed.  We were delighted with the results.  We are gradually expanding the indications for Doppler Guided Hemorrhoid Artery Ligation.  In those patients where an excellent result can be produced from a rubber band ligation, this is a simpler and quicker procedure and may be preferred. Many patients were treated with rubber band ligation, as that had been the only alternative to an operative hemorrhoidectomy. Many of these patients would be expected to do better with Doppler Guided Hemorrhoid Artery Ligation. This technique has been successfully employed in patients who have hemorrhoidal symptoms of bleeding, recurrent acute attacks of piles, or protrusion.  Pure external hemorrhoids would not be expected to respond to hemorrhoid artery ligation and still would require an operative technique.  In putting Doppler Guided Hemorrhoid Artery Ligation in proper perspective, it is not as simple as hemorrhoid rubber band ligation or injection sclerotherapy, but a lot simpler than an operative hemorrhoidectomy. This technique is particularly applicable to patients who already have problems with continence or who are considered to be at risk for post hemorrhoidectomy incontinence as well patients who prefer an alternative to a possibly painful postoperative period of up to 2 weeks. Doppler Guided Hemorrhoid Artery Ligation can readily be performed as an office procedure.  No hospitalization is required. There is far less postoperative pain then an operative hemorrhoidectomy with more rapid return to normal activities and work.  Over 90% of patients are back at work within 48 hours.

Contraindications

The main contraindication to this procedure is the required use of anticoagulants.  Both Coumadin and aspirin predispose to late bleeding and this would be a relative contraindication to hemorrhoid artery ligation.

Complications

Reported complications from this procedure were quite infrequent.  Approximately 1/2% of patients developed delayed hemorrhage, infection or perianal thrombosis.  Approximately 1% developed anal fissures.  There were no cases of urinary retention and no cases of incontinence.

 

2001 Copyright Dr. Miller K.