Key words: Hemorrhoids, Hemorrhoidal artery, Doppler guided hemorrhoidal artery ligation, Vicryl.

 

 

THE INSTRUMENT

 INTRODUCTION

MATERIALS AND METHODS

INTRODUCTION                    

Problem of hemorrhoids dates as far as the human race can be traced. It has been said that about 80% of humans suffer from this

disease in their life time. Although occurring at the lower end, takes every patient head on if it goes it’s path. Major morbidity is bleeding that causes anemia, sometimes severe. A wide range of factors are known to predispose humans to the disease such as heredity, climate, age, sex, pregnancy, obesity, chronic use of enemas or suppositories. It is known that spices, irregular dietary habits,

alcoholic drink, smoking or a diet that promotes small quantity of hard stools all aggravate the problem. A fibre rich diet and plenty of water intake allows good action of defaecation and reduces the risk of hemorrhoids. Sometimes they prolapse out completely and the patients land into great agony, such a condition can be crippling for the patients. There are many different schools of thought for etiology, pathogenesis and treatment of hemorrhoids. Many different modes of treatment are available namely hemorrhoidectomy, sclerotherapy, band ligation, Infra red coagulation, Radiofrequency Surgery and very lately Doppler guided hemorrhoidal artery ligation (DGHAL). So far there is no gold standard treatment agreed upon for the treatment of hemorrhoids. In this article I am presenting my study of DGHAL results in about 300 cases.

The superior rectal artery gives out six branches at the level of lower rectum that is supposed to be ligated successfully for excellent results.

The results are spectacular as proved by the world-wide studies.

 

 

 

                      ANATOMY

 

 

MATERIALS AND METHODS:

 

Two hundred and ninety cases of Internal hemorrhoids had been  selected with ages between 16 to 94 years [mean age 52 years] between May’03 and Nov’03. 18 cases were females and 272 were males. The youngest being male at 16 and oldest, a female at 94. There were five patients of prolapsed hemorrhoids that were reduced at the same sitting and DGHAL done immediately. Twelve patients had Diabetes Mellitus and were under good control as checked by the sugar test immediately before the procedure. One patient had a CABG done about 4 months back and one young male had valvular replacement in childhood.

                          

PROCEDURE:

 

All the patients were prepared with Sodium Phosphate Enema, and premedicated with Inj. Diclofenac sodium 75mg IM, an IV line was established, Inj. Atropine 0.6mg IV, , Inj. Xylocard 2ml IV to prepare the vein for IV Propofol. During the procedure, for induction IV Propofol was given @ 1.4mg/kg @ 2ml every 5 seconds and maintained @ 4mg/kg/hr infused as bolus every 2 to 3mts, as per the ICU sedation chart dosing (few exceptions for each drug had been observed viz. no atropine for hypertensive on spot etc.). Local anesthesia had been  

 

 

 

 

 

 

 

used as perianal infiltration of 2% xylocaine. Good amount of Xylocaine 2% jelly is used for local lubrication and passage is checked by two finger dilatation. DGHAL Proctoscope is gently introduced as the patient is relaxing and the six hemorrhoidal arteries to be ligated are precisely identified and locations landmarked. The Doppler equipment gives a very clearly audible sound when it is directly over the artery. The needle under runs the artery, the suture is knotted outside the  HYPOTHESIS                    proctoscope and it is pushed in using   the knot pusher and placed properly.Each artery is then ligated separately using Vicryl 2/0 mounted on a strongly curved  needle(costing @ Rs.800/-, required 3-4 foils in each case) or otherwise simple linen No.100 mounted on a strongly  curved

                    

One hemorrhoidal artery under ligation process

 cutting needle (to cut down the costs for the poor patients).The Doppler sound disappears totally as the artery is ligated and that confirms a successful ligation. Total 45 cases were done using the imported Vicryl and the rest 245 cases were done using simple linen. Figure of 8 ligation was done in a total of 65 cases of which 45 were from the vicryl group and 20 of the linen thread group, rest had simple ligature. A revision check after completion of the procedure is done to be very sure about the ligation of the arteries. The total time duration taken in each case for first 50 patients was ranging from 90 to 135 minutes. Time taken in each case for last 50 patients was 12 to 25 mts. They were told to take rest in the observation wards for another one or two hours and then discharged if comfortable. If compained of pain injectable Tramadol 100mg IM was given, that was the sole analgesic requirement in the hospital. For first 150 cases the requirement for the analgesic was pretty higher even after discharge, whereas for next 140 cases it had been very low the credit goes to the time duration taken for the procedure. Few patients needed a routine analgesic for first fifteen days such as Nimesulide 200 mg BD for seven days, later Valdecoxib 20 mg BD for another seven to ten days. Ciprofloxacin 250 mg BD and Tinidazole 300 mg as prophyactic doses for ten days, some stool softener for one month and prophylactic doses of proton pump inhibitor. All the patients are called upon for re-check Doppler examination and it was a great regret to observe 1 to 3 failed ligations in first 100 cases later this disappointment had tapered to nil for most [96%] of the cases. Failed ligations had been redone without much of discomfort for the patient without any premedication and anesthesia. At higher centers the same checking is done using Ultrasound Doppler with screen monitoring. 

COMPLICATIONS:

 S.No.   Feature            1 –100cases[%]        101-300cases[%]

1           Pain                       35 [35%]                     12 [6%]

2           Bleeding                5 [5%]                         4 [2%]

3           Infection                2 [2%]                          1 [0.5%]

4           Anal incontinence  NIL                               NIL

5           Granulation           1 [1%]                           NIL

6           Fissure in ano       2 [2%]                           NIL

7           Fistula in ano        NIL                                NIL

8           Perianal cellulitis   NIL                                NIL

9           Perianal abscess  NIL                               NIL

10         R-V Fistula            NIL                               NIL

11         Prostatitis              NIL                               NIL

12         Urinary fistula        NIL                               NIL

         

RESULTS: The bleeding stops within 48 hours and the masses start receding in 7 to 10 days and the best effect can be assessed in 4 to 6 weeks time. Having 6 patients lost the results in rest 294 patients is being discussed.

ADVANTAGES: 

This is a very simple and easy technique for cure of hemorrhoids and doesn’t take a long time, early return to work is the clear and big advantage. Very little medication and least anesthesia is required which doesn’t hold the patient for long. It prevents the prolapse by anchoring the mucosa to the muscularis. This method has a very special advantage for bleeding hemorrhoids. It is suitable for outpatient surgery for any grading of the disease. Since the total blood supply is obstructed hence the masses shrink very fast and the bleeding stops within 48 hours. This procedure doesn’t cause any type of swelling or wound externally.

 CONCLUSIONS:

I believe that it is quite evident that this is a very safe, quick, convenient, economic modality of treatment. This is very promising and should replace the conservative methods very fast. The only problem it has is a very long learning curve of about 100 to 200 cases.   

HOW IT WORKS

 Now it is well known that the hemorrhoidal masses contain a good quantity of arterioles that have aneurismal tortuosity and they are very friable get abraded very easily and responsible for bright red bleed from the piles. Ligation of all the terminal branches of superior rectal artery totally blocks the arterial supply causes immediate shrinkage of the masses and fibrosis as the late results. Since all the blood supply to the masses is blocked there are very low chances of recurrence, in a followup of 4 to 5 years worldwide the success rates are up to 98%.