From June 2004 to April 2005 we have induced simple hemorrhoidal vascular ligation (HVL), in 98 consecutive 77 male and 21 female patients with symptomatic hemorrhoidal disease who have attendet with prolapsing,bleeding,itching or aching anal swellings. We have ligated the arterial and venous vasculature of the symptomatic Grade 2, 3 and some Grade 4 hemorrhoidal piles, together, at once, without isolating the arterial branches and without the aid of a Doppler flowmeter. The unswollen or innocent piles were have been left untouched. Frequently we have ligated 4 or 3 but never more then 5 piles or less than 2 swollen piles and we have resected the heavy Grade 4 and thrombosed piles if presenet. HVL was successfull to treat bleeding in %98 of cases;prolapsing in %97 of cases; pain in %95 of cases and wet anus or pruritus ani in %94 of cases.

Only 2 cases of late bleeding, 2 cases of anal fissure. Only 2 hemorrhoidal recurrency has been seen in 10 month follow up.Simple hemorrhoidal vascular ligation(HVL) also seems to be a very promising technique for treating the symptomatic hemorhoids,as like as hemorrhoidal arterial ligation(HAL) and Longo technique.

INTRODUCTION

Since Morinaga first had introduced transanal hemorrhoidal arterial ligation(HAL) or dearterialization of the symptomatic hemorrhoids by 1995 soon, several very similar studies have been reported that confirming the new method(1,2,3,4,5,6)(Norman Sohn,Bursics A,Shelygin IuA,Arnold S,Muller-Lobeck H).It seems to be a promising innovative ,and also encouraging alternative method by the time,as all the others were in the past.

In that, it is announced that a Doppler flowmeter was essential in isolating and ligating at least 6 arterial branches of the diseased and also innocent hemorrhoidal piles, with the claim of shrinking the presenting prolapsed cushions and also obviating the probable hemorrhoidal recurrencies in other sites(1,2).

A claim from a few author was that; don’t to ligate the corresponding venous vasculature,as it might be hazardous(1,2);however it is almost impossible to isolate the corresponding veins ,even with the aid of Doppler.While in the hemorrhoidopexy technique of Longo(7),the hemorrhoidal veins are ligated together with the accompanied arteries, with no hazardous.However we have observed only 2 cases of anal thrombosis,which we have atributed them to our of technical error.

While we still believe that the hemorrhoidal disease is an arteriovenous sacculation of the internal hemorrhoidal cushions due to long straining, it means more than %25 of the sitting time(Corman) or long sitting for any reason, like for constipation in spastic colon or habitual newspaper reading on the toilet where the venous tension and the venous engorgment increases due to regurgitation, inevitabely. We don’t believe that the anorectal areterial tension increases in squating or in any other position,but the venous tension might have increased by straining in the squating position with a mecanism of regurgitation. If it had been an exact parameter of an arterial condition;than more and more of the population had to experienced the hemorrhoidal disease.

So, we stil say that it is very reasonable to obliterate the venous vasculature, also not the arterial structure, alone, as we all do in sclerotherapy and infrared coagulation.

Therefore we have modified the technique, to be a more simple one and which will not necessisate an expensive device like a Doppler flowmeter; for it may not be available in many conditions.

PATIENTS AND METHOD

In this study,98 consecutive adult patients with symptomatic hemorrhoidal disesase,have been treated by hemorrhoidal vascular ligation(HVL),between the ages of 21-68 years ;whose complaints were bleeding in 90%, prolapsing in 85%, pain in 18% and wet-anus or pruritus ani in %9;or the combination 2 or 3 of them (Table 1).

Table 1:HEMORRHOIDAL SYMPTOMS AND FINDINGS IN CASES SELECTED FOR HVL

To confirm the symptomatic pile we have induced anoscopy in every case. A cleansing enema was applied in dirty cases ;so the symptomatic piles became more evident and ready to treat.

The cases indicated for HVL; an intravenous 0,9%NaCl solution with drip infusion was started in Sims position ; then 0,1 mg /Kg Dormicum(Midazolam) was induced for an half hour conscious sedation.In any painful sensetion ,intravenous Ketamin 1-2 mg/Kg and local aenestesia was given right through the site of ligation just before tightening the knots.

No serious,morbity was seen due to Midazolam ;but nausea and vomiting due to Ketamin in several cases.

All of the Grade 1, 2,3 ;and even the some of the medium size Grade 4 piles ,have been ligated ,but the thrombosed or seriously prolapsed or large Grade 4 piles have been resected in the way of Fergusson technique,in the same session.

We have induced 8 suture technique by 2 or 3/0 Vicryl ,which have inserted the 1’rst needle step 3-4 cm proximally of the dentate line,and the second step, 1 cm more proximally ,with the aim of to retract each corresponding pile into the anal canal. In 20 cases with large protruding or mixed piles,we have inserted 2 or 3 more steps distally or proximally,to have a sufficient retraction or hemorrhoidopexy.

We have also started to treat the predisposing factors of hemorrhoidal disease,like to left habitual long sitting and long straining on the toilet,abondoning tea,coffe,cola taking,1 week before the planned HVL,if possible.We have advised to take flaxseed (Linum usitatissimum) , with the bulking diet,permanently.

RESULTS

Most of the patients were male with spastic colon history.Whole of them used to strain or wait more than 10 minutes on the toilets some times more then 30 minutes. Most of the patients had no regular defecating time, nor satisfying defecation and gass passing.

Most of the patients had at least 3 traditional hemorrhoidal piles which we have ligated all in such cases but in many times we have ligated 4 or 5 piles.

More then half of the syptomatic hemorrhoids were in mixed type that means combinating type of internal and external hemorrhoid.

All the prolapsing internal ,mixed and external hemorrhoidal piles, have been retracted into the anal canal,just at the the end of the opration but two, which one of tem was resected on second week for the continuing of preoperative pruritus ani.

Two patients had experienced hemorrhoidectomy,2 patients had infrared coagulation and 3 patients had rubber band ligation, 4 cases had painfull anal fissure before all of which have got well after operation.

In the first few weeks of the study we have met ,peroperativ pain in 8 cases ,inspite of intravenous Midazolam and local aenesthesia. So in the subsequent cases we have added Ketamin injections when needed.

Two cases have experienced anal fissure after HVL due to the operative manuplation ,one of which needed lateral anal sphincterotomy for subsiding of postoperative anal pain at end of second week.

All the patients could have gone home after the sedation had weared off within 45-60 minutes. Three of our cases have cotinued to bleed until the 1rst,2nd and 3rd days,respectively which they have subsided spontaneosly but no heamatocrit reduction have been encountered.While 1 patient bleeded on the 8th day,which had lovered the heamatocrit from 34% to 28%.

In 2 cases anal trombosis had been obserwed one of wich needed trombectomy, with no event.

Approximately half of the oversewn cases had complained of anal pain for 1-5 days which had been controled by several Diklofenak injections, have been satisfied by the resection of the prolapsing single pile, inspite of HVL.

We have met no hazardous event due to the combined ligation of arterio-venous hemorrhoidal vasculature.While ,even in the Doppler guided operations,it is very reasonable that some of the venous vasculature have to be ligated together with the arteries because,anatomically the superior ,middle,and inferior hemorrhoidal veins,which drain blood from the tissues of the canal,correspond to each of the hemorrhoidal arteries(7)(28,106,199,CORMAN,p178) .As we see in Longo technique ,all the corresponding veins are ligated together with the arteries;but no hazardous is seen(8)(Longo).So the claim to isolat the arteries through the Moricon slit is very suspicious ,because every one knows well that all the peripheric arteries and veins run together. Also we don't find essential to ligate the innocent hemorrhoidal vasculature for prevention of new hemorrhoid formation while we find essential to prevent the chronical constipation by a dietary program.

Table 2:OUTCOMES AFTER HEMORRHOIDAL VASCULAR LIGATION IN THE 1st MONTH

-Almost all patinets have found the treatment satisfying ,but only 2;who have been sutisfied after the resection of the prolapsing piles.

COMMENTS

Bleeding and prolapsing were almost the standart or the most common complains in this study.The bleeding hemorrhoids were almost all internal or mixed type,while the external types were seen not to bleed frequently,but in occasion ;and the main complaint about of them was obstructing sense.

The troublesome finding was the painful, thrombosed ,tender piles in 12 cases,and Grade 4 piles in 8 cases;which have given some pain after resection,comparing to the HVL;whic all of them have been resected in style of Fergusson.

The oversewing or shrinking the mixed huge prolapsing Grade 3 or some mild Grade 4 hemorrhoids ,may be disputed for inducing the postoperative pain due to the aproximating sutures very near to the dentate line, but,as a gratitude, it was less then resected cases;and has controlled the prolapsing or outside swellings, wet anus and also the pruritus ani ,more then expected;almost as well as the resection. However ,the patients seemed not to bother it so much ,because the shriking of the swellings ,subsiding of bleeding or wet anus ,surely was more important then a temporary pain, for them.

The simple HVL or hemorrhoidopexy seems to be very effective in controling the hemorrhoidal bleeding and prolapsing,and so the aching and itching,even if in he huge mixed hemorrhoids so that it may applied in mild Grade 4 hemorrhoids also as Arnold(..) and Shelygin(...),have applied to all of the grades, already. As we have observed in our huge and in a few Grade 4 hemorrhoids now we are more hopefull that also many of Grade 4 hemorrhoids can be ligated successfuly, if the resembling radices should have been ligated by two different 8 sutures instead of one 8 suture..The retracting and fixating function of the 8 sutures have worked more then we had expected;almost as well as the Longo technique;in which the Longo technique,the retracting function of the piles is managed by resection of a 1,5-2 cm rectal mucousal ring just at the level of level of our 8 sutures;remember that both of the techniques are a kind of hemorrhoidopexy.

Only 3 patients had continued to have minute bloody stool postperatively ,which have subsided on the 2nd and 3rd days,speontaneosuly. They were mixed,huge prolapsing hemorrhoids and it has could not be proved if the bleeding was to be a continuing type or a suture complication.

The late bleeding on the 8th day was due to eroding or cutting of a shrinking Vicryl suture the anal mucosa near at the dentate line, who had a bleeding mixed huge hemorrhiod.It might also be due to long tiring working on the 8 th postoperative day. He was a floor maker have been working in squating position for 22 years,and also he was a chronical constipate which has continued until the late bleeding day. He had bleeded for several years and his heamatocrit was 30% in 1rst attending time so his operation had been postponed for 2 weeks to restoring the bloog loss. .He had already addaptated to the aenemia due to the slow and chronical bleeding for several years;and he had not needed transfusion before, nor in the operative and neither in the late postoperative bleeding time; however he had suffered of an acute sencope with palor and the lovered blood tension, as 90/50 mmHg,and the pulse rate was 104/min by the end of the late postoperative bleeding,which was not a vascular oozing and has easily subsided by the electrocautery at emergency,under local aenestesia. It can be said that ,as a caution,it may prefered to resect the suspicious bleeding mixed piles or may be better to prolong the hom stay.

Anal pain was seen in the prolonged prolapsing piles,and particularly in the thrombosed of some piles all which have been resected so it have returned to operative pain and could have subsided by injectional anelgesics in postoprative days.

Almost all of the constipated hemorrhoidal patients were emotionaly sensible, very bussy ,or very hard workers,or had some family problems ;many of them were suffering of psychosomatic disorders like gastritis,peptic ulcer, sleeping problems etc. So we can say that many of them have irritable or spastic colon leading to constipation,then to sympmtomatic hemorrhoids.However we have not confirmed the spastic colon disease by barium enema,but almost all the patients had mild or moderate abdominal colics and swere gaseous distension ,sheep like interrupted stool,oversecreation of viscous mucus in the rectal lumen at the first ispection,before cleansing enema in many cases as almost a routine symptom or finding in such cases.

We have prefered to resect the huge and severly symptomatic prolapsed mixed external type piles if the patients have agreed with us ,but we have never offered HVL to them for the reason that they must be accepted as Grade 4 hemorrhoids as Sohn and collagues say they must be resected(Norman Sohn).

Peroperative and also postoperative pain was our sole troublesome problem in the beginning of the study,probaly due to manuplations and heavy 2/0 Vicryl sutures which we have solved the former one by Ketalar ifusion ,or by extra local injection of oue aenestezic coctail;and the later one by Diklofenak İM injections when needed.

The cases with hemorrhoidopexy needed more anelgesics and some more home stay ,and also sitz baths to control pain.However one of them bleeded sverly on the 8th postoperative day,but he did not need transfusion.

However we had hasitated during ligating the some huge and mixed grade 3 piles,

The 8 month results of HVL in this study are encourraging,but the long term results must be considered, which we are hopefull taht they also will do well, particularly in the cases who will obey to the diatery program.We believe that the hemorrhoidal reccurrencies likely have to be seen if the therapy or the dietary program is interrupted;because spastic colon is a relapsing disease ,particularly when the patient don’t take care of his/her psychological and dietary demands.For the last one year we have added flaxseed (Linum usitatissimum) to diet to of all constiapated patients. We have found the flaxseed as an important participant in solving the spastic colon type constipation ,and also some psychosomatic disorders, like gastritis,colonic distention and colics ,some ; sleeping disorders.

We still find essential to limit tea, cola, coffe, cold and gasseous drinks and refined food intake which is a matter of education.

Almost all of the cases have been psycologically very sensible individuals or hard workers,or living with in stressing conditions for several years and so spastic colon disease has been found to be the leading factor of the constipation proceeding the hemorrhoidal disease. Almost all the cases were have been defecating step by step or as in too many divided portions permanently,for what ever long time they have been straining or siting on the toilet.

In the begining of the study, some difficulties like lacking of a slit on the standard anascopes;adaptation time to a flute like ansocope or Hill –Ferguson retractor,to recognize the swollen or symptomatic piles,and some less comfortability comparing to the Morinaga device.However it is very possible to be trained after several applications,particularly with the aid of Dormicum and Ketamin aided local enesthezia;even with no local aenesthezia in some cases.

HVL is an office procedure like HAL and as efficient as it but may not be as comfortable as it becuse of lacking a Doppler flowmeter.

REFERENCES

1. Morinaga K,Hasuda K,Ikeda T.A novel therapy for internal hemorrhoids:ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjuction with a Dopple flowmeter.Am J Gastroenterology 1995;90:610-3.

2. Sohn N,Aronoff J S,Cohen F S,Weinstein M A.Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy.Am J Surgery 2001;182:515-519.

3. Bursics A,Morvay K,Kupcsulik P,Flautner L.Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid aretery ligation:a randomized study.Int J Colorectal Dis 2003 July 5(Epub ahead of print).

4. Shelygin IuA,Titov Aıu,Veselov VV,Kanametov MKh.Results of ligature of distal branches of the upper rectal artery in chronic hemorrhoid with assistance of Doppler ultrasonography.Khirurgiia(Mosk) 2003;1:39-44.

5. Arnold S,Antonietti E,Rollinger G,Scheyer M.Doppler Doppler ultrasound assisted hemorrhoid artery ligation.A new therapy in symptomatic hemorrhoids.Chirurg 2002 Mar;73:269-73.

6.Muller-Lobeck H.Ambulatory hemorrhoid therapy.Chirurg 2001 Jun;72(6):667-76