Hemorrhoidal Artery Ligation (H.A.L.

) using Ultrasound Blood Flow Detector HAL-Doppler: an innovation in proctology

N. GALLESE
Department of General Surgery , UCP Coloproctology Unit , San Gavino Monreale Hospital (CA) - Italy

Dr. N. Gallese,

Via Martin Luther King s.n.

09037 San Gavino,

Italy

Tel.: 0709378247

Fax: 0709375273

e-mail: nan.doc@tiscalinet.it

Original article

Abstract

Background: This study was not carried out for statistical purposes, but only as an experiment to attempt to determine the effectiveness of the H.A.L. method. Methods: Artery legation of terminal hemorrhoidal branches is an essential element in controlling bleeding, in all types of hemorrhoid treatment. H.A.L. using HAL-Doppler make easy and effective this technique. Personal experience is widest in Italy, with beyond 150 cases. Results: When properly used, HAL is highly effective, with >98 % positive responses, even if further experimentation and verification are necessary. Conclusion: the H.A.L. tecnique involves simple artery ligations, on the level of rectal mucosa, without excisions or tissue necrosis; the method is painless and can be done on an out-patient basis with immediate return to work.

Presented in part at the meeting of SICADS (Italian Society of Day Surgery), Chieti (Italy), October 2000

Introduction The importance of arterial hyperafflux or the discrepancy between arterial afflux and venous discharge, hindered by kinking or sphincter compression, is a well-known component in determining the bleeding typical of hemorrhoids. Longo definid this concept in detail only a few years ago, making one of the fundamental assumptions on which his tecnique is based. Moreover, all relative techniques (photocoagulation, cryo- or sclero-therapy, rubber band, resectioning operations like Salmon, Ferguson, Milligan-Morgan, Parks, etc.), in some way involve, usually unintentional and often without the inventors themselves being aware of it, a sectioning, ligation or sclerosis of the upper hemorrhoidal artery: those branches, that is, responsible for flow in the rich vascular network of the submucosa, covering hemorrhoidal swelling and accounting for the characteristic arterial bleeding in a malady like that of hemorrhoids, wich, only apparently, seems to particulary regard venous structures. In fact, internal hemorrhoidal plexuses have a cavernous structure and circulatory disorders in that sector soon affect the capillary system of submucous plexuses; the latter are rich in arterio-venous shunts and are provided with remarkable vaso-motorial capacity carried out by the pre- and post-capillary sphincters, in response to thermal, chemical (ex: alcohol) or mechanical (fecal traumatism, etc.) stimuli of vasodilation. For these reasons, acute crises arise suddenly, accompanied by evident edema, pain, abundant bleeding and thrombotic phenomena. Artery ligation of terminal hemorrhoidal branches thus appear to be an essential element in controlling bleeding in all types of hemorrhoid treatment. Circulatory disorders of submucous plexuses are often stricly correlated with the severity of mucohemorrhoidal prolapse, but cases of bleeding are often observed in absence of evident prolapse. In such cases therapeutic options vary widely, from simple hygienic-dietetic or farmacological measures, to out-patient treatment or even hemorrhoidectomy. In Italy the H.A.L. technique (Hemorrhoidal Artery Ligation) is completely new, although it is already being used in Asiatic Countries, Canada, USA and in Northern Europe (Austria and Germany): it is carried out using an instrument called HAL-Doppler, from the name of its inventor, Prof. Morinaga (Saga, Japan).

Patients and methods The HAL-Doppler consist of an anoscope with a self-illuminated tip, closing its distal end, equipped with a lateral window placed near a Doppler flowmeter, connected to a central amplifying unity, which permits acoustic evalutation of flow in hamorrhoidal arteries. Patients are administered microenemas and, except in special cases, do not require hospitalization, test or anaesthesia: those parts of the procedure causing bleeding are carried out a few centimetres above the pectinate line, thus being relatively painless. An accurate anamnestic study, payng particular attention to alterations in coagulation, is obviously indispensable, as well as a preliminary proctological examination using an anoscope and/or rectosigmoidoscopy. The patient may lie on his side, but I personally prefer a lithotomic position. After preliminary proctoscopic exploration and adeguate lubrification, the Moricorn is inserted, delicately rotated and, thanks to the Doppler, it localizes the terminal branches of hemorrhoidal arteries: farther up it is possible to suture the mucosa and submucosa protruding from instrument window: traction on the ends of the wire causes the Doppler signal to disappear, confirming arterial inclusion in the ligation, which at that point may be rendered definitive. The operation is repeated along the whole rectal circumference; the number of ligations required varies according to the number of terminal hemorrhoidal branches (from 2 to 12, with average of 6,2, in the personal experience). Prof. Kazumasa Morinaga is presently using sclerosing injections as an alternative to suturing.

Results From October 2000 to June 2002 we performed HAL in bejond 150 patients; 100 consecutive cases were considerated for this study: 72 with II, 24 with III, 4 with IV degree; age range 24-76 years, with a mean age of 45; there were 66 males and 34 females (2:1); anesthesia was not required in 64 cases of pure emorrhoidal sindrome; 1 case required general anesthesia and 35 local anesthesia, for associated lesions (anal fissures, etc.); the number of necessary ligations has been from 2 to 12, with average of 6,2 , in the personal experience. Method was immediately effective in 100 % of patients; there were no important operative and postoperative complications; only 1 patients, with abnorme moucous reptal prolapse, required a convertion to prolapsectomy with stapler PPH (Longo technique); 3 months later another patient required Longo technique.

Twelve months after 97 % of the patients it is declared totally satisfied of the method HAL, even if with residual bleeding; 2 % of the patients are declared partially satisfied: all would be ready to repeat one HAL. Only a patient (female), slices from anal pain, declares itself totally not satisfied.

Discussion Presentation of the H.A.L. method does not entail comparison with other methods, but only intends to indicate a new tool, in accordance with previously-established principles, in the field of hemorrhoid treatment. This study was not carried out for statistical purposes, but only as an experiment to attempt to determine the effectiveness of the H.A.L. method. The treatment can be used for hemorrhoids of varying severity, but is specific for those of the II and III degree, symptomatic (bleeding), which do not respond to conservative hygienic-dietetic or pharmacological therapy. The method is less effective in the presence of anal fissures or fistulas, etc.; it may however complement other techniques, preceding or following them. Ineffectivenes does not preclude any other therapy, but the handiness of H.A.L. method encourages its use prior to any other method which is more invasive and potentially more dangerous in terms of complications. Patient approval is extremely high, and the procedure can be repeated several times. Conventional hemorrhoid treatments use a combination of artery ligation and excision of hemorrhoidal tissue or rectal mucosa; alternative, less invasive methods (cryo-, photo-, sclero-therapy) affect, however, more or less extensive portions of hemorrhoidal tissue; the H.A.L. method involves simple artery ligations, on the level of rectal mucosa, without excisions or tissue necrosis. For this reasons, using the HAL-Doppler is painless and can be done on an out-patient basis with immediate return to work; it is thus economical for the patient, the medical establishment and for society as a whole. In addition, when properly used, the method seems highly effective, even if further experimentation and verification are necessary. Interested Collegues are invited to begin using it so that, after preliminary evalutation, an eventual multicentric study can be planned.

References

1.

Morinaga K., Hasuda K., Ikeda Y. A novel therapy for internal hemorrhoids: ligation of the hemorhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler Flowmeter. The American Journal of Gastroenterology 1995; 90:610-613

2.

Longo A. Trattamento della malattia emorroidaria mediante correzione del prolasso mucoso rettale con suturatrice circolare: tecnica originale. Archivio ed Atti 100 Congresso Societ Italiana di Chirurgia 1998; 2:233-246