title: Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy.
abstract: OBJECTIVE
  The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures.
  
  
  METHODS
  The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%).
  
  
  RESULTS
  More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied.
  
  
  CONCLUSIONS
  DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.
authors.affiliation: First Department of Propaedeutic Surgery, Athens Medical School, Hippocration General Hospital, Athens, Greece. georgetheocrs@hotmail.com
authors.forename: G E
authors.initials: GE
authors.lastname: Theodoropoulos
authors.forename: N
authors.initials: N
authors.lastname: Sevrisarianos
authors.forename: J
authors.initials: J
authors.lastname: Papaconstantinou
authors.forename: S G
authors.initials: SG
authors.lastname: Panoussopoulos
authors.forename: D
authors.initials: D
authors.lastname: Dardamanis
authors.forename: P
authors.initials: P
authors.lastname: Stamopoulos
authors.forename: K
authors.initials: K
authors.lastname: Bramis
authors.forename: J
authors.initials: J
authors.lastname: Spiliotis
authors.forename: A
authors.initials: A
authors.lastname: Datsis
authors.forename: E
authors.initials: E
authors.lastname: Leandros
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000098:blood supply* / Q000601:surgery*; D001158:Arteries / Q000601:surgery; D005260:Female; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011446:Prospective Studies; D013536:Suture Techniques; D018615:Ultrasonography, Doppler, Color; D018084:Ultrasonography, Interventional