title: Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient?
abstract: BACKGROUND
  Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation.
  
  
  METHODS
  During a 53-month period (February 2009-July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery.
  
  
  RESULTS
  During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455-3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study's 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049).
  
  
  CONCLUSIONS
  These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.
authors.affiliation: Florida Hospital, Winter Park, FL, USA. atallah@post.harvard.edu.
authors.forename: S
authors.initials: S
authors.lastname: Atallah
authors.affiliation: Florida Hospital, Winter Park, FL, USA.
authors.forename: G K
authors.initials: GK
authors.lastname: Maharaja
authors.affiliation: Florida Hospital, Winter Park, FL, USA.
authors.forename: B
authors.initials: B
authors.lastname: Martin-Perez
authors.affiliation: Florida Hospital, Winter Park, FL, USA.
authors.forename: J P
authors.initials: JP
authors.lastname: Burke
authors.affiliation: Florida Hospital, Winter Park, FL, USA.
authors.forename: M R
authors.initials: MR
authors.lastname: Albert
authors.affiliation: Florida Hospital, Winter Park, FL, USA.
authors.forename: S W
authors.initials: SW
authors.lastname: Larach
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D016063:Blood Loss, Surgical; D005260:Female; D061865:Hemorrhoidectomy / Q000009:adverse effects / Q000379:methods*; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D019106:Postoperative Hemorrhage / Q000209:etiology*; D012008:Recurrence; D012189:Retrospective Studies; D000067368:Transanal Endoscopic Surgery / Q000009:adverse effects
chemical_list: D000925:Anticoagulants
keywords: Anticoagulation; Hemorrhoids; Postoperative hemorrhage; THD; Transanal hemorrhoidal dearterialization