Objective: the aim of this study is to clinically test the efficacy of a new approach for patients having symptomatic grade III and IV hemorrhoids. Material and method: 32 patients (17 females) complaining of grade III or IV hemorrhoids were included in the study. A specially designed proctoscope coupled with a Doppler transducer on its tip was used to identify the hemorrhoidal arteries, which were afterwards suture ligated. Operating time as well as per-and postoperative complications were anlyzed. Follow-up was planned following discharge after 1 week, 1 month, 6 months and 1 year. Results: mean operation time was 27 (range 18-43) minutes, and 5 (range 4-7) arteries were located on average. No patient had severe or moderate postoperative pain, with anal discomfort being the main complaint. Rectal bleeding and tenesmus were the commonest post-operative complications. After one year of follow-up, 19 patients were free of symptoms and 6 of them had significant symptom relief. According to grade, the technique failed in just 3 grade III patients, but in as many as 4 grade IV hemorrhoid cases. Conclusions: doppler-guided hemorrhoid artery ligation is an easy-to-perform technique that is well accepted by patients and has good results for grade III hemorrhoids.

The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

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The only patient-related factor that significantly influences the incidence of incisional hernia in morbidly obese patients is body mass index.