Transanal Hemorrhoidal Dearterialization: A Systematic Review

Giordano, Pasquale; Overton, John D.; Madeddu, Francesco; Zaman, Sabir; Gravante, Gianpiero

doi:10.1007/dcr.0b013e3181af50f4

Cited by 215 publications

(155 citation statements)

References 26 publications

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“…Estimates of the incidence of pain, at least in the first postoperative day, vary from 15% to 18.5%. 5,19 No indication is given as to the degree of pain, presumably explaining the inconsistency with our results, for which significantly more patients experienced at least a degree of discomfort and only 6% had no pain at all. There are a few RCTs for which VAS scores are utilised in a similar fashion to our trial: collecting VAS scores on various days after the procedure.…”

Section: Paincontrasting

confidence: 92%

“…5 However, it should be noted that the recurrence rate among the constituent studies varied considerably and ranged up to 60%. 64 Similarly, reported recurrence rates for RBL also vary widely in the literature, ranging from 11% to > 50%.…”

Section: Main Findingsmentioning

confidence: 99%

Section: Surgical Complicationsmentioning

confidence: 99%

“…From the literature, bleeding occurs in around 4-5% of patients after a HAL procedure, 5,19 but only 0.15% of these were significant haemorrhages requiring blood transfusion. 5 The incidence of bleeding after RBL is 1-2.8%. 3,77 Significant bleeding requiring admission or intervention is more difficult to analyse, but pooling of the data available suggests an incidence of 0.7%, 3,11,[14][15][16][17][18] Bleeding is more common if patients are taking anti-platelet agents, non-steroidal anti-inflammatory drugs (NSAIDs) or anticoagulants.…”

Section: Surgical Complicationsmentioning

confidence: 99%

“…Recurrence rates are reportedly similar to SH, but complication rates are lower. 5 There are substantial data in the literature concerning the efficacy and safety of RBL, including multiple comparisons with other interventions. [6][7][8][9][10][11][12] Recurrence varies from 11% to > 50%.…”

Section: Introductionmentioning

confidence: 99%

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The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

Brown

Tiernan

Biggs

et al. 2016

Health Technol Assess

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BackgroundOptimal surgical intervention for low-grade haemorrhoids is unknown. Rubber band ligation (RBL) is probably the most common intervention. Haemorrhoidal artery ligation (HAL) is a novel alternative that may be more efficacious.ObjectiveThe comparison of HAL with RBL for the treatment of grade II/III haemorrhoids.DesignA multicentre, parallel-group randomised controlled trial.PerspectiveUK NHS and Personal Social Services.Setting17 NHS Trusts.ParticipantsPatients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL.InterventionsHAL with Doppler probe compared with RBL.OutcomesPrimary outcome – recurrence at 1 year post procedure; secondary outcomes – recurrence at 6 weeks; haemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness.ResultsA total of 370 participants entered the trial. At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [adjusted odds ratio (OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51;p = 0.0005]. The main reason for the difference was the number of extra procedures required to achieve improvement/cure. If a single HAL is compared with multiple RBLs then only 37.5% recurred in the RBL arm (adjusted OR 1.35, 95% CI 0.85 to 2.15;p = 0.20). Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL), suggesting significant deterioration in both groups over the year. Symptom score, EQ-5D-5L and Vaizey score improved in both groups compared with baseline, but there was no difference between interventions. Pain was less severe and of shorter duration in the RBL group; most of the HAL group who had pain had mild to moderate pain, resolving by 3 weeks. Complications were low frequency and not significantly different between groups. It appeared that HAL was not cost-effective compared with RBL. In the base-case analysis, the difference in mean total costs was £1027 higher for HAL. Quality-adjusted life-years (QALYs) were higher for HAL; however, the difference was very small (0.01) resulting in an incremental cost-effectiveness ratio of £104,427 per additional QALY.ConclusionsAt 1 year, although HAL resulted in fewer recurrences, recurrence was similar to repeat RBL. Symptom scores, complications, EQ-5D-5L and continence score were no different, and patients had more pain in the early postoperative period after HAL. HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY.LimitationsBlinding of participants and site staff was not possible.Future workThe incidence of recurrence may continue to increase with time. Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness. The polysymptomatic nature of haemorrhoidal disease requires a validated scoring system, and the data from this trial will allow further assessment of validity of such a system. These data add to the literature regarding treatment of grade II/III haemorrhoids. The results dovetail with results from the eTHoS study [Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A,et al.Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial.Lancet2016, in press.] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy. Combined results will allow expansion of analysis, allowing surgeons to tailor their treatment options to individual patients.Trial registrationCurrent Controlled Trials ISRCTN41394716.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 88. See the NIHR Journals Library website for further project information.

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Section: Paincontrasting

confidence: 92%

Section: Main Findingsmentioning

confidence: 99%

Section: Surgical Complicationsmentioning

confidence: 99%

Section: Surgical Complicationsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

Brown

Tiernan

Biggs

et al. 2016

Health Technol Assess

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Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications

Ratto¹,

Parello²,

Donisi³

et al. 2011

British Journal of Surgery

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BackgroundDearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries.MethodsFifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated.ResultsHaemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001).ConclusionThis study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization.

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Hemorrhoids

Singer¹

2011

The ASCRS Textbook of Colon and Rectal Surgery

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Transanal Hemorrhoidal Dearterialization: A Systematic Review

Abstract: Transanal hemorrhoidal dearterialization appears to be a potential treatment option for second-degree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

Cited by 215 publications

References 26 publications

The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications

Hemorrhoids

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