Artery ligation in the treatment of hemorrhoidal disease

Abstract

The aim of this thesis was to study the working principle in relation to the outcome of the artery ligation procedure; a treatment for hemorrhoidal disease.

Hemorrhoidal artery ligation, known as HAL (hemorrhoidal artery ligation) or THD (transanal hemorrhoidal dearterialization) procedure, is a common treatment modality for hemorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligated. It has been suggested that the use of the Doppler transducer does not contribute to the beneficial effect of these ligation procedures.

We first aimed to evaluate the artery ligation procedure from a patient perspective. In a retrospective study the clinical status of patients, who had undergone HAL for the treatment of grade II and III hemorrhoidal disease, was investigated.

Second we elucidated the vascular anatomy of the anal canal in the distal rectum and its role in the artery ligation procedure by means of an anatomical study.

Finally the contributory value of the Doppler transducer in the artery ligation procedure was assessed. A randomized controlled trial (HEMARTY) was initiated for the determination of the added value of the use of Doppler during HAL. In this study patients suffering from hemorrhoidal disease grade II and III were either treated by means of the conventional HAL with or without the use of Doppler. Further the vascular anatomy of the corpus cavernosum recti in patients suffering from hemorrhoidal disease was investigated in the preoperative and postoperative situation.

In conclusion may HAL be regarded as an attractive, easy to learn and perform procedure for the treatment of hemorrhoidal disease. Studies by us and others show that patients may benefit from the procedure, although most patients develop some degree of recurrence of complaints in the long term.

The studies in this thesis reveal that in HAL, the contributory value of the Doppler transducer is highly overrated, to the extent that, in our opinion, it can safely be omitted. The existing literature reveals only limited attempts to define the role of HAL between all other available treatment entities. We therefore strongly support the execution of a broad and multicenter randomized trial on the effectivity of HAL in relation to other standard procedures, particularly rubber band ligation.