NEW ORLEANS — Transanal hemorrhoidal dearterialization gets patients back to their normal activities faster than does the procedure for prolapse and hemorrhoids, and appears to be associated with fewer serious complications, Dr. Piero Nastro reported at the annual clinical congress of the American College of Surgeons.
And although dearterialization is slightly more expensive than stapled hemorrhoidopexy (SH)—about $150—the fact that most patients return to work within 4 days may actually make the procedure cheaper overall, said Dr. Nastro of Whipp's Cross University Hospital, London.
Transanal hemorrhoidal dearterialization (THD) is performed with a dedicated proctoscope outfitted with a Doppler transducer. Under ultrasound guidance, the surgeon identifies the terminal branch of the hemorrhoidal artery, and inserts two stitches to close off the blood supply. A ligation of the rectal mucosa then lifts the hemorrhoid up inside the anal canal.
The technique was introduced in Japan about 10 years ago, Dr. Nastro said. “Case studies suggest that it is safe, associated with minimal postoperative pain, easy to learn, and quick to perform.”
However, data comparing THD to other techniques are limited. Dr. Nastro's nonrandomized prospective trial compared THD with SH in 52 patients (average age 50 years) with second- and third-degree hemorrhoids. The investigators did not have approval for randomization, so they explained both procedures in detail and let the patients choose. THD was performed on 28 patients, while 24 received SH.
Postoperative pain scores were slightly, but not significantly, different between the groups. “Patients in the THD group reported slightly less immediate postoperative pain, while those in the SH group reported slightly less actual postoperative pain versus expected pain,” Dr. Nastro explained.
There were three minor complications in the THD group: one submucosal hematoma and two technical problems during surgery, which required no additional treatment. In the SH group, five complications occurred: two cases of fecal urgency; one rectal stenosis that required surgery; and two postoperative bleeds that required readmission, but were successfully addressed in one visit.
Symptoms resolved in almost all patients (25 of 28 in the THD group, and 21 of 24 in the SH group). At a mean follow-up of 4 months, there was no significant difference in recurrence.
Almost all of the THD patients (25) returned to work 4 days after their surgery, while only 50% (12) of the SH patients were able to do so. This significant difference probably makes THD more cost effective, Dr. Nastro said, because patients are not losing as much productive time to recovery.
In discussing the paper, Dr. Bradford Sklow said that THD may prove a viable alternative for SH. Stapled hemorrhoidopexy “is not the magic bullet we once thought it was,” said Dr. Sklow of Salt Lake City. “It has a learning curve, and because of the potential serious complications—including pelvic sepsis, rectovaginal fistula, and even death—physicians need special credentialing to perform it.”
THD looks to be easier to learn, he said, and, from the limited data available now, seems to be associated with fewer serious complications than SH.
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