Doppler-guided hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) for the treatment of grade IV hemorrhoids: long-term results in 100 consecutive patients.

Background: Doppler-guided hemorrhoidal artery ligation is a minimally invasive technique for the treatment of symptomatic hemorrhoids that has been applied successfully for grade II and III hemorrhoids but is less effective for grade IV hemorrhoids. Development of a special proctoscope enabled the combination of hemorrhoidal artery ligation with transanal rectoanal repair (mucopexy), which serves to lift and then secure the protruding hemorrhoids in place.

Objective: The purpose of this study was to describe our experience with this combined procedure in the treatment of grade IV hemorrhoids.

Design: Prospective observational study.

Setting: Outpatient colorectal surgery unit.

Patients: Consecutive patients with grade IV hemorrhoids treated from April 2006 to December 2008.

Intervention: Hemorrhoidal artery ligation-rectoanal repair.

Main Outcome Measures: Operating time, number of ligations, number of mucopexies and associated procedures, and postoperative symptoms were recorded. Pain was graded on a visual analog scale. Follow-up was at 2, 6, and 12 months after surgery, and then annually.

Results: A total of 100 consecutive patients (64 women, 36 men) with grade IV hemorrhoids were included. Preoperative symptoms were bleeding in 80 and pain in 71 patients; 19 patients had undergone previous surgical treatment for the disease. The mean operative time was 35 (range, 17-60) minutes, with a mean of 9 (range, 4-14) ligations placed per patient. Eighty-four patients were discharged on the day of the operation. Nine patients developed early postoperative complications: pain in 6, bleeding in 4, dyschezia in 1, and thrombosis of residual hemorrhoids in 3. Late complications occurred in 4 patients and were managed conservatively. Recurrence was observed in 9 patients (9%), with a mean follow-up of 34 (range, 14-42) months.

Limitations: The 2 main weaknesses of the study were the lack of very long-term follow-up and the absence of a comparison with hemorrhoidectomy or hemorrhoidopexy.

Conclusion: Doppler-guided hemorrhoidal artery ligation with rectoanal repair is safe, easy to perform, and should be considered as an effective option for the treatment of grade IV hemorrhoids.