Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy

Objective The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures. Method The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%). Results More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR ( 18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-) cutaneous excision (MMCE) was added in 23 patients. SHP / RAR was applied more frequently in grade IV HR (60% vs 16%, P < 0.001). In patients not having MMCE, SHP / RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and > 7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP / RAR was associated with greater discomfort (17% vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied. Conclusions DGHAL with the selective application of SHP / RAR is a safe and effective technique for advanced grade HR.