|Year : 2018 | Volume
| Issue : 1 | Page : 193-198
Ligation anopexy in the treatment of hemorrhoids
Ayman A Omar1, Tarek M Rageh2, Mohamed A Elmanakhly2
1 Department of General and Vascular Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||13-Dec-2016|
|Date of Acceptance||17-Feb-2017|
|Date of Web Publication||14-Jun-2018|
Mohamed A Elmanakhly
Sedi Bishr, Alexandria
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare the preliminary results of traditional transfixion excision versus ligation anopexy in the management of advanced (grades III and IV) hemorrhoidal disease with respect to postoperative pain, bleeding, and short-term follow-up complications.
Ligation anopexy of hemorrhoids is a simple, cost-effective, and convenient modality for treating grade III hemorrhoids.
Patients and methods
We carried out a prospective, controlled, randomized study including 40 patients with hemorrhoidal disease grades III and IV. The participants were divided into two groups: group I was treated by classical transfixion excision hemorrhoidectomy, and group II was treated by ligation anopexy. Detailed history of all participants was obtained. Effectiveness, safety, postoperative complications, operative time, length of hospital stay, and time off work were evaluated.
There was no significant difference between groups regarding age, sex, and preoperative symptoms. The duration of surgery was significantly shorter in patients treated with ligation anopexy (P < 0.001). Intraoperative bleeding was significantly decreased in patients treated with ligation anopexy. The postoperative pain score in the ligation anopexy group was significantly lower than that in group I at 24, 48, 72 h, and the second week postoperatively. Time off work in patients treated with ligation anopexy was significantly shorter compared with transfixion excision hemorrhoidectomy.
Ligation anopexy for prolapsing hemorrhoids is simple and safe with less postoperative bleeding, minimal analgesic requirement, no external wound problems, lower postoperative complications, and earlier return to normal activities.
Keywords: anopexy, hemorrhoids, ligation, transfixion excision hemorrhoidectomy
|How to cite this article:|
Omar AA, Rageh TM, Elmanakhly MA. Ligation anopexy in the treatment of hemorrhoids. Menoufia Med J 2018;31:193-8
| Introduction|| |
Hemorrhoids are one of the most common anorectal disorders and lead to disability and a reduced quality of life . Multicenter randomized clinical trials have demonstrated that the classical method of hemorrhoidectomy is still an effective procedure for resolving hemorrhoidal symptoms but is limited by numerous complications. In addition to excessive postoperative pain, anal incontinence, and stenosis have been reported [2–5]. Therefore, efforts are being made to develop a new, more effective, and less invasive method of treatment for hemorrhoidal disease [3–6].
The complications of stapled hemorrhoidopexy include rectal perforation, retroperitoneal sepsis, anovaginal fistula, and pelvic sepsis, which are likely due to excision of full-thickness rectal wall rather than mucosa and submucosa only .
Less invasive techniques have been suggested – for example, Doppler-guided hemorrhoidal artery ligation is effective in controlling bleeding from third-degree and fourth-degree hemorrhoids and significantly decreases postoperative pain. Although Doppler-guided hemorrhoidal artery ligation has obvious advantages, it requires the use of specialized, expensive equipment ,.
A simpler technique for the reduction of the size of hemorrhoids with control of bleeding and prolapse is ligation anopexy . The rationale of this technique is based on the fact that hemorrhoid prolapse is a result of sliding down of the anal mucosa caused by attenuation of the anchoring elastic tissue system, and fixing this sliding mucosa will restore the cushion to its original position and minimize blood flow to the plexus .
This technique is based on the fact that hemorrhoidal vessels have a constant anatomical location. Usually, they penetrate the hemorrhoid at its base. A stitch at the base of the hemorrhoid cushion is able to diminish the blood flow to the hemorrhoidal plexus significantly. In addition, if complete ligation of all the visible hemorrhoid cushions is performed, along with ligation of the base, it will control the prolapse as well .
The aim of the present study was to compare the preliminary results of traditional transfixion excision versus ligation anopexy in managing advanced (grades III and IV) hemorrhoidal disease with respect to postoperative pain, bleeding, and short-term follow-up complications.
| Patients and Methods|| |
This was a prospective study that included 40 patients with grades III and IV hemorrhoidal disease admitted to the departments of surgery at Menoufia University Hospital and Alexandria Police Hospital. They were randomly divided into two groups – group I included 20 patients who were treated by classical transfixion excision hemorrhoidectomy, and group II included 20 patients who were treated by ligation anopexy. All patients had symptomatic third-degree and fourth-degree hemorrhoidal disease. Exclusion criteria were as follows – patients with grades I and II hemorrhoidal disease, patients with associated anorectal diseases such as fistulas, Crohn's disease, complete rectal prolapse and anal stricture, complicated hemorrhoidal disease (thrombosed, strangulated, etc.), and patients with systemic bleeding tendencies.
Informed written consent was obtained from all participants, and the study was approved by two professors of the Ethics Committee of Menoufia Faculty of Medicine on 15th of February 2015.
All operations were performed with the patient under general or spinal anesthesia, in the supine lithotomy position. Patients were prepared with enema 24 h earlier and with intravenous antibiotic prophylaxis (cefotaxime) before induction of anesthesia.
In group I, the sphincter was gently dilated. The skin-covered component of each of the main piles was seized with an artery forceps and retracted outward. Using another artery forceps, the purple and mucosal components of each pile were grasped and drawn downward and outward. A V-shaped incision in the anal and perianal skin was made with scissors. The venous plexus was dissected from the internal sphincter. Proceeding upwards, the mucosa was divided on either side to the pedicle converging toward its apex. Transfixation of the apex was performed using absorbable sutures. The three hemorrhoidal cushions at 3, 7, and 11 O'clock were resected.
In group II, introduction of Sims' speculum or by Purse string Suture Anoscope (PSA33) was provided with the Procedure for Prolapse and Hemorrhoids (PPH) set by Ethicon Endosurgery (Covidien, Minneapolis, MN, USA), causes reduction of the prolapse to the anoderm and the anal mucosal membrane. After reduction of hemorrhoidal prolapse, a suture was placed to fix the mucosa and the submucosa to the underlying internal sphincter. After the suture was tied, the redundant mucosa was pulled distally to be incorporated into the ligature, and the thread was relegated around it to form a mucosal tag, which varied according to the amount of redundant mucosa. The redundant mucosa had to be pulled distally to form a large mucosal tag as possible to ensure adequate retraction of prolapsed hemorrhoids; the same procedure was performed for each of the other positions as shown in [Figure 1], [Figure 2], [Figure 3].
|Figure 1: A stitch was inserted 2 cm above the dentate line, deep enough to fix the mucosa and submucosa to the underlying internal sphincter.|
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An average of six to eight sutures were used during surgery to eliminate all the final branches of the hemorrhoidal arteries, which are located in the right posterior lateral, right middle lateral, right anterior lateral, left anterior lateral, left middle lateral, and left posterior lateral positions (1, 3, 5, 7, 8, and 11 O'clock).
This minimally invasive ambulatory procedure is developed as an option for patients who are candidates for operative hemorrhoidectomy. The rationale of the technique is based on the fact that hemorrhoidal prolapse is the result of sliding down of the anal mucosa caused by attenuation of the anchoring elastic tissue system, and fixing this sliding mucosa will restore the cushion back to its original position.
All patients were followed-up every day for 3 days and every week for 1 month anticipating the occurrence of postoperative pain using the visual analog scale, amount of analgesic requirements, reactionary hemorrhage, or urine retention. Further follow-up every 1 month for 3 months was performed to detect any postoperative complications such as strictures, stenosis, fecal incontinence, secondary hemorrhage, or recurrence of any relapsing symptoms. The groups were compared regarding effectiveness, safety, complications after procedures, operative time, length of hospital stay, time until return to work, and postoperative pain score.
Data were fed to a computer, and analyzed using IBM SPSS software package (version 20.0; IBM Corp., Armonk, New York, USA). All statistical analyses were performed using the statistical package for the social sciences. The χ2-test, Student's t-test, and Fisher's exact test were used for comparing demographic data, preoperative presenting symptoms, grade and onset of symptoms, operative data, complications, and time off work, and the Mann–Whitney U-test was used for comparing postoperative pain score and hospital stay.
| Results|| |
This prospective study included forty patients with advanced uncomplicated hemorrhoidal disease of grades III and IV who were admitted to the departments of surgery of Menoufia University Hospital and Alexandria Police Hospital from December 2014 to August 2016. They were randomly divided into two groups: group I included 20 patients treated by transfixion excision hemorrhoidectomy, and group II included 20 patients treated by ligation anopexy.
There was no statistically significant difference between both groups with regard to age and sex as well as presenting symptoms as shown in [Table 1] and [Table 2].
|Table 1: Comparison between the two studied groups according to demographic data|
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|Table 2: Comparison between the two studied groups according to presenting symptoms|
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The duration of surgery was significantly shorter in patients treated with ligation anopexy. Intraoperative bleeding was significantly decreased in patients treated with ligation anopexy [Table 3].
|Table 3: Comparison between the two studied groups according to operative data and hospital stay|
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There was a significant decrease in postoperative pain in patients treated with ligation anopexy at 24, 48, 72 h, and the second week postoperatively [Table 4]. The incidence of reactionary hemorrhage significantly decreased in patients treated with ligation anopexy [Table 5].
|Table 4: Comparison between the two studied groups according to the visual analog scale|
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|Table 5: Comparison between the two studied groups according to early complications|
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The present study showed that the number of patients with residual skin tags increased in patients treated with ligation anopexy, especially with grade IV hemorrhoids [Table 6].
|Table 6: Comparison between the two studied groups according to skin tags|
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Time off work in patients treated with ligation anopexy was significantly shorter compared with transfixion excision hemorrhoidectomy [Table 7].
|Table 7: Comparison between the two studied groups according to time off work (days)|
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| Discussion|| |
Hemorrhoidectomy is the most effective and definitive treatment for prolapsed hemorrhoids. Nevertheless, postoperative complications such as pain and bleeding after conventional excision hemorrhoidectomy continue to be major problems. Various techniques have been developed with the aim of reducing postoperative pain. Modern methods of hemorrhoid surgery such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization are associated with a lower rate of complications. Thus, surgery for hemorrhoids has been upgraded to using sophisticated and expensive instrumentation that may not be readily available and may require specific training to attain proper expertise in these techniques. Meanwhile, hemorrhoid surgery is usually carried out in a wide range of hospitals, mostly peripheral ones where sophisticated equipments are not available .
The principle of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization is also disruption of blood flow from the superior hemorrhoidal arteries to the hemorrhoidal cushions. Furthermore, each procedure must be accomplished well above the dentate line in the poorly innervated zone .
Hussein  proposed ligation anopexy of hemorrhoids as a method to control their prolapse and bleeding. He reported successful outcome in 40 patients. This was based on the anatomy of the blood supply to the hemorrhoidal cushions. The arteriovenous plexi are located in constant anatomical positions. Studies of the exact anatomy of the superior hemorrhoidal arteries have found them to be at the base of each hemorrhoidal cushion in the rectal submucosa .
Therefore, ligation anopexy is an available and simple option for the surgeon without specialist training. The simplicity of the procedure has no need for newer sophisticated and expensive instruments such as the Doppler anoscopy, which is becoming quite popular. Similar results can be achieved with ligation anopexy, which is not only a safe procedure but is also much simpler and cheaper without any serious complication or troublesome outcome .
From the previous demographic data, we can notice the close proximity between our patients and those of the compared studies.
The mean operative time for ligation anopexy was 18.35 ± 2.54 min, similar to the opertative times in the study by Hussein  (13.9–17 min) and the study by Bronstein et al.  (15–17 min). A shorter duration was reported by Gupta and Kalaskar  (8 ± 0 min). However, for patients treated by transfixion excision hemorrhoidectomy, the mean operative time in our study was 23.65 ± 3.48 min, and shorter durations were reported in similar studies by Tan et al.  (18.2 min), Dowidar et al.  (20 min), and by Omar et al.  (20 ± 4). Although a longer duration was reported in the study by Gentile et al.  (27.4 min), in our study, ligation anopexy needed less time than transfixion excision hemorrhoidectomy (18 vs. 23 min); this may be explaned by the time wasted in excising the piles and for hemostasis.
According to our study, ligation anopexy was associated with mild postoperative pain and minimal analgesic requirement – visual analog scale 4 or less was reported by 95% of patients. A single dose of oral analgesics was sufficient to control postoperative pain in 90% of patients. Lack of severe postoperative pain may be linked to the distance between the ligation site and the sensitive mucosa above the dentate line, as well as the absence of surgical trauma or wounds and the low incidence of anal spasm, edema, and hematoma.
Postoperative bleeding was reported in two patients with grade IV hemorrhoids (5%), treated with transfixion excision hemorrhoidectomy. Similar results were obsereved in the studies by Tan et al.  (4.5%), Omar et al.  (5.5%), and by Gentile et al.  (6%). Postoperative bleeding was uncommon in patients treated with ligation anopexy, and only one patient had postoperative bleeding in our study. Similar results were reported in the study by Hussein  (2.5%) and by Gupta and Kalaskar  (<2%), whereas higher incidence was reported by Shafik & Mostafa, .  (12.5%).
Lack of postoperative bleeding after ligation anopexy can be explained by the high ligation of the main blood supply without any wounds and restoring the normal physiological site of the piles. On the contrary, the external wound made by diathermy increases the risk of postoperative bleeding.
Time off work in patients treated with ligation anopexy was shorter than that in patients treared with transfixion excision hemorrhoidectomy (7.25 ± 1.55 versus 10.40 ± 1.85 days); these data were confirmed by the results of Gupta and Kalaskar  (9 days) and Tan et al.  (19 days).
| Conclusion|| |
Ligation anopexy for prolapsing hemorrhoids is simple and safe, with less postoperative bleeding, pain, minimal analgesic requirement, no external wound problems, lower postoperative complications, and earlier return to normal activities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]