Clinical trial NCT03298997: Ligation and Hemorrhoidopexy Technique Versus Ligation of Hemorrhoidal Arteries Using Ultrasound for Hemorrhoids
Official title: Comparison Between the Ligation and Hemorrhoidopexy Technique and the Conventional Ligation of Hemorrhoidal Arteries Using Ultrasound: a Prospective, Randomized Controlled Study
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Hemorrhoids
Keywords: Hemorrhoids
Ligation
Ultrasound
Prospective
Randomized Controlled Trial
Lead sponsor: Larissa University Hospital
Sponsor class: OTHER
Collaborators: name: University of Thessaly
First posted: 2017-10-02
Enrollment: 60
Sex: ALL
Minimum age (years): 18
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The purpose of this study is to compare two techniques for treating hemorrhoids, the ligation and hemorrhoidopexy technique and the conventional ligation of hemorrhoidal arteries using ultrasound, in patients with non-complicated hemorrhoids.

Detailed description: Surgical operations for the treatment of perianal diseases are a major part of all elective surgical cases. The reduction in the hospitalization time of patients undergoing surgical procedures for benign perianal diseases is to the benefit of both the patient and healthcare provider. The importance of 'one day' surgical operations lies in the fact that the patient returns directly to his social and working environment, while the number of occupied hospital beds and the total hospitalization costs are reduced. A typical example is the goal set by National Health Service (NHS), where the 75% of the scheduled operations should consist of 'one day' operations. In order to achieve this goal, several obstacles should be dealt with, including the implementation of more efficient and safe surgical techniques. Therefore, this would be associated with a decrease in the operation time, early recovery and faster hospital discharge.

Hemorrhoids is one of the most common benign perianal diseases. According to a recent prospective study of 976 patients, 38.93% of them suffered from hemorrhoids, with 8.16% and 0.53% being Grade III and IV, according to Goligher classification, respectively. The percentage of the symptomatic patients was, also, significant (44.74%). Symptomatic hemorrhoids, include bleeding, pruritus, pain, poor hygiene and the presence of palpable hemorrhoid nodules.

As far as the blood supply of the rectum and the broader anatomic region is concerned, it is provided by the superior, middle and inferior hemorrhoidal arteries. The superior hemorrhoidal artery is a branch of the inferior mesenteric artery and is carried behind the rectum, where it provides branches up to the internal sphincter muscle. The right and left middle hemorrhoidal artery originate from the respective internal iliac artery and their branches are cross-linked with the respective branches deriving from the superior hemorrhoidal artery. Finally, inferior hemorrhoidal arteries derive from the respective internal pudendal arteries. Correspondingly, hemorrhoidal venous plexus consists of the middle and inferior hemorrhoidal veins, which through the internal iliac veins drain into the inferior cava vein. Hemorrhoidal tissue constitutes a continence mechanism of the upper rectum and consists of vascular tissue, connective tissue and smooth muscle fibers, within the rectal canal. Through the approximation of the hemorrhoidal tissue, closure of the anal canal and protection of the sphincter mechanism is achieved. Since modern pathogenesis theories of hemorrhoidal disease attribute to the increased arterial flow in the hemorrhoidal plexus the generating cause of this disease, recent anatomical studies mapped the vascular network, indicating that the arteries are not confined to the anatomical regions described in the literature.

According to recent guidelines, the modification of dietary intake, through the increase of fluid and fiber intake, consists the first line treatment of symptomatic hemorrhoidal disease. However, in Grade III-IV hemorrhoidal disease or in Grade II, where conservative therapy failed, surgical intervention is required. Surgeon has plenty of techniques at his disposal, in order to treat hemorrhoids. Examples of these techniques are operations, such as hemorrhoidectomy (open, closed, Milligan-Morgan, Parks, using staplers, using energy sources, e.g. Harmonic, Ligasure, Laser, bipolar forceps), elastic rings ligation, sclerotherapy and Hemorrhoidal Arteries Ligation (ΗΑL) or Transanal Hemorrhoidal Dearterialization (THD).

Ligation of hemorrhoidal arteries using a Doppler apparatus, is a minimally invasive technique that was first applied by Morinaga et al. in 1995 and has as principle the elective ligation of the arteries that supply the hemorrhoidal plexus. In a recent meta-analysis, the superiority of HAL in areas such as, postoperative bleeding, emergency reoperation, operative duration, length of hospital stay and postoperative pain, was shown. A major drawback of this technique, however, remains the high rate of recurrence, which ranges from 11.1% to 59.3%, for Grade IV hemorrhoids.

Despite the comparative advantages of this minimally invasive technique, the high cost of the necessary equipment and the respective consumables, is a barrier to its broad application. Gupta et al. in a prospective randomized study, compared Doppler-Guided HAL (DG-HAL) to hemorrhoid artery ligation and hemorrhoidopexy. Ligation was performed on the hemorrhoid nodule at the 3rd, 7th and 11th hours, followed by continuous hemorrhoidal nodule ligation and hemorrhoidopexy. The DG-HAL group had a significantly longer operative time (31 min vs 9 min) and post-operative pain (4.4 vs 2.2), without any differences in complication or recurrence rates. Similarly, Huang et al., reported a respective ligation technique, where, through the use of the index finger, the artery was palpated, followed by repeating compression and ligation cycles, in order to fix the affected hemorrhoids above the dental line. In this group, operative time was longer when compared to the DG-HAL group (35.57 vs. 12.73). There was no difference in terms of postoperative improvement of symptoms and hospitalization duration. In the experimental group, however, the cost of hospitalization and the relapse rate was significantly lower. Finally, Aigner et al., in a recent randomized study, investigated the efficacy of hemorrhoidopexy for Grade III hemorrhoids. They concluded that the techniques of hemorrhoidopexy are effective and the addition of DG-HAL does not affect the results.

Given these facts, the present trial was designed, in order to compare the two techniques for hemorrhoidal disease treatment, the ligation and hemorrhoidopexy technique and the conventional ligation of hemorrhoid arteries using ultrasound.

Eligibility criteria: Inclusion Criteria:

* Μale or female
* Age: 18 to 80 years
* American Society of Anesthesiologists (ASA) score: I and II
* Grade I, II, and III hemorrhoids

Exclusion Criteria:

* Acute perianal diseases, such as perianal abscesses, complicated hemorrhoids (e.g., thrombosis) and acute anal fissure
* Malignant perianal disorders
* Patient age ≥ 80 years
* ASA score ≥ ΙΙΙ
* Presence of inflammatory bowel disease
* History of a previous rectoanal operation
* Presence of a clinically significant cardiovascular, respiratory, renal, hepatic or metabolic disorder. Furthermore, diseases, such as obesity, psychiatric disorders or gastrointestinal disorders constitute exclusion criteria

Primary outcomes:
measure: Symptoms Remission Rate
timeFrame: 1 month postoperatively
Secondary outcomes:
measure: Operative time
timeFrame: Intraoperative period
measure: Postoperative mobilization time
timeFrame: Maximum time frame 24 hours postoperatively
measure: Onset of oral feeding
timeFrame: Maximum time frame 24 hours postoperatively
measure: Postoperative pain level at 12 hours
timeFrame: 12 hours postoperatively
measure: Hypotension
timeFrame: Maximum time frame 24 hours postoperatively
measure: Nausea
timeFrame: Maximum time frame 24 hours postoperatively
measure: Vomiting
timeFrame: Maximum time frame 24 hours postoperatively
measure: Headache
timeFrame: Maximum time frame 24 hours postoperatively
measure: Urinary retention
timeFrame: Maximum time frame 24 hours postoperatively
measure: Bleeding at the operative site
timeFrame: Maximum time frame 24 hours postoperatively
measure: Postoperative discharge time
timeFrame: Maximum time frame 48 hours postoperatively
measure: Postoperative pain level at 7 days
timeFrame: 7 days postoperatively
measure: Oedema at the operative site
timeFrame: 7 days postoperatively
measure: Hematoma at the operative site
timeFrame: 7 days postoperatively
measure: Infection at the operative site
timeFrame: 7 days postoperatively
measure: Stenosis at the operative site
timeFrame: 7 days postoperatively
measure: Postoperative return to work time
timeFrame: Postoperative period up to 1 month
measure: Pruritus
timeFrame: 1 year postoperatively
measure: Mucosal proptosis
timeFrame: 1 year postoperatively
measure: Perianal nodules
timeFrame: 1 year postoperatively
measure: Constipation
timeFrame: 1 year postoperatively
measure: Tenesmus
timeFrame: 1 year postoperatively
measure: Reoperation
timeFrame: 1 year postoperatively
measure: Disease recurrence rate
timeFrame: 1 year postoperatively
measure: Satisfaction level
timeFrame: 1 year postoperatively
measure: Difference in the quality of life of the patient
timeFrame: Preoperatively, 1 month postoperatively and 1 year postoperatively
Other outcomes:
Locations:
city: Lárisa
country: Greece
facility: Department of Surgery, University Hospital of Larissa
state: Larissa
Study officials:
affiliation: Department of Surgery, University Hospital of Larissa
name: Konstantinos Tepetes, Professor
role: STUDY_DIRECTOR
References:
citation: Faiz OD, Brown TJ, Colucci G, Grover M, Clark SK. Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005. Colorectal Dis. 2008 Nov;10(9):935-42. doi: 10.1111/j.1463-1318.2008.01481.x. Epub 2008 Feb 21.
citation: Riss S, Weiser FA, Schwameis K, Riss T, Mittlbock M, Steiner G, Stift A. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012 Feb;27(2):215-20. doi: 10.1007/s00384-011-1316-3. Epub 2011 Sep 20.
citation: Schuurman JP, Go PM, Bleys RL. Anatomical branches of the superior rectal artery in the distal rectum. Colorectal Dis. 2009 Nov;11(9):967-71. doi: 10.1111/j.1463-1318.2008.01729.x. Epub 2008 Oct 31.
citation: Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL; Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011 Sep;54(9):1059-64. doi: 10.1097/DCR.0b013e318225513d. No abstract available.
citation: Ho YH, Seow-Choen F, Tan M, Leong AF. Randomized controlled trial of open and closed haemorrhoidectomy. Br J Surg. 1997 Dec;84(12):1729-30.
citation: Hosch SB, Knoefel WT, Pichlmeier U, Schulze V, Busch C, Gawad KA, Broelsch CE, Izbicki JR. Surgical treatment of piles: prospective, randomized study of Parks vs. Milligan-Morgan hemorrhoidectomy. Dis Colon Rectum. 1998 Feb;41(2):159-64. doi: 10.1007/BF02238242.
citation: Senagore AJ, Singer M, Abcarian H, Fleshman J, Corman M, Wexner S, Nivatvongs S; Procedure for Prolapse and Hemmorrhoids (PPH) Multicenter Study Group. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum. 2004 Nov;47(11):1824-36. doi: 10.1007/s10350-004-0694-9.
citation: Chung CC, Cheung HY, Chan ES, Kwok SY, Li MK. Stapled hemorrhoidopexy vs. Harmonic Scalpel hemorrhoidectomy: a randomized trial. Dis Colon Rectum. 2005 Jun;48(6):1213-9. doi: 10.1007/s10350-004-0918-z.
citation: Lawes DA, Palazzo FF, Francis DL, Clifton MA. One year follow up of a randomized trial comparing Ligasure with open haemorrhoidectomy. Colorectal Dis. 2004 Jul;6(4):233-5. doi: 10.1111/j.1463-1318.2004.00608.x.
citation: Pandini LC, Nahas SC, Nahas CS, Marques CF, Sobrado CW, Kiss DR. Surgical treatment of haemorrhoidal disease with CO2 laser and Milligan-Morgan cold scalpel technique. Colorectal Dis. 2006 Sep;8(7):592-5. doi: 10.1111/j.1463-1318.2006.01023.x.
citation: Chung CC, Ha JP, Tai YP, Tsang WW, Li MK. Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique. Dis Colon Rectum. 2002 Jun;45(6):789-94. doi: 10.1007/s10350-004-6299-5.
citation: Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA. Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy. Br J Surg. 2005 Dec;92(12):1481-7. doi: 10.1002/bjs.5185.
citation: Khoury GA, Lake SP, Lewis MC, Lewis AA. A randomized trial to compare single with multiple phenol injection treatment for haemorrhoids. Br J Surg. 1985 Sep;72(9):741-2. doi: 10.1002/bjs.1800720924.
citation: Ratto C, Donisi L, Parello A, Litta F, Doglietto GB. Evaluation of transanal hemorrhoidal dearterialization as a minimally invasive therapeutic approach to hemorrhoids. Dis Colon Rectum. 2010 May;53(5):803-11. doi: 10.1007/DCR.0b013e3181cdafa7.
citation: Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol. 1995 Apr;90(4):610-3.
citation: Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015 Dec;102(13):1603-18. doi: 10.1002/bjs.9913. Epub 2015 Sep 30.
citation: Giordano P, Overton J, Madeddu F, Zaman S, Gravante G. Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009 Sep;52(9):1665-71. doi: 10.1007/DCR.0b013e3181af50f4.
citation: Gupta PJ, Kalaskar S, Taori S, Heda PS. Doppler-guided hemorrhoidal artery ligation does not offer any advantage over suture ligation of grade 3 symptomatic hemorrhoids. Tech Coloproctol. 2011 Dec;15(4):439-44. doi: 10.1007/s10151-011-0780-7. Epub 2011 Oct 28.
citation: Gupta PJ, Kalaskar S. Ligation and mucopexy for prolapsing hemorrhoids--a ten year experience. Ann Surg Innov Res. 2008 Nov 28;2:5. doi: 10.1186/1750-1164-2-5.
citation: Huang HX, Yao YB, Tang Y. Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids. Exp Ther Med. 2016 Aug;12(2):1022-1028. doi: 10.3892/etm.2016.3339. Epub 2016 May 12.
citation: Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L, Pratschke J, Peer S, Gruber H. Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial. Colorectal Dis. 2016 Jul;18(7):710-6. doi: 10.1111/codi.13280.
citation: Spyridakis M, Christodoulidis G, Symeonidis D, Dimas D, Diamantis A, Polychronopoulou E, Tepetes K. Outcomes of Doppler-guided hemorrhoid artery ligation: analysis of 90 consecutive patients. Tech Coloproctol. 2011 Oct;15 Suppl 1:S21-4. doi: 10.1007/s10151-011-0727-z.
citation: Tepetes K, Symeonidis D, Christodoulidis G, Spyridakis M, Hatzitheofilou K. Pudendal nerve block versus local anesthesia for harmonic scalpel hemorrhoidectomy: a prospective randomized study. Tech Coloproctol. 2010 Nov;14 Suppl 1:S1-3. doi: 10.1007/s10151-010-0614-z.
citation: Honca M, Dereli N, Kose EA, Honca T, Kutuk S, Unal SS, Horasanli E. Low-dose levobupivacaine plus fentanyl combination for spinal anesthesia in anorectal surgery. Braz J Anesthesiol. 2015 Nov-Dec;65(6):461-5. doi: 10.1016/j.bjane.2014.01.007. Epub 2014 Feb 20.
citation: Alkhaldi HM, Salaita WM, Shabaneh MA, Al-Horut MI, Aldabbas RM, Uraiqat AA. Postoperative Outcome Comparison Between Pudendal Nerve Block and Caudal Block After Lateral Open Internal Sphincterotomy. Med Arch. 2015 Jun;69(3):187-9. doi: 10.5455/medarh.2015.69.187-189. Epub 2015 Jun 10.
citation: Pappa E, Kontodimopoulos N, Niakas D. Validating and norming of the Greek SF-36 Health Survey. Qual Life Res. 2005 Jun;14(5):1433-8. doi: 10.1007/s11136-004-6014-y.
citation: Flight L, Julious SA. Practical guide to sample size calculations: non-inferiority and equivalence trials. Pharm Stat. 2016 Jan-Feb;15(1):80-9. doi: 10.1002/pst.1716. Epub 2015 Nov 25.
citation: Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth. 1995 Sep;7(6):500-6. doi: 10.1016/0952-8180(95)00130-a.
citation: Perivoliotis K, Spyridakis M, Zintzaras E, Arnaoutoglou E, Pramateftakis MG, Tepetes K. An enhanced outpatient modality for the treatment of hemorrhoidal disease: preliminary results. G Chir. 2019 Mar-Apr;40(2):153-157.
citation: Perivoliotis K, Spyridakis M, Zintzaras E, Arnaoutoglou E, Pramateftakis MG, Tepetes K. Non-Doppler hemorrhoidal artery ligation and hemorrhoidopexy combined with pudendal nerve block for the treatment of hemorrhoidal disease: a non-inferiority randomized controlled trial. Int J Colorectal Dis. 2021 Feb;36(2):353-363. doi: 10.1007/s00384-020-03768-8. Epub 2020 Oct 6.