DGHAL with recto-anal-repair modification:
functional evaluation and safety assessment of a
new minimally-invasive method of treatment of
advanced hemorrhoidal disease
Piotr Walega MD, PhD, Michal Romaniszyn MD, Jakub Kenig MD, PhD, Roman
Herman* Prof, Wojciech Nowak Prof
3rd Department of General Surgery, Jagiellonian University School of Medicine,
Pradnicka Str. 35-37 31-202, Krakow, Poland
*Department of Experimental and Clinical Surgery, Institute of Physiotherapy, Jagiellonian University
School of Medicine, Michalowskiego Str. 12, 31-126 Krakow, Poland
Phone: +48126331995
Fax: +48126333105
Email: pwalega@mp.pl
Abstract
PURPOSE: The aim of this paper is to present 12-month follo w-up results of functional evaluation and
safety assessment of an innovative modification of hemorrhoidal artery ligation (DGHA L) called Recto -
Anal-Repair (RAR) in the treatment of IIIrd and IVth grade hemorrhoidal disease (HD), conducted in the
3rd Depart ment of General Surgery, Jagiellonian University. M ETHODS: A total of 38 patients with grade
III and IV HD underwent the RAR procedure consisting of Doppler Guided Hemorrhoid Artery Ligation
combined with restoration of the prolapsed hemorrhoids to their anatomical position with longitudinal
continuous sutures. Each patient had a rectal examination, anorectal manometry and Quality of Life
questionnaire performed before, 3 months, and 12 months after the RAR procedure. RESULTS: Of the
initial 38 patients 18 were lost to follow-up. A mong the rema ining 20 patients, there were three cases
(15%) of intraoperative and one (5%) of early postoperative bleeding. 3 months after RAR 5 cases of minor
residual mucosal prolapse were detected (25%), wh ile on ly 3 patients (15%) reported persistence of some
symptoms. 12 months after RAR another 3 cases of hemorrhoid disease recurrence were detected, to a total
of 8 patients (40%) with minor HD recurrence 12 months after RA R. Anal p ressure levels 3 months after
RAR were significantly lower than before the procedure (p0.05).
Table 1.
Grade (Parks)
n Mean age III III/IV IV
Male 12 54 (29-70) 3 6 3
Female 8 56 (40-68) 6 1 1
The RAR procedure itself took about 35 minutes on average (25-75) from beginning of
anesthetical procedures to transportation of the patient back to bed from the operating
table. Mean number of arteries ligated during the procedure was 5,65 (4-8), most
frequently found on 1 and 11 o'clock (in Loyd-Davis’ position, corresponding to 5 and 7
o’clock in supine position). There were on average 2,5 (1-4) longitudinal sutures used to
pull prolapsed mucosa up into the anal canal. There were three cases (15%) of
intraoperative bleeding requiring additional haemostatic sutures. Early postoperative
bleeding (approximately 60 ml of blood) was reported in one patient (5%), on the first
day after surgery. The bleeding was successfully managed with sterile anal tamponade
(Lockhart-Mummary type). There were no other complications in perioperative period
which would require surgical intervention. Postoperative pain was easily managed with
NSAIDs administered i.v. or p.o.
In the follow-up examination 3 months after RAR procedure there were 5 cases (25%) of
minor residual hemorrhoidal prolapse among the 20 patients included in the final
analysis, while only 3 of them (15%) reported residual symptoms (painful defecation and
itching). These 3 patients were all among the first 10, who underwent Recto-Anal Repair
in our Department. There were no cases of persistent bleeding within the first 3 months
after RAR procedure.
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In anorectal manometry assessment, anal pressure levels recorded 3 months after RAR
were significantly lower than before the procedure (Table 2). On average BAP dropped
11,53%, SAP 12,2% in women, BAP dropped 5,82% and SAP 6,03% in men (p0,05).
Table 2. Mano metric findings upon qualificat ion and 3 months after DGHA L-RA R procedure
Mean BAP Mean SAP Physiological RSCC present
upon 3 months 12 months upon 3 months 12 months RAIR (before/after)
qualification after RAR after RAR qualification after RAR after RAR (before/after)
Male 78,83 72,17 67,92 214,50 199,75 198,75 12/ 12 12/ 12
Female 64,50 56,50 58,75 129,38 111,25 119,38 8/8 8/8
Based on the Quality of Life questionnaires (GIQL, FIQL), most of the patients (95%)
were satisfied with the results of the treatment, reporting better overall wellness and self-
confidence, despite of non complete reduction of mucosal prolapse in a few cases.
However, one of the 20 patients (5%), 73 year old male, reported occasional continence
problems at the follow-up examination 3 months after the procedure (incontinence of
gases, occasional soiling), with onset about one month after surgery. Manometric
findings were also normal in this patient. Change of diet and simethicone administration
three times a day was sufficient to relieve the patient’s symptoms.
In the follow- up examination 12 months after RAR procedure there were 3 new cases of
hemorrhoidal prolapse recurrence, giving a total of 8 known patients with hemorrhoidal
prolapse 12 months after the procedure. There were no cases of persistent bleeding, and
the satisfaction level measured with quality of life questionnaires was still high in most of
the patients (95%).
In anorectal manometry assessment, anal pressure levels recorded 12 months after RAR
were similar to values recorded 3 months after the procedure in the same patients
(p>0,05). There were no new cases of functional disorders recorded, the patient who
reported incontinence after the procedure, reported at the 12- month follow-up slight
improvement, with persistence of gases incontinence.
Discussion
Is it estimated that up to 75% of professionally active people suffer from hemorrhoidal
disease (HD). The prevalence of this complaint in the overall population might be even
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higher, as many patients are too ashamed to visit a doctor or are afraid of conventional,
painful procedures with long recovery.
The researchers are in a constant search of new methods of treating hemorrhoidal disease
that would offer not only high effectiveness and low morbidity, but also short recovery
and good postoperative comfort. Rubber band ligation used in stage II and III
hemorrhoids can be complicated by post-procedure bleeding in up to 5% of cases[9]. The
efficacy of this method is 76% in stage II, 66% in stage III, and less then 20% in IV
degree hemorrhoids. Rubber band ligatures are placed under limited visual control, near
the dentate line; heamorrhoidal arteries are left open, which results in a high probability
of recurrence[10]. Baron’s method also requires several applications of rubber bands
since most of proctologists refrain from ligation of all hemorrhoidal piles during one
procedure. Moderately invasive methods such as Longo’s operation are burdened with a
relatively high risk of complications, including severe complications such as perforation,
occlusion of rectum, retroperitoneal hematoma, and Furnier’s gangrene[11-16]. During
the DGHAL-RAR procedure all sutures are placed under direct visual control, so risk of
misaligned sutures is greatly reduced. Additionally, during stapler-based procedures a
continuous ring of mucosa is being cut out, while in DGHAL-RAR longitudinal stripes of
untouched mucosa between the RAR sutures reduce the risk of impairment of anorectal
function and sensation. Conventional surgical hemorrhoidectomy according to Milligan
Morgan, Ferguson, and their modifications represent the most effective treatment method
of HD that is currently available. However, the effectiveness of these methods is limited
by various complications such as sphincter dysfunction (in up to 25% of patients), recto-
anal coordination impairment due to partial resection of anal mucosa (another 10% of
patients), postoperative bleeding or infection up to 5–15% of patients[15]. Also
postoperative recovery usually lasts from a few days to 2 weeks. Therefore, taking all
these facts into consideration, new methods of treatment like DGHAL and RAR, aside
from enhancing effectiveness, concentrate on preserving natural anatomical and
histological structure of anorectal region as much as on possibility to prevent from
anorectal function impairment. They are also aimed at shortening of pos t procedure
recovery[28, 29].
It is said that hemorrhoidal plexus is responsible for 15-20% of resting anal pressure.
According to some studies[17-19], these pressures are significantly higher in patients
with HD compared to healthy individuals, and drop after surgical management of HD
regardless of chosen method (Barron, Milligan-Morgan, Longo) was also reported[17, 18,
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20]. Some authors even raise a question if elevated resting anal pressure is secondary to
swelling of hemorrhoidal cusions, or if it is an etiological factor of hemorrhoidal
disease[17]. On the other hand, many other authors state, that there was no significant
change in manometric findings in patients treated for hemorrhoidal disease[21-23]
leaving the question of initially raised pressure unanswered. Papers concerning the
DGHAL method also report no significant changes in basal and squeeze pressures[23].
Our study shows a significant drop in resting anal pressure after RAR, with coexistent
minor influence of the RAR procedure on squeeze anal pressure, although we have no
proof if the pressures were elevated initially as compared to healthy individuals. There is
still a need for a complex study involving an age and gender matched control group of
healthy individuals for comparison or perhaps a large scale prospective trial, to answer
this question.
The clinical results of the Recto-Anal Repair procedure are very promising, as most of
the patients were satisfied with the outcome, although the observation period of 12
months is too short to conclude the long-term effectiveness of the procedure. Moreover,
many of the patients treated with this method in our Department didn’t complete full
follow-up visits plan, so clinical results in those patients are unknown. It can be only
guessed that most of them didn’t have any symptoms after the treatment, and so didn’t
find visiting a doctor necessary. In short-term studies concerning stapler-based techniques
the recurrence rates were lower than in our analyzed group of patients[24-27].
DGHAL/RAR however may offer better safety profile and lower risk of anorectal
disturbances. Additionally, recovery after RAR procedure was much quicker compared to
classical Milligan-Morgan or Ferguson hemorrhoidectomy[4].
Conclusion
Recto-Anal Repair seems to be a safe method of treatment of IIIrd and IVth grade
hemorrhoidal disease with no major complications and a high rate of good short term
results. The procedure has a significant influence on resting and squeeze anal pressure,
with no evidence of risk of fecal incontinence after the operation. It remains to be
answered if that is a result of return to normal anal tone or should be considered as an
adverse effect. However, this is a preliminary study with small series of patients and short
follow-up time, so it is difficult to assess long-term efficacy, recurrence rates and long-
term influence on anorectal function, which still need to be assessed in larger studies with
longer follow-up period and bigger groups of patients.
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Disclosures
Drs. P. Walega, M. Romaniszyn, J. Kenig, R. Herman, W. Nowak have no conflicts of
interest or financial ties to disclose.
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