Research Article
Comparative Outcomes between Ligasure and THD Techniques for the Management of Haemorrhoidal Disease
Bahena-Aponte JA1, de Jesus Mosso M2*, Hernández MV3, Narsil A. Arcadia SM4, Aldana-Martínez OH5 and González Contreras QH6
1Head of Teaching and Research and Surgery Specialist, Hospital General Ajusco Medio, México
2Hospital HMG Coyoacan, México
3Medical Specialist in Anesthesiology, Hospital HMG Coyoacan, México
4Hospital Central Militar, México
5Medical Resident of Urology, Hospital Regional de Monterrey, México
6Specialist in Coloproctology, Hospital HMG Coyoacan, México
*Corresponding author: Monica de Jesus Mosso, Hospital HMG Coyoacan, Av. Division del Norte 3395, El Rosario, Delegation Coyoacan. CP 04380, Mexico DF
Published: 06 Dec, 2016
Cite this article as: Bahena-Aponte JA, de Jesus Mosso
M, Hernández MV, Narsil A. Arcadia
SM, Aldana-Martínez OH, González
Contreras QH. Comparative Outcomes
between Ligasure and THD Techniques
for the Management of Haemorrhoidal
Disease. Clin Surg. 2016; 1: 1229.
Abstract
Background: The major concern in the surgical management of hemorrhoidal disease has been
the postoperative recovery, particularly pain. In recent years new technologies has been developed,
such as Ligasure (small jaw) and transanal hemorrhoidal dearterialization (THD), demonstrating
encouraging surgical result during the postoperative period.
Aim: To compare ligasure vs. THD in retrospective fashion analyzing a total of 50 cases of
hemorrhoidal disease divided in two groups, group A for Ligasure and group B for THD approach
in terms of surgical outcomes and recurrences.
Materials and Methods: During the period of June 2012 to August 2014 a total of 50 patients were
included into two groups. Group A Ligasure and Group B THD. Demographic data as age, sex,
surgical outcomes and recurrence rate were analyzed. The patients were treated in several private
third level hospitals in Mexico City.
Results: Group A had an average age of 39.5 years old, group B 40.2 years old. In both groups
the male sex predominates, 80% and 54% respectively. None patient developed recurrence in both
groups, however, 3 patients in Group A developed skin tags.
Conclusion: Our study supports that both Ligasure and THD techniques are probably very similar
outcomes in regard to postoperative pain, recovery time and complications in modern surgery for
the treatment of hemorrhoidal disease. However, the Ligasure could have slightly more favorable
postoperative immediate results as well as technical and economical advantages.
Keywords: Ligasure; THD; Hemorrhoidal disease
Background
Hemorrhoidal disease (HD) is a global health problem. The prevalence of this disease is estimated
between 4 and 34%. In the UK it is estimated that from 50 years of age, almost 50% of people
present a hemorrhoidal crises [1-3]. A numerous treatments for HD has been proposed, ranging
from nonsurgical to minimally invasive surgical approaches such as: a) stapled rectal mucosectomy,
b) Doppler guided transanal hemorrhoidal dearterialization (THD) c) LigaSure and traditional
hemorrhoidectomy. Although, the latter either open or closed has proven to be the more effective for
the treatment of grade 3 and 4 HD, it has been associated with a higher incidence of complications,
postoperative pain and prolonged recovery [3]. For these reasons, a minimally invasive procedures
such as THD and LigaSure have gained popularity because of their advantages in terms of been less
traumatic, decrease in postoperative pain, shorter recovery periods and low recurrence rate with a
good safety margin. In regards to the THD surgical dots over the hemorrhoidal artery, that carries
blood flow to the hemorrhoidal packages guided by Doppler ultrasound, this maneuver is combined
with a pexia of the mucosal hemorroidal prolapse, repositioning the mucosal to its original location;
while the Ligasure technique involves resection of hemorrhoidal packages by an electrosurgical
generator which allows sealing arteries and veins of up to 7 mm in diameter of tissue groups.
This product works fusing hemostatic collagen and elastin in the
vessel walls to create an autologous and permanent seal
As demonstrated by Albert M et al. [3] who after analyzing 175
patients with hemorrhoidal disease grade I-IV, who underwent to
THD, with a 17.2 months follow-up of, conclude that this technique
is highly effective, with minimal complications, little pain and high
patient satisfaction.
Table 1
Table 2
Objective
The aim of this study is to compare two techniques for
management of hemorrhoidal disease such as: LigaSure vs. THD.
A total of 50 cases were divided into two groups, Group A and B,
LigaSure vs. THD hemorrhoidectomy, respectively, in terms of
surgical results and recurrences.
Material and Methods
During the period of June 2012 to August 2014 a total of 50
patients were divided randomly into Group A (Ligasure) and
Group B (THD). All of the patients signed an informed consent
and privacy notice. Patients with previous anal surgery and who
were immunocompromised were excluded. All patients underwent
preoperative evaluation including a detailed medical history, complete
Proctologic exploration, in order to rule out other diseases. All
patients were operated by the same surgical team. Demographics such
as age, sex, as well as surgical results within that time contemplating
operative time, bleeding, hospital stay, complications such as urinary
retention and recurrent disease were analyzed. Patients were treated
at several private third level Mexican hospitals.
Surgical technique
For patients in group A, LigaSure™ Small Jaw Open Instrument
was used. For group B, the THD device System was used.
Preoperative preparation consisted of rectal application of
sodium phosphate (Fleet enemaR 133 ml) one hour before the
surgical procedure and the administration of a dose of 500 mg of
metronidazole (verifying that no patients were allergic). Spinal block
was used in all patients. All patients were operated in a Sevillian knife
position. Group A: A Pratt anoscope was introduced, with a previous
rectal examination, in order to localize hemorrhoidal packages. Once
they were located, dissection with LigaSure caliper was developed.
Hemostasis was verified and a local hemostatic (SpongostanR) was left
into the anal canal and compression bandages in gluteal region, that
were withdraw 4 hours after the procedure.
Group B: A Pratt anoscope was introduced, with a previous
rectal examination, in order to localize hemorrhoidal packages.
Subsequently the THD device was introduced, with a subsequent
ligation of them into six different points in the quadrant of the
1,3,5,7,9,11 hrs according to a clockwise direction. Hemostasis was
verified and a local hemostatic (SpongostanR) was left into the anal
canal and compression bandages in gluteal region, that were withdraw
4 hours after the procedure.
Postoperative control
Patients remained hospitalized for six to 24 hours in order to
monitor their immediate postoperative evolution. They start normal
diet at 6 hrs postoperatively. The pain was controlled with intravenous
ketorolac and paracetamol. At discharge they take ketorolac 10 mg
tablets, paracetamol 750 mg tablets as well as metronidazole 500 mg
three times a day for seven days.
Statistical analysis was performed using SPSS version 19, given a
program P value of 0.05 as significant. Also it required the use of chisquare
and Student's t test.
Results
Within group A 40 men (80%) and 10 women (20%) were
included, while the B group was formed of 27 men (54%) and 23
women (46%). The median age for group A was 39.5 and 40.2 years
for group B. In both groups hemorrhoidal disease grade III was
the most common, accounting for 80% and 70%, respectively, and
followed by grade II and finally grade IV (Table 1). A follow up of
12 to 36 months was recorded. Among the symptoms reported by
patients highlights: a) bleeding, b) itching and c) foreign body
sensation, without statistically significant difference between the two
patient groups.
In analyzing the intra-operative variables such as surgical time, we
note that the Ligasure group was faster with 10.1 min, ranging from 8
to 15 min, while the THD group was 18.7 min (ranging from 15 to 20
min), with a p value of 0.05. In regard to pre and postoperative hospital
stay and bleeding there were no significant difference between both
groups. Any patient required reoperation. The only post-operative
complications demonstrated were urinary retention and skin flaps,
the former was presented in three patients, two of them belonging to
group A and one for group B. Three patients in group A developed
skin flaps. The post operative pain was assessed with a visual analog
scale, assessing at postoperative day one and seven, without observing
statistically significant difference between the two groups. Taking an
average of 4.8 pain in group A and 4.7 in group B. During the first day.
Significantly decrease was observed at the seventh day. The return to
activities was 11.2 and 10 days, respectively, showing no statistically
significant difference (Table 2).
Discussion
Hemorrhoidal disease is the most common disease of the anal
canal, being hemorrhoidectomy still the gold standard for the
management of this pathology; However, this procedure is still
associated with significant postoperative pain, bleeding and even
structural alterations of the anal canal stenosis.
It is for this reason that various techniques have been
developed for the treatment of this disease in order to reduce these
complications and postoperative discomfort, THD and Ligasure
have been used widely for the last years. Both techniques have been
demonstrated in several clinical trials a less postoperative pain and
a speedy resumption of everyday activities, when compared with
open or closed hemorrhoidectomy [4-9]. Although both procedures
are promising, they are also relatively new, so we still do not have
a long term follow up, that reveal their true usefulness, in regard
to their recurrence rate and/or possible long-term complications.
However, with the information we currently have, we know that both
procedures are safe, with low rates of short and midterm recurrence,
requiring a less surgical time and reducing the length of hospital stay
and the use of postoperative analgesics. It is the last three aspects
that definitely outweigh the cost of both devices. Without forgetting
that the recovery is also faster, with a speedy reintegration into work
activities, with a secondary positive impact in terms of cost that
involves this pathology. There are many studies that shown that
the use of THD for grade IV hemorrhoidal disease increases the
percentage of recurrence at almost 60%, with favorable out-comment
when performed in grades II and III [10-11].
Both techniques have proven to be reproducible and consisting of
simple and very specific steps to achieve the expected results, which
certainly is a plus for both techniques [11] and their minor surgical
times and short recovery periods.
Moreover intra-operative bleeding and postoperative pain
control as well as return to daily activities in both groups were similar.
In any group, the recurrence rate was recorded.
Any patient require reoperation, since 3 patients only present
minor complications, such as urinary retention, requiring two of
them physical therapy and the third a bladder poll. The cost of both
procedures was excluded in this study; however, considering only the
cost of the device, use Ligasure turned out to be more economical
when compared to the THD.
It is noteworthy that the authors do not have conflict of interest
in this study.
Conclusion
Our study supports that both Ligasure as THD techniques are probably very similar with respect to postoperative pain, recovery time and complications in modern surgery for treatment of hemorrhoidal disease. However, the Ligasure could have slightly more favorable postoperative immediate results and technical and economic advantages.
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