Literature Overview:

HAL-RAR Methods
DG-RAR for the treatment of symptomatic grade III
and grade IV haemorrhoids: a 12-month multi-centre,
prospective observational study
S. ROKA (*) – D. GOLD (**) – P. WALEGA (***) – S. LANCEE (****) – E. ZAGRIADSKY (*****) –
A. TESTA (******) – A. KUKREJA (*******) – A. SALAT (*)
(*) Department of Surgery, Medical University of Vienna, Austria
(**) Professorial Department of Surgery, St Vincents Clinical School, University of New South Wales, Sydney, Australia;
Department of Surgery, North Hampshire Hospital, Basingstoke, UK
(***) 3rd Department of Surgery, Collegium Medicum, Jagiellonian University, Krakow, Poland
(****) Department of Surgery, Landeskrankenhaus Bludenz, Bludenz, Austria
(*****) Medical Coloproctology Center, Moscow, Russia
(******) Department of Surgery, General Surgery Unit, Ospedale San Pietro Fatebenefratelli, Rome, Italy
(*******) Ratandeep Surgical Hospital and Endoscopy Clinic, Ahmedabad, India
Ultrasound-guided techniques represent a new treatment option in the treatment of haemorrhoids. Doppler-guided
haemorrhoidal artery ligation (DG-HAL) proved efficacious in early haemorrhoidal disease, but lacks efficacy for stages
III/IV. For these patients, haemorrhoidal artery ligation (HAL) has been combined with a running suture to reduce
prolapsing haemorrhoidal tissue (recto-anal repair (RAR)).
A prospective observational study was conducted in 184 patients with grade III (58%) or grade IV (42%) haemorrhoids in
seven coloproctological centres. Primary endpoints were the recurrence of symptoms and need of further treatment
(medical or surgical).
Post-operative complications were seen in 8% of patients. After a follow-up of 3 months, 91% of patients were free of
symptoms and 91% of patients were satisfied with the result. After a follow-up of 12 months, 89% of patients were free
of symptoms and 88% were satisfied with the result. Nineteen per cent of patients received further medical or surgical
Doppler-guided recto-anal repair (DGRAR) proves to be an effective treatment option for the treatment of advanced
haemorrhoidal disease that shows equal results to other established treatment options.
Eur Surg 2013 February; 45(1): 26-30

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Literature Overview:
HAL-RAR Methods
Color-coded Doppler sonography of the anorectum.
Is Doppler-guided hemorrhoidal artery ligation effective?
Koloproktologische Klinik, Klinikverbundes St. Antonius und St. Josef, Wuppertal, Germany
The highest priority in treating hemorrhoids is the alleviation of transanal bleeding and prolapse in advanced stages. In
addition to the traditional surgical methods, which are always associated with excision of hemorrhoidal tissue, newer
methods offer a more pathogenetically oriented approach. In addition to stapled hemorrhoidopexy, reduction of the
arterial flow into the corpus cavernosum of the rectum and reduction of mucosal prolapse and parts of the hemorrhoids
to the regular site within the anal canal can also be used. The hemorroidal artery ligation (HAL) rectoanal repair (RAR)
method is an effective alternative. It is questionable whether ligation of the artery is sufficient or success of the method is
due to secondary mechanisms, such as fibrosis or fixation of the mucosa.
Material and Methods:
In a prospective study 15 patients were examined preoperatively and postoperatively at defined intervals following
HAL/RAR using 3D endosonography and color-coded Doppler sonography.
It was found that the DG-HAL could effectively prevent the main trunks of the afferent arteries connecting to the corpus
cavernosum of the rectum and was maintained even after 3 months. Smaller residual vessels remained unaffected.
The DG-HAL method can effectively stop arterial inflow into the corpus cavernosum of the rectum and was
demonstrated by postoperative color-coded Doppler studies.
coloproctology 2012 · 34:124–130
Literature Overview:
HAL-RAR Methods
Outcome of stapled hemorrhoidopexy versus dopplerguided
hemorrhoidal artery ligation for grade III
Department of Surgery ‘A’, Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
To evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with
grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation

Operative and follow-up patients’ data were prospectively collected for patients undergoing either SH or DGHAL by a
single surgeon during a 2-year period. A retrospective comparison between patients’ outcome operated by one of the
two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first
bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6 weeks, 6, 12, and
18 months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by
a standardized questionnaire that was conducted during the last visit 18 months postoperatively.
A total of 63 patients underwent SH (aged 52 ± 3.2 years) and 51 patients underwent DGHAL (aged 50 ± 7.3 years).
DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1 ± 1.4 vs. 5.5 ± 1.9
for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete
functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from
persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH
patients reported greater satisfaction compared with DGHAL patients at 1 year postoperatively.
Both SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids.
DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence
rates and lower satisfaction rates compared with SH.
Tech Coloproctol (2011) 15:267–271