Preserving anatomy, restoring function: urgent hemorrhoidopexy for massive grade IV thrombosed prolapse

Excerpt

Hemorrhoidal disease (HD), characterized by pain, bleeding, and/or prolapse, significantly impairs the quality of life in affected individuals. While conservative measures and lifestyle modifications can manage mild to moderate symptoms, surgical intervention is often necessary for chronically severe cases. Goligher grade IV hemorrhoidal prolapse, characterized by irreducible prolapsed hemorrhoidal tissue, is a challenging scenario. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines recommend hemorrhoidectomy for patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with grade IV prolapse [1]. Hemorrhoidal artery ligation (HAL) is a viable treatment option for grades II–III HD, and in experienced hands, also for grade IV HD [2]. HAL is associated with reduced postoperative pain, fewer postoperative complications, and a quicker recovery when compared to excisional hemorrhoidectomy, albeit with a higher risk of recurrence [2]. In a randomized study, Ahmad et al. [3] showed that overall control of bleeding and recurrence rates were similar between HAL with and without Doppler guidance in grades I–III after 1 year of follow-up. Additionally, there were no significant differences in secondary outcome measures (pain, soiling, and itching), suggesting that HAL can be effectively performed without the use of a Doppler transducer. In a more recent comparative study in patients with grades II–III HD, the use of Doppler guidance did not reduce recurrence risk and increased operative times [4]. …