Hemorrhoidal disease (HD) is a prevalent and debated proctologic condition (1). According to the severity of the disease (2), different treatment options, ranging from dietary-lifestyle measures to surgical treatment, have been proposed (3–5). However, the commonly adopted Goligher Classification (2) does not comprehensively consider the etiopathogenesis, the symptoms of the disease, their influence on the quality of life (QoL) (6), and need to be supplemented with clinical characteristics.

In the last few years, non-excisional surgical treatments have gained increasing popularity because they allowed to reduce most patients’ discomforts, such as post-operative pain and recovery of working independence (7), with the advantage of keeping in place a physiologically useful tissue both for the defecation and continence. The Transanal Hemorrhoidal Dearterialization (THD), firstly described in 1995 (8), represents a valid choice in patients with II to IV degree HD (9), despite possible recurrences, whose risk is higher the greater the severity of the disease (10, 11).

Several variants of THD procedure have been described in recent years: doppler-guided hemorrhoidal artery ligation (DGHAL) (12), targeted mucopexy (13) and Anolift (14). The DGHAL allows the surgeon to identify and ligate the terminal branches of the superior rectal artery that feed the hemorrhoidal plexus. Frequently, the surgical indications are also expanded to the prolapses of hemorrhoidal tissue by carrying out standard mucopexy (12, 13) or recent Anolift procedure, conceived to overcome the inadequacy of the needle shape (14). However, no technical variant has been shown to be superior to the other while the surgeon's experience can improve the outcomes (5, 10, 15).

In 2018, the American Society of Colon and Rectal Surgeons (ASCRS) clinical practice guidelines listed DGHAL with mucopexy among surgical treatments for hemorrhoids (16). A consensus statement from the Italian Society of Colorectal Surgery (SICCR) (9, 17), aiming at establishing an evidence-based approach to HD, described THD and DGHAL techniques as associated with lower postoperative pain and faster recovery than excisional hemorrhoidectomy (i.e., Milligan-Morgan and Ferguson procedures, or radiofrequency hemorrhoidectomy), but carries higher recurrence rates [Level of evidence 1, Grade of recommendation A (18)]. The current recurrence rate ranged between 3% and 20%, with 4.1–17.8% of patients required reoperation (13).

The aim of the present observational study is to show the outcomes of the last 75 THDs performed in our center. We provide a critical review of the literature, giving evidence-based recommendations to improve patients' postoperative QoL.

Hemorrhoidal disease affects 50% of the over-50 people worldwide (1). Etiology is complex and not fully understood. In many cases, hemorrhoids are associated with conditions that increase pressure in the hemorrhoidal venous plexus, such as straining during bowel movements secondary to constipation. Other associations include obesity, pregnancy, chronic diarrhea, anal intercourse, cirrhosis with ascites, pelvic floor dysfunction, and a low-fiber diet (26).

The increase in prevalence in developed countries led to the need to organize fast-track procedures, with short operative times, very early discharge, and rapid return to work activities (27). Anyway, when conservative treatment fails, consisting of a diet rich in fiber, lactulose, and flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) (28), surgery is a feasible and suitable option, optimally improving the patient's QoL (9). Debate continues about the best surgical technique of management of mild-severe HD (12–14). Recent literature demonstrates that when compared to conventional hemorrhoidectomy, modern non-invasive surgical procedures for internal hemorrhoids, such as THD, reduce postoperative pain and facilitate a quicker discharge (7, 29). Indeed, although the “true” etiopathogenesis is still debated (mucosal prolapse (30) or “vascular hypothesis”), the THD technique would treat both causes. To date, the use of Doppler transducer is controversial (31). Nonetheless, while effective DGHAL reduces vascular flow to the hemorrhoid pads, mucopexy resolves the prolapse, resulting in THD being safe and effective in both primary and recurrent hemorrhoids (27).

The rationale of the potential clinical benefit of THD in HD is based upon three main cornerstones: 1.

Therapeutic alternative in non-eligible patients. After rubber band ligation of hemorrhoids, secondary bleeding normally occurs in 10 to 14 days and patients taking anti-platelet and/or anticoagulant medication may have a higher risk, with some reports of massive life-threatening hemorrhage (32). However, Hite et al. reported that the risk of bleeding complication does not appear to be increased in patients taking clopidogrel (33). In 2016, Atallah et al reported similar rate of postoperative morbidity and hemorrhage between anticoagulated patients and who were not taking anticoagulant therapy (34), proving the safety of THD.

In our series, we focused on four different points in time post-operatively: at 1 week = T1, at 2 weeks = T2, at 1 month = T3, and at 6 months = T4. We evaluated the occurrence of symptoms such as soiling, bleeding, itching, tenesmus, and pain as well as disease recurrences. Moreover, we measured the Vaizey incontinence score and the HSS at T1, T3 and T4. Overall, we found out that our patients moderately experienced bleeding (8% of patients at T1 and 1.3% at T2) and pain (37.3% of patients at T1% and 12% at T2), which decreased dramatically in the following controls. At T4 most of the symptoms were completely gone except for some patients who still experienced soiling (5.3%) and tenesmus (8%), thus documenting the absence of severe complications, such as bleeding and pain at T4. The novel Anolift technique may allow for a more even distribution of the tension along the suture lines and reduce the risks of creating a pocket in the rectal lumen, resulting in a lower rate of persistent rectal tenesmus (up to 1 in 10 patients at 6 months after surgery). Moreover, median Vaizey incontinence score decreased until reaching the minimum score at T4. Post-operative HSS highlights the efficacy of THD, which definitively results in improved QoL of patients. Lastly, recurrence rate was surprisingly low with only 2 cases (2.7%), probably as a result of a limited postoperative follow-up.

Interestingly, in our previous experience, neither 30-days severe postoperative complications nor postoperative readmission were registered; tenesmus occurred in 75% of patients underwent THD for degree II and III, which, however, solved spontaneously on the first postoperative day (27). Even though other studies had much higher number of patients to work on, the results of our study were somewhat similar to those of Ratto et al. showed even better outcomes in bleeding and pain 1 month after surgery and in recurrence rate (10). In the present study, THD has a low rate of symptom relapse and recurrence even in stage IV disease. We argue that high recurrence rate following THD, as reported in previous literature, could be influenced by technical experience (49).

Nowadays, the treatment of HD constitutes a narrow-minded approach that doesn't account for patients' needs, expectations and personal characteristics often leading to a blurry definition for success of surgical procedures in the long term and not compelling for an approach tailored to every single patient (50–52). The surgeon's experience seems to be the only key factor in the decision on surgical technique. Consequently, it remains unclear how much the surgeon's skill affects the outcome of patients (8).

The THD is a safe and effective atraumatic technique associated, not influencing sphincter complex or anal function, with the best short-term clinical and surgical outcomes (rapid symptoms relief, lesser surgical site infection (53) and postoperative complications). Fast postoperative recovery, early discharge, and quickly return to normal daily activities and works substantially improves patient's QoL (54).

The main limitation of our observational study is a small cohort of enrolled patients, even given that all procedures were performed by the same expert surgeon, and a limited follow-up. Despite its exploratory nature, our study offers some insight into the “real” clinical practice. Further prospective studies are necessary to implement the paucity of evidence still available, investigating, on one hand, long-term outcomes, QoL and patients' satisfaction, and, on the other hand, predictive factors of recurrence.

THD is a safe and effective procedure for selected patients with hemorrhoids of every degree, with no significant differences in the rates of post-operative complications or recurrences, and improved patient's QoL. We recommend THD as a valid therapeutic option for Goligher's degree II and III hemorrhoids.