HEMOROİD NEDİR?

Halk arasında basur olarak bilinen hemoroid anüs ve rektum hastalıklarının başında yer alır. Anüs ve rektum, boşaltım sisteminin çıkış kapısı olup yaklaşık yirmi çeşit hastalığın görülebildiği ve pek çok hastalığın da indirekt belirtilerinin izlenebildiği yerdir. Bu bölgenin hastalıklarına proktolojik hastalıklar ve proktoloji ile ilgilenen hekimlere de proktolog denir. Hemoroid, anüs içindeki hemoroidal toplar damarların zaman içinde anormal genişleyip kırmızı ve mor torbalar (memeler) şeklinde dışarı sarkması, (Resim 1 ve 2) bazen aşınıp delinerek dışkılama sırasında sık sık, parlak kırmızı kanamalar yapması, bazen memelerin aniden pıhtı ile dolup şiddetli ağrı, ödem, iltihaplanma, yaralanma ve ağrı yapmasıdır.

HEMOROİDİN OLUŞMA SEBEPLERİ

Birinci sebep kabızlıktır.. Ayrıca, kolit, proktit, enterit gibi barsak enfeksiyonları; içki, tahriş edici aşırı acılı gıda tüketimi; yetersiz hijyen, anüs içi hemoroidal damar duvar yapısının doğuştan zayıf olması veya sonradan zayıflayıp torbalanması; prostat büyümesi ve kabızlık nedeni ile tuvalette uzun süre oturmak ve aşırı ıkınmak; gün boyu oturmak veya ayakta kalmak; aşırı yorgunluk; portal hipertansiyon; hamilelik myoma uteri, over kisti vb. gibi karın içi büyük urlar; kronik ökrürük, şişmanlık gibi karın ve damar içi basınçlarını artıran başka hastalıklar genel sebepler arasında sayılabilir.

HEMOROİD ÇEŞİTLERİ VE TEDAVİSİ

Hemoroidler öncelikle iç (internal) ve dış (eksternal) olmak üzere ikiye ayrılırlar. Hemoroidlerin çoğu iç hemoroid olup bunlar 4 derece olarak sınıflanır. Ayrıca basit ve komplike; tromboze, akut ve kronik olmak üzere alt sınıflara ayrılırlar.. Anüsün dış kenarındaki eksternal hemoroidal damarların aniden noktasal, tarzda cilt veya mukoza altına kanamaları ve pıhtı oluşturmaları da bir başka hemoroid çeşidi sayılabilir. 

1) Grade I (1. Derece) Hemoroidler: Hemoroid memesinin yukarı konumda kalıp, anüs dışına çıkmayıp ancak anoskop ile içeriye girildiğinde görülebilmesi halinde 1. derece hemoroid söz konusudur. Kendini sadece kanama ile belli eder. Bu memeler genellikle ağrısız olup, 1 cm'den daha küçük boyutlu, gergin ve ince duvarlı kanamaya hazır iç memeler şeklindedir ve ele gelmezler 

TEDAVİ: 1. derece hemoroidler lastik bantla bağlama, sklerozan ilaç enjeksiyonu, halk arasında LASER olarak bilinen infirared ışık koagülasyonu gibi konservatif tıbbi yöntemlerle tedavi edilebilir; ameliyat gerekmez. Bazan sadece melhem, uygun diyet, ılık su oturma banyosu ve istirahat yeterli olabilir. Ancak hazırlayıcı sebepler araştırılıp onlar da ayrıca tedavi edilmelidir; örneğin asıl sebep akut bir barsak enfeksiyonu veya ishal ise; sadece antibiyotik ve ishal diyeti uygulaması bile yeterli olabilir. Cerrahi girişim gerektirmezler. 

2) Grade II (2. Derece) hemoroidler: Bunlar dışkılama sırasında tuvalette ıkınınca anüs dışına çıkan ve ele gelen, ayağa kalkınca anal kanal içine çekilip kaybolan, ağrısız, 1 - 3 cm çapında Hemoroid memeleri olup, taharetlenirken genellikle püskürür tarzda veya hızlı damlalar şeklinde kanama yapar.Kanamalar bazan bir iki ay ara verebilir, bazan aylarca, her tuvalet çıkışında az da olsa görülür. Ve zaman içinde mutlaka kansızlık yapar ve bazan da aniden alevlenip büyüyerek anüs dışında kilitlenip kalarak acilleşebilir.

TEDAVİ: İkinci derece Hemoroidler yine cerrahi tedavi gerektirmezler. Bağlama, sklerozan ilaç enjeksiyonu veya infrared ışık koagülasyonu ile tedavi edilirler. Ayrıca uygun diyet, büzüştürücü ve antibiyotikli melhemler, ılık su oturma banyoları ve ağrı kesiciler tedaviye eklenmelidir. 

3) Grade III (3. derece) hemoroidler: İç (internal) hemoroid memelerinin kolayca anüs dışına çıkması, sık sık pıhtı ve ödemle birlikte ağrı yapması, üzerinde iltihap ve aftlar şeklinde yaraların ve kanlı akıntının olması; içeriye itilmediği sürece anüs dışında kalması veya içeri geç çekilmesi halidir. 

TEDAVİ:Tedaviye duruma göre önce tıbbi ve konservatif yöntemlerle başlanır; çok az vakada cerrahi eksizyon gerekir. Bunlarda en ideal yöntem lastik bant veya infrared koagulasyon uygulamaktır (Şekil I - II). 

4) Grade IV (4. derece) hemoroidler: Yıllarca süren kronik kabızlık hallerinde eski iç ve dış hemoroidlerin topluca aşağı sarkması, tuvalette veya koltukta çok oturma sonucu, memelerin büyük, ağrızsız, sulu, ıslak pakeler halinde anüs dışında çepeçevre yerleşip temelli kalmasıdır. Kronikleşmiş grade IV hemoroidli hastaların, iyi temizlenememe ve sürekli mukuslu ve iltihablı akıntılar, kaşıntılar ve az fakat sık sık kanama sorunları vardır. Memelerin üzerine oturunca hastanın canı yanar. 

TEDAVİ: Pekçoğu iyi bir tıbbi tedavi, kabızlığı önleyici bol posalı diyet, düzenli tuvalet alışkanlığı gibi tıbbi ve hijyenik tedbirlerden kısmen yarar görürler. Bir kısmında lastik bant veya skleroterapi ve infrared ışık ile koagülasyonu yeterli olabilir; ancak çoğunda cerrahi tedavi endikedir; ancak cerrahiye engel varsa, ömür boyu, konservatif tıbbi yöntemlere devam eder ve daima bol su, bol sebze, bol meyva alırlar; asla çay, kahve, kola, rafine gıda ve baharat alamazlar. 

HEMOROİD KOMPLİKASYONLARI

Hemoroid komplikasyonlarının başlıcaları:

a) Uzun süreli kanamalar sonucu anemi ve buna bağlı hipotansiyon, halsizlik, iştahsızlık ve solukluktur. 

b) Memelerde yaralanma ve iltihaplanma sonucu lokal ve sistemik ateş. 

c) Strangulasyon, yani dışarda duran hemoroid memelerinin; stres, alkol, ağır yemek, kabızlık, mushil kullanımı ve ishal gibi bir nedenle aniden pıhtılarla dolması sonucu şişip tamamının anüs dışına fırlaması ve orada kilitlenip kalması, anormal şişmesi ve şiddetli ağrı yapması. Bu safhada hemoroid memelerinin kan dolaşımı bozulmuştur ve dolayısı ile nekroz ve şiddetli ağrı gelişir. Artık geriye itilemez ve el değmez ve dışkılamaya, fitil koymaya, hatta melhem bile sürmeye izin vermez; dışkılama ve günlük yaşam ve bütün işler engellenir; ağrı ve kanamalar, enfeksiyon ve ateş yüzünden halsizlik ve iştahsızlık gelişir. Hemoroidin en kötü şeklidir. Tedavi aciliyet gerektirir. Duruma göre önce konservatif tıbbi yöntemlerle başlanır. Gerekirse anında genel anestezi ve regional anestezi ile cerrahi eksizyon veya trombektomi, sistemik ve lokal antibiyotik uygulanır.

HEMOROİD VE SPASTİK KOLON HASTALIĞINDA DİKKAT EDİLMESİ GEREKENLER VE DİYET

1. Düzenli, dakik, kahvaltı ve tuvalet . Tuvaletten 5 dakikada çıkın.Gerekirse tuvalete günde 2 kez gidin.
2. Kahvaltı dahil her 3 öğünde,mutlaka bir tabak çoban salata yiyin.
3. Öğünlerinizde özellikle ıspanak, bamya, pırasa, semiz otu, yeşil fasulye gibi sebzeli yemekler. Mümkünse çorba, börek türü her şey sebzeli olsun
4. Her öğünde bir tabak dolusu hoşaf veya erik, incir, üzüm, kayısı gibi meyveler yiyin.
5. Tahıl,mısır ve baklagiller gibi lifli gıdalar ve kepekli ürünler tüketin.
6. Her yemekten sonra oda sıcaklığında bol ılık su için.
7. Her öğünde mutlaka Melisa çayı için ve Keten tohumu alın. Keten tohumunu herhangi bir tabak yemeğe bir tatlı kaşığı kadar katın.
8. Tuvalette aktif, hızlı kanama olunca hemen kalkın ve 10 dk uzanıp istirahat edin.
9. Çay, kola, muz, beyaz ekmek, sandviç, kurabiye ,gofret, çikolata, pirinç pilavı, makarna, su böreği vb. gibi posasız ürünleri kısıtlayın. Bunlardan illa da yerseniz, birlikte bol sebze, meyve de yiyin ve bol su için.
10. Soğuk içeceklerden uzak durun; içecekleriniz oda sıcaklığında su, erik, kayısı cinsinden olsun.

 

25-29 MAYIS 2005 - AVRUPA CERRAHLARI CERRAHİ ARAŞTIRMA KONGRESİNDE SUNDUĞUMUZ YAYINLAR.

SIMPLE  VASCULAR LIGATION OF THE SYMPTOMATIC HEMORRHOIDS:ATRILE OF 102 CASES

Nihat Bengisu, Serap Pamak, Erol Kisli, Sebahattin Aytekin

Proctology Office, Istanbul, TURKEY

SUMMARY

         From June 2004 to April 2005 we have induced simple hemorrhoidal vascular ligation (HVL), in 98 consecutive 77 male and 21 female patients with symptomatic hemorrhoidal disease who have attendet with prolapsing,bleeding,itching or aching anal swellings. We have ligated   the  arterial and venous vasculature of the symptomatic Grade 2, 3 and some Grade 4 hemorrhoidal piles, together, at once, without isolating the arterial branches and without the aid of a  Doppler flowmeter. The unswollen or innocent piles were have been left untouched. Frequently we have ligated 4 or 3 but never more then 5 piles or less than 2 swollen piles and we have resected the heavy Grade 4 and thrombosed piles if presenet.

         HVL was successfull to treat bleeding  in %98 of cases;prolapsing in  %97  of cases; pain in %95 of cases and wet anus or pruritus ani in %94 of cases.

         Only  2 cases of late bleeding, 2 cases of  anal fissure. Only 2 hemorrhoidal  recurrency has been seen in 10 month follow up.

Simple hemorrhoidal vascular ligation(HVL) also seems to be a very promising technique for treating the symptomatic hemorhoids,as like as  hemorrhoidal arterial ligation(HAL) and Longo technique.

INTRODUCTION

        Since Morinaga first had  introduced transanal hemorrhoidal arterial ligation(HAL) or dearterialization of the symptomatic hemorrhoids by 1995 soon, several very similar studies have been reported that confirming the new method(1,2,3,4,5,6)(Norman Sohn,Bursics A,Shelygin IuA,Arnold S,Muller-Lobeck H).It seems to be a  promising innovative ,and also  encouraging alternative method  by the time,as all the others  were in the past. .

       In that, it is announced that a Doppler flowmeter was essential in isolating and ligating at least 6  arterial branches of the diseased and also innocent hemorrhoidal piles, with the claim of shrinking  the presenting prolapsed cushions and also  obviating the probable hemorrhoidal recurrencies in other sites(1,2).

       A claim from a few author was that; don’t to ligate the corresponding venous vasculature,as it might be hazardous(1,2);however it is almost impossible to isolate the corresponding veins ,even with the aid of Doppler.While in the hemorrhoidopexy technique of Longo(7),the hemorrhoidal veins are  ligated together with the accompanied arteries, with no hazardous.However we have  observed only 2 cases of anal thrombosis,which we have atributed them to our of technical error.

        While we still believe that the hemorrhoidal disease is an arteriovenous sacculation of the internal hemorrhoidal cushions due to long straining, it means more than %25 of the sitting time(Corman) or long sitting for any reason, like for constipation in spastic colon or habitual  newspaper reading on the toilet where the venous tension and the venous engorgment increases due to regurgitation, inevitabely. We don’t believe that  the anorectal areterial tension increases in squating  or in any other position,but the venous tension might have increased by straining in the squating position with a mecanism of regurgitation. If it had been an exact parameter of an arterial condition;than more and more  of the population had to experienced the hemorrhoidal disease .

        So, we stil say that it is very reasonable to obliterate  the venous vasculature, also not the  arterial structure, alone, as we all do in sclerotherapy and infrared coagulation.

        Therefore we have modified the technique, to be a more simple one and which will not necessisate  an expensive device  like a Doppler flowmeter; for it may not be available in many conditions.

PATIENTS AND METHOD

In this study,98 consecutive adult patients with symptomatic hemorrhoidal disesase,have been treated by hemorrhoidal vascular ligation(HVL),between the ages of  21-68 years ;whose complaints were bleeding in 90%, prolapsing in 85%,  pain in 18% and wet-anus or pruritus ani in %9;or the  combination  2 or 3 of them (Table 1).

Table 1:HEMORRHOIDAL SYMPTOMS  AND FINDINGS IN CASES SELECTED   FOR HVL

To confirm the symptomatic pile we have induced anoscopy in every case. A cleansing enema  was applied in dirty cases ;so the symptomatic piles became more evident and ready to treat.

The cases  indicated  for HVL; an intravenous 0,9%NaCl solution with drip infusion was started in Sims position ; then 0,1 mg /Kg Dormicum(Midazolam) was induced for an half hour conscious sedation.In any painful sensetion ,intravenous Ketamin  1-2 mg/Kg  and local aenestesia was given right through the  site of ligation just  before tightening the knots.

No serious,morbity was seen due to Midazolam ;but nausea and vomiting due to Ketamin in several cases.

 All of the Grade 1, 2,3 ;and even the  some of the medium size Grade 4 piles ,have been ligated  ,but the thrombosed or seriously prolapsed or large Grade 4 piles have been resected in the way of Fergusson technique,in the same session.

We have induced 8 suture technique by 2 or 3/0 Vicryl ,which have inserted the 1’rst needle step 3-4 cm proximally of  the dentate line,and the second step, 1 cm more proximally ,with the aim of to retract  each corresponding  pile into the anal canal. In 20 cases with  large protruding or mixed piles,we have inserted  2 or 3 more  steps   distally or proximally,to have a sufficient retraction or hemorrhoidopexy.

 We have also started to treat the predisposing factors of hemorrhoidal disease,like to left habitual long sitting and long straining  on the toilet,abondoning tea,coffe,cola taking,1 week before the planned HVL,if possible.We have advised  to take flaxseed (Linum usitatissimum) , with the bulking diet,permanently.

  RESULTS

 Most of the patients were male with spastic colon history.Whole of them used to strain or wait more than 10 minutes on the toilets some times more then 30 minutes. Most of the patients had no regular defecating time, nor  satisfying  defecation and gass passing.

Most of the patients had at least  3 traditional  hemorrhoidal piles which we have ligated  all in such cases but in many times we have ligated 4 or 5 piles.

More  then  half of the  syptomatic hemorrhoids were in  mixed type that means combinating type of internal and external hemorrhoid.

All the prolapsing internal ,mixed and external  hemorrhoidal piles,  have been  retracted into the anal canal,just at the  the end of the opration but two, which one of tem was resected on second week for the continuing of preoperative pruritus ani.

Two patients had experienced hemorrhoidectomy,2 patients had infrared coagulation and 3 patients had rubber band ligation, 4 cases had painfull  anal fissure before all of which have got well after operation.

In the first few weeks of the study we have met ,peroperativ pain in 8 cases ,inspite of intravenous Midazolam and local aenesthesia. So in the subsequent cases we have added Ketamin injections when needed.

Two cases  have experienced  anal fissure after HVL due to  the operative manuplation ,one of which  needed lateral anal sphincterotomy for subsiding  of  postoperative anal pain at end of second week.

All the patients could have gone home after the sedation had weared off within  45-60 minutes. Three of our cases have cotinued to bleed until the 1rst,2nd and 3rd days,respectively which they have  subsided spontaneosly but no heamatocrit reduction have been encountered.While 1 patient  bleeded on the 8th day,which had lovered  the heamatocrit from 34% to 28%.

In 2 cases  anal trombosis had been obserwed one of wich  needed trombectomy, with no event.

Approximately half of the oversewn  cases had complained of  anal pain for 1-5 days which had been controled by several Diklofenak injections, have been satisfied by the resection of the prolapsing single pile, inspite of HVL.

 We have met no hazardous event due to the combined ligation of arterio-venous hemorrhoidal vasculature.While ,even in the  Doppler guided operations,it is very reasonable that some of the venous vasculature have to  be ligated together with the arteries because,anatomically the superior ,middle,and inferior hemorrhoidal veins,which drain  blood from the tissues of the canal,correspond to each of the hemorrhoidal  arteries(7)(28,106,199,CORMAN,p178) .As we see in Longo technique ,all the corresponding veins are ligated together with the arteries;but no hazardous is seen(8)(Longo).So the claim to isolat  the arteries through the Moricon slit is very suspicious ,because every one knows well that all the peripheric arteries and veins run together. Also we don't find essential to ligate the innocent hemorrhoidal vasculature for prevention of new hemorrhoid formation while we find essential to prevent the chronical  constipation by a dietary program. 

Table  2:OUTCOMES AFTER HEMORRHOIDAL VASCULAR LIGATION  IN THE 1st MONTH

         -In our series hemorrhoidal vascular ligation HVL was successful in 96% for subsiding  of bleeding, in 90% for shrinking or retracting  of the piles,and in 88% for reliefing of pain.

        -Almost all patinets  have found the treatment satisfying ,but only 2;who have been sutisfied after the resection of the prolapsing piles.

COMMENTS

    Bleeding  and prolapsing  were almost  the standart or the most common complains  in this study.The bleeding hemorrhoids  were almost all internal or mixed type,while the external types were  seen  not to bleed frequently,but in occasion ;and the main complaint about of them was obstructing sense.

The  troublesome finding was the painful, thrombosed ,tender  piles in 12 cases,and Grade 4 piles  in 8 cases;which have given some pain after resection,comparing to the HVL;whic all of them have been resected in style of Fergusson.

The  oversewing or shrinking  the mixed huge prolapsing Grade 3  or some mild Grade 4 hemorrhoids ,may be disputed for inducing the postoperative  pain due to the aproximating  sutures very near to the dentate line, but,as a gratitude, it was less then resected cases;and has controlled the prolapsing or outside swellings, wet anus  and also the pruritus ani ,more then expected;almost as well as the  resection. However ,the patients seemed not  to  bother it so much ,because  the shriking of the swellings ,subsiding of bleeding or wet anus ,surely was more important then a temporary pain, for them.

The simple HVL or hemorrhoidopexy seems to be very effective in  controling the hemorrhoidal bleeding and prolapsing,and so the aching and itching,even if in he huge mixed hemorrhoids so that it may applied in mild Grade 4 hemorrhoids also as Arnold(..)  and Shelygin(...),have applied to all of the grades, already. As we have observed in   our huge and in a few Grade 4 hemorrhoids now we are  more hopefull that also many of Grade 4 hemorrhoids can be ligated successfuly, if the resembling radices should have been ligated by two different 8 sutures instead of one 8 suture..The retracting and fixating function of the 8 sutures have worked more then we had expected;almost as well as the Longo technique;in which the Longo technique,the retracting function  of the piles  is managed by resection of a 1,5-2 cm rectal mucousal ring just at the level of level of our 8 sutures;remember that both of the techniques are a kind of hemorrhoidopexy.

Only 3 patients had continued to have minute bloody stool postperatively ,which have subsided  on the 2nd and 3rd days,speontaneosuly. They were mixed,huge prolapsing hemorrhoids and it has could not be  proved if the bleeding was to be a continuing type or a suture complication.

The late  bleeding on the 8th day was due to eroding or  cutting of  a shrinking  Vicryl suture the anal mucosa  near  at the dentate line, who had a bleeding mixed huge hemorrhiod.It might also be due to long tiring working on the 8 th postoperative day. He was a floor maker have been working in squating position  for 22 years,and also he was  a chronical constipate which has continued until the late bleeding day. He had bleeded for several years and his  heamatocrit was 30% in 1rst attending time so his operation had been postponed for 2 weeks to restoring the bloog loss. .He had already addaptated to the aenemia due to the slow and chronical bleeding for several years;and he had not needed transfusion  before, nor in the operative  and neither in  the late postoperative bleeding time; however he had suffered of an acute sencope with palor and the lovered blood tension, as 90/50 mmHg,and the pulse rate was 104/min by the end of the late postoperative bleeding,which was not  a  vascular oozing and has easily subsided  by the electrocautery at emergency,under local aenestesia. It can be said that ,as a caution,it may prefered to resect the suspicious bleeding mixed  piles or  may be better to prolong the hom stay.

 Anal pain was seen  in the prolonged  prolapsing piles,and particularly  in the  thrombosed of some piles all which have been resected so it have returned to operative pain and could have subsided by injectional anelgesics in postoprative days.

Almost all of the constipated hemorrhoidal  patients were emotionaly  sensible, very  bussy ,or very hard workers,or had some family problems ;many of them were  suffering of  psychosomatic disorders like gastritis,peptic ulcer, sleeping problems etc. So we can say that  many of them have irritable or spastic colon  leading  to constipation,then to sympmtomatic hemorrhoids.However we have  not confirmed the spastic colon disease by barium enema,but almost all the patients had mild or moderate abdominal colics  and swere gaseous distension ,sheep like interrupted stool,oversecreation of viscous  mucus in the rectal lumen at the first ispection,before cleansing enema in many cases as almost a routine  symptom or finding in such cases.

We have prefered to resect the   huge and severly symptomatic prolapsed  mixed external   type piles if the patients have agreed with us ,but we have never offered  HVL to them for the reason that they must be accepted as Grade 4 hemorrhoids as Sohn and collagues say they must be resected(Norman Sohn) .

Peroperative and also postoperative  pain was our sole   troublesome problem in the beginning  of the study,probaly  due to  manuplations and heavy 2/0 Vicryl sutures   which we have solved the former one  by Ketalar ifusion ,or by extra local injection of oue aenestezic coctail;and  the later one by Diklofenak  İM injections when needed.

The cases with hemorrhoidopexy needed more anelgesics and some more home stay ,and  also sitz baths  to control pain.However one of them bleeded sverly on the 8th postoperative day,but he did not need transfusion.

However we  had hasitated during ligating the some huge and mixed  grade 3 piles,

The 8 month  results of  HVL in this study are  encourraging,but  the  long term results must be considered,which we are  hopefull taht they also will do well, particularly in the  cases  who will  obey to the diatery program.We believe that the hemorrhoidal reccurrencies likely have to be seen if the therapy or the dietary program  is interrupted;because spastic colon is a relapsing disease ,particularly when the patient don’t take care of  his/her psychological and dietary demands.For the last one year we have  added flaxseed (Linum usitatissimum) to diet to of all  constiapated patients. We have found  the flaxseed as an important participant in solving the spastic colon type constipation ,and also some psychosomatic  disorders, like gastritis,colonic distention  and colics ,some ; sleeping disorders.

We still find essential to limit tea, cola, coffe, cold and gasseous drinks  and refined food intake which is a matter of education.

Almost all of  the cases have been psycologically very sensible individuals or hard workers,or living with in stressing conditions  for several years and so spastic colon disease   has been found to be the leading factor  of the constipation proceeding the  hemorrhoidal disease. Almost all the cases were have been defecating step by step or as in too many divided portions,permanently,for what ever long time they have been straining or siting on the toilet..

In the begining of the study, some difficulties like lacking of   a slit on the standard anascopes;adaptation time to a flute like ansocope or Hill –Ferguson retractor,to recognize the swollen or symptomatic piles,and some less comfortability comparing to  the Morinaga device.However it is very possible  to be trained after several applications,particularly with the aid of Dormicum and Ketamin aided local enesthezia;even with no local aenesthezia in some cases.

HVL is an  office procedure like HAL and as efficient  as it but may not be as comfortable as it becuse of lacking a Doppler flowmeter.

REFERENCES

1.     Morinaga K,Hasuda K,Ikeda T.A novel therapy for internal hemorrhoids:ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjuction with a Dopple flowmeter.Am J Gastroenterology 1995;90:610-3.

2.     Sohn N,Aronoff J S,Cohen F S,Weinstein M A.Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy.Am J Surgery 2001;182:515-519.

3.     Bursics A,Morvay K,Kupcsulik P,Flautner L.Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid aretery ligation:a randomized study.Int J Colorectal Dis 2003 July 5(Epub ahead of print).

4.     Shelygin IuA,Titov Aıu,Veselov VV,Kanametov MKh.Results of ligature of distal branches of the upper rectal artery in chronic hemorrhoid with assistance of Doppler  ultrasonography.Khirurgiia(Mosk) 2003;1:39-44.

5.     Arnold S,Antonietti E,Rollinger G,Scheyer M.Doppler Doppler ultrasound assisted hemorrhoid artery ligation.A new therapy in symptomatic hemorrhoids.Chirurg 2002 Mar;73:269-73.

6.     Muller-Lobeck H.Ambulatory hemorrhoid therapy.Chirurg 2001 Jun;72(6):667-76