What is Emborrhoid?

//What is Emborrhoid?
What is Emborrhoid?2018-08-09T15:48:26+00:00

What is Emborrhoid?

With a prevalence of 4–35 %, hemorrhoidal disease is the most common anorectal condition. One of the main chronic symptoms is rectal bleeding. Its recurrence can alter the quality of life and, more rarely, cause anemia. Pain is less common, only occurring in the event of a complication (congestive exacerbation, external hemorrhoidal thrombosis, fissures). The most common treatment involves hygiene and dietary measures, phlebotonics and/or nonsurgical outpatient treatment (infrared photocoagulation, elastic band ligation).

The hemorrhoidal arteriovenous network is a normal vascular formation. There is a clear distinction between the external hemorrhoidal network below the dentate line, under the skin of the anal margin dependent on the pudendal artery (branch of the inferior rectal artery), and the internal hemorrhoidal network located in the upper part of the anal canal, above the dentate line, in the submucosal space depending on the superior rectal artery.

Internal hemorrhoids are now thought to result from an increase in arterial blood flow from the superior rectal artery into the hemorrhoidal cushion (corpus cavernosum recti)[1]. Replacement of muscle tissue by connective tissue causes an expansion of the vascular network of the anorectal submucosa, initiating a negative vicious circle of progressive vascular dilation and venous insufficiency leading to hemorrhoidal hyperplasia. This hyperplasia causes an increase in blood pressure, arterial inflow and anal pressure in the corpus cavernosum recti. The lower part of the rectum and the anal canal are known to be supplied with blood by the inferior and middle rectal arteries, both of which have origins at some distance from the inferior mesenteric artery (pudendal artery, iliac network)[2]. By contrast, the mechanical function of the corpus cavernosum recti is dependent on the influx of arterial blood from the branches of the inferior mesenteric artery: the superior rectal arteries.

Ten years ago, proctologists developed a new concept of treatment: elective transanal Doppler-guided hemorrhoidal artery ligation (DG-HAL). DG-HAL technique consists in the identification and ligation of the superior rectal arteries under transanal Doppler guidance. Ligation of the superior rectal arteries provides a significant reduction of arterial blood flow to the hemorrhoidal and is effective in treating hemorrhoid disease [3].

It was feasible that this concept could be compatible with embolization. We have so suggested that arterial ligation can be performed with coils in the terminal branches of the superior rectal arteries via the endovascular route.

The advantages of Emborrhoid and DG-HAL versus surgery are that it maintains the hemorrhoidal tissue in place, preserving anal continence, with no rectal wounds (no local care), significantly less pain and avoid the complications of open surgery, thus allowing a faster return to activity.
“Emborrhoid” embolization is performed using a right femoral route. The inferior mesenteric artery is catheterized using a Simmons catheter. The superior rectal arteries are then catheterized with a microcatheter. Coils used for the embolization are 0.018”, from to 2 to 3 mm in diameter.

Technical success of the Emborrhoid technique has been reported in up to 90 %. Clinical success of the Emborrhoid technique has been reported between 74 to 83 % of patients with no complications [2, 5].

Advantages

The main advantages of Emborrhoid technique are:

  • Patients have absolutely no pain

  • No major complication have been related to Emborrhoid and especially no ischemic or continence complication

  • This technique is available for outpatient

  • Patient can return to activity the day after embolization

  • Embolization does not close the door to a complementary treatment if mandatory

  • The technique is easy to perform in not more than one hour

There are many benefits of endovascular treatment including complete visualization of all the branches of superior rectal arteries and anastomoses with middle and inferior rectal arteries [6]. With DG-HAL, it is possible that not all arteries are detected, which can lead to incomplete treatment especially if there are anastomoses.

Obviously embolization eliminates the risk of direct anorectal trauma.

There are many patients who suffer from hemorrhoids but do not complain to physicians because they refuse to have an endorectal treatment. If we can offer a treatment for outpatients without pain, we believe more patients will seek treatment for this condition.

Given the preliminary results reported in our studies, we believe that there is sufficient evidence to include embolization in therapeutic options for patients with bleeding related to hemorrhoidal disease.

We have demonstrated that distal coil embolization of the superior rectal arteries to stop chronic bleeding is safe and effective.

References

1. Aigner F, Bodner G, Conrad F, Mbaka G, Kreczy A, Fritsch H. The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am J Surg 2004; 187:102–108

2. Moussa N, Sielezneff I, Sapoval M, Tradi F, et al. Embolization of the superior rectal arteries for chronic bleeding due to hemorrhoidal disease. Colorectal Dis. 2016 Jun 24. doi: 10.1111/codi.13430.

3. Infantino A, Altomare DF, Bottini C et al. Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids. Colorectal Dis 2012; 14:205–211

4. Vidal V, Louis G, Bartoli JM, Sielezneff Y. Embolization of the hemorrhoidal arteries (the emborrhoid technique): a new concept and challenge for interventional radiology. Diagn Interv Imaging 2014 95:307–315

5. Vidal V, Sapoval M, Sielezneff Y, De Parades V, Tradi F, Louis G, Bartoli JM, Pellerin O. Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases. Cardiovasc Intervent Radiol 2015; 38:72–8

6. Bilhim T, Pereira JA, Rio Tinto H, et al. Middle rectal artery: myth or reality? Retrospective study with CT angiography and digital subtraction angiography. Surg Radiol Anat 2013; 35:517–522