HET™ Bipolar system
We offer you to get acquainted with one of the latest minimally invasive procedures to eliminate hemorrhoids – HET™ Bipolar system .
of Hemorrhoid Energy Therapy – is a special device developed by U.S. company Medtronic, which has:
A Ligator that provides a tissue compression under the sensored control of the temperature.
Bipolar electrodes generating a heat energy.
A Built-in LED lighting to facilitate visual observation.
How is the ligation of the nodes done?
System HET™ affects patients vessels of the rectum. Coagulation occurs as a result of brief exposure of high temperature (60 degrees Celsius). A Hemorrhoidal node devoid of blood supply is getting atrophied.
The power and duration of the exposure of HET™ system is automatically adjusted. Compared to other methods of treatment of hemorrhoids, Hemorrhoid Energy Therapy has a more gentle impact on the body of the patient, is the most gentle intervention.
Duration is about 20 minutes.
Any patient is worried even if he is going to have a simple medical manipulation. Sometimes even a simple intramuscular injection, quite rightly, does not cause you positive emotions. For how long could you be “afraid of” agreeing to bipolar ligation?
We hasten to reassure – not for long. Your stay in the cabinet will not exceed 20 minutes. Agree, such a short period of time, can permanently relieve you from the pain associated with hemorrhoids, you can live through it.
Using this technique the doctor is able to work on related hemorrhoidal pathology, if any. The HET system™ is able to cover a larger area of problem zone than, for example, a laser surgery.
A Traumatic effect on the tissues of the patient is also less than with other types of interventions, since manipulation is done very precisely and with comparatively low temperature.
Reviews of patients with this intervention performed are excellent, without early or late complications been identified.
Safety and absolute scientificness of the method is officially confirmed by the American FDA. More than 10 000 of such interventions were performed in the United States without negative reviews.
Friendly and correct attitude of our staff will allow you to feel comfortable before and after the intervention. And the high quality of our services is guaranteed.
Sclerotherapy of hemorrhoids
The use of sclerosing agents in the treatment of hemorrhoids has quite a long history. Sclerosing treatment of hemorrhoids was applied even in the XIX century. Currently, sclerosing treatment of hemorrhoids is used rather widely. Effective and safe implementation of this technology is based not only on a thorough development of the methodology by a doctor, but also on the use of modern drugs and special accessories (anoscope with lighting, special syringe, needle, etc.).
Sclerotherapy is used in patients with a first, second, third stage of hemorrhoids and as a way to stop the bleeding, in patients with the fourth stage as a preparation for the ligation of hemorrhoids with latex rings or hemorrhoidectomy.
The occurrence of such complications of sclerotherapy as pain, paraproctitis, oleogranulomas, is related to the improper administration of the drug or with insufficient experience of the coloproctologist. Observance of the basic rules of sclerotherapy, including methods of drug administration to hemorrhoidal nodes, avoids complications both during and after the procedure.
Contraindications to sclerotherapy are inflammatory diseases of the anal canal and perineum, acute hemorrhoids, paraproctitis, fissure of anal canal. Combined Hemorrhoids with the lack of boundaries between external and internal hemorrhoidal nodes is also a relative contraindication to sclerosing treatment.
The results of sclerosing treatment of hemorrhoids
Criterias for evaluation of good results of sclerosing treatment, as well as of photocoagulation, is termination of bleeding and prolapse of nodes. Satisfactory result is considered as termination of prolapse of nodes, but a slight bleeding from the anus may remain. Unsatisfactory result – is a disease recurrence, continued bleeding and prolapse of nodes.
Positive immediate results are obtained in early stages of the disease, where the main and often the only symptom is a bleeding from the anus. In the third and the fourth stages of the disease where the main symptom is a prolapsed hemorrhoid, the number of good results is markedly reduced.
Complications of sclerotherapy are those phenomena which are manifested in the form of severe acute pain, often associated with the ingress of the drug into the muscle layer of the bowel, or inflammatory changes in the tissues, and require additional measures up to surgical intervention.
The occurrence of pain and thrombosis of external hemorrhoids usually is due to a violation of methods of procedure and the infiltration of sclerosing drug into the submucosal layer of tissue located distal to the dentate line, and also into the external hemorrhoids.
Complications after sclerosing treatment may be inflammatory. Thrombosis of external and internal hemorrhoids with perianal edema and hyperemia of the perineal skin is also possible. Such complications often occur after a simultaneous injection of the drug into three hemorrhoidal nodes. In practice, it’s better to avoid such methods for reducing the number of such complications. Thrombosis is possible due to use of sclerotherapy in so-called combined type of hemorrhoids, in the absence of clear boundaries between the external and internal hemorrhoidal nodes. With well defined external component, it is necessary to take a very strict approach to the choice of minimally invasive treatment, including sclerotherapy.
In rare cases of non-compliance with the manipulation techniques and due to getting the drug into the subcutaneous tissue, an acute subcutaneous submucosal paraproctitis may develop. Careful adherence to technique, strict control of the concentration and volume of the drug injected into the lumen of the node, compliance with the rules of asepsis and antisepsis will help to avoid this complication.
Treatment of hemorrhoids by infrared coagulation
The principle of this technique is to coagulate the leg of the internal hemorrhoid, under the action of the heat flow generated by a focused infrared beam sent through the optical fiber to the hemorrhoidal node.
The method of infrared coagulation
Infrared coagulator is used for coagulation, it consists of power block, manual applicator and a solid quartz light guide tip made of special heat resistant polymer.
The principle of the coagulator is that low-voltage halogen-tungsten lamp, which is located in the spherical reflector with a perfectly smooth gold plating, focuses the infrared luminous flow directed to the quartz light guide. The tip of the optical fiber made from a special polymer, which provides the transmission of infrared light without loss of thermal power and provides free contact with mucous membrane the internal hemorrhoid. A timer regulates the length of exposure of heat flow from 0.5 to 3 seconds.
Infrared light flow penetrates the tissue of hemorrhoid and converts into thermal energy, which causes coagulation of tissues. The depth of coagulation depends on the impulse duration.
The indication for infrared coagulation are internal bleeding hemorrhoids of the first or second stage, circular combined hemorrhoids of the first or second stage, in which internal hemorrhoids are located at the level of the anorectal line. This procedure is also performed in small bleeding internal nodes remaining after ligation of latex rings or hemorrhoidectomy.
The procedure is performed by the following method. On the gynecological chair, the patient takes a supine position with legs extended to the belly, located on the supports. If necessary, the procedure can be performed also in the knee-elbow position of the patient or in the side position.
To perform the intervention an anoscope with a tube of 6-8 cm length and a diameter of 18 mm is used, with a fiber illuminator or external light source. The anoscope is introduced into the anal canal so that the hemorrhoid is located in the lumen of the anoscope tube. The tip of infrared coagulator is introduced into the lumen of the anoscope tube and set in projection of the vascular pedicle, slightly pressing it to the mucosa. Then the coagulation is getting started. Moving the optical guide at 45° to the right and left, coagulation is performed in the 3-4 spots in the area of the pedicle of a node, leaving between them intervals of free mucosa up to 0.5 cm. Duration of each coagulation, depends on the size of the node, is from 1 to 3 seconds.
Optionally, in one step simultaneously coagulated up to three hemorrhoids. Re infrared coagulation is conducted in 12-14 days after the first treatment. In case of large hemorrhoids of 3-4 points additionally coagulated the surface of the node. During the procedure, patients often notice an increase in body temperature in the field of manipulation and, rarely, a sensation similar to the prick of the needle. These phenomena usually pass away within one hour after the manipulation.
Infrared coagulation on the background of ongoing bleeding is performed as follows. The anoscope in the rectum is set so that the bleeding node is located in the lumen of its end part. Cotton swab is used to thoroughly dry the surface of the node, the tip of the optical fiber is pressed to the bleeding site which is coagulated with the exposition in 3 seconds. All patients stop bleeding during the manipulation.
In patients with late stages of the disease (when along with bleeding there is a prolapse of nodes) combined techniques can be used. A major prolapsed nodes ligated with latex ligature and at the same time with this procedure coagulated two small haemorrhoids. It is also possible first to perform coagulation of prolapsed bleeding hemorrhoids, and after 14-16 days to ligate reduced in size prolapsed hemorrhoids.
The results of infrared coagulation
Depending on the stage of hemorrhoids and the severity of symptoms, from one to six stages of infrared coagulation is performed. At the same time, coagulation is exposed to from one to three nodes. With proper indications for the procedure, the treatment in one stage is carried out in most cases.
During 1-6 hours after infrared coagulation, patients may experience a feeling of discomfort. Sometimes during the first day there is a mild pain syndrome that, apparently, is due to coagulation of tissue in the sensitive area of the dentate line. In case of proven technology and precise guidance of the tip of the infrared coagulator on the pedicle of the hemorrhoidal node above the dentate line, the procedure is virtually painless.
After the infrared coagulation can develop the following complications: pain, thrombosis of the node, necrosis of the mucous membrane of the hemorrhoid, bleeding.
Pain syndrome is associated with the coagulation in the sensitive area of the anal canal, below the dentate line. The elimination of pain may be achieved by use of non-narcotic analgesics in combination with topical agents. In addition, the targeting coagulation of the pedicle of hemorrhoids located proximal to the pectinate line, reduces the probability of occurrence of pain syndrome.
Thrombosis of internal hemorrhoids is associated with an increase in area of coagulation, which in turn leads to the development of inflammation in the hemorrhoidal node. After the appointment of phlebotropic drugs and local anti-inflammatory treatment these phenomena subside.
In case of increase in the total area of coagulation more than 1 cm2 and increase in the duration of exposure of the heat flow on the tissues, develops necrosis of the mucous membrane of the hemorrhoid with the possible development of mild bleeding, which is usually resolved without any consequences. Anti-inflammatory liniments are prescribed in these cases.
To prevent the appearance of pain syndrome after infrared coagulation, it’s possible to coagulate the pedicle of the haemorrhoidal node or the bleeding area above the dentate line only. Necrosis and bleeding of hemorrhoids after the infrared coagulation can be prevented by adjusting the duration of the exposure of the heat flow so that it does not exceed 3 seconds and its area of impact does not exceed 0.5 cm2. When you create 2-3 sites of coagulation, the free areas of the mucosa between them should not be less than 3-5 mm. Keeping the duration of the exposure up to 3 seconds and coagulating up to 4 areas of mucosa of haemorrhoid, each with an area less than 0.5 cm2, good results are obtained in most cases.
Criterias of good results of minimally invasive methods, including infrared photocoagulation and ligation of hemorrhoids with latex rings are discontinuation of bleeding and prolapsing of the nodes. Satisfactory result is considered as termination of prolapse of nodes, and continuation of a slight bleeding from the anus. Unsatisfactory result — recurrence of bleeding and prolapse of the nodes.
This type of treatment is most effective in the initial stages of hemorrhoids. In later stages, this technique is effective only as a temporary measure to stop bleeding and does not affect the degree of prolapses of hemorrhoids.
Ligation of hemorrhoids with latex rings (or Rubber-band ligation)
Currently widespread among Coloproctologists in the post-Soviet countries got quite a simple and effective outpatient treatment of internal hemorrhoids – ligation of hemorrhoids with latex rings. In the 60-ies of the 20 century E. Barron has designed a special Ligator for ligation of internal hemorrhoids with elastic rubber ring, and this method rapidly became the Arsenal of treatment of hemorrhoids.
At the time a special device was developed, which helped to throw a circular ligature around the pedicle of haemorrhoid, made from a special latex rubber. After clamping of the pedicle and cessation of blood flow to the node, it`s rejected along with the ligature on 11th — 14th day after manipulation. As a result of gradual cutting of tissues by elastic ligature, after its rejection formed a stump, covered with connective tissue.
Ligation is hemorrhoids is performed in patients with second or third stage of hemorrhoids. At the first stage due to low intensity of hemorrhoids this procedure is not performed. In some cases the procedure can be performed in the fourth stage of the disease, i.e. with constantly falling hemorrhoids, but with distinct borders, without pronounced external hemorrhoids.
In the absence of clear boundaries between the external and internal hemorrhoidal nodes, performing of ligation is not considered appropriate. The lack of boundaries between external and internal hemorrhoidal nodes, as happens with the combined hemorrhoids, complicates and restricts the imposition of latex ligatures.
Contraindicated for ligation of internal hemorrhoids are inflammatory diseases: the fissure of the anal canal, chronic paraproctitis, proctitis in the inflammatory phase.
The technique of ligation of hemorrhoids with latex rings
The essence of the method consists in the following. A special vacuum Ligator, connected to a suction system to create a negative pressure, is bringing closer to the hemorrhoidal node through the anoscope. The suction is set ON and the hole in ligature is covered by a thumb of the right hand to create a negative pressure in the head of the tool. Due to the negative pressure the hemorrhoidal node retracts to the inside of the head. After reaching a negative pressure of 0.7-0.8 atmospheres by means of a trigger mechanism for a greater reliability two rubber rings are dropped down on the hemorrhoidal node and the thumb is taken off the hole on ligature, aligning the external pressure and the pressure in the head. Then the ligator is removed from the lumen of the intestine. The removal of ligator without pressure equalization is fraught with avulsion of haemorrhoidal node and bleeding.
Elastic rings made from natural rubber (latex), with outer diameter 5 mm and the inner 1 mm are used in the method. Feature of latex ring is the good elasticity and the gradual compression of the tissues with a gradual crossing of the pedicle of haemorrhoidal node during 12-14 days.
The technique of vacuum ligation is simple and convenient. In particular when using vacuum legator there is no need to use an assistant during the manipulation. In addition, the technique of vacuum ligation is used not only in cases of clearly limited pedicle of haemorrhoid, but also with circular internal hemorrhoids when it is difficult to determine the pedicle of the node. While technically correct procedure elastic ligature constricts the pedicle of node and is located 5-7 mm above the dentate line.
Procedure of ligation of internal hemorrhoids is usually conducted over two, three (most often) or more sessions. Best done in a single session – ligation of one hemorrhoidal node.
Sometimes it may be necessary to conduct additional (repeated) legation in the case of rather large hemorrhoids that does not allow you to fully capture the node by the head of vacuum ligator. In this case, re-ligation of the hemorrhoidal node should be no earlier than a month.
The results of ligation of hemorrhoids with latex rings
Ligation of hemorrhoids with latex rings allows you to avoid hemorrhoidectomy approximately in 80% of patients with hemorrhoids.
All procedures are performed on an outpatient basis, without disability. The vast majority of cases, the application of this technique in the 2nd and 3rd stage of the disease allows to achieve good results — to stop the blood excretion and prolapse of hemorrhoids.
At the 4th stage, the method of ligation with latex rings, is advisable to use only in patients with clear outliers of prolapsed nodes.
During the first two days after ligation, most patients report a feeling of a foreign body in the anal canal and not intensive pain, which is relieved by non-narcotic analgesics. These phenomena are not considered complications, they are associated with the clamping of the pedicle of haemorrhoidal node and do not require a special treatment.
- Thrombosis of external hemorrhoids.
- Rectal bleeding.
In some cases after the procedure of ligation the patient may experience pain. In most cases, a severe pain occurs after the simultaneous ligation of three hemorrhoidal nodes and because of ligation of the pedicle of haemorrhoid at the level of the pectinate line, i.e. in the region of the anus, equipped with pain receptors. To exclude the occurrence of severe pain syndrome it is necessary to strictly follow the rule of gradual ligation of hemorrhoids with an interval between treatments of at least 14-16 days.
If you experience an acute pain, persisting for 1-2 hours and not releasable with non-narcotic analgesics, re-anoscopy should be performed, and the imposed ligature is cut with thin scissors and removed.
It should be remembered that retraction of the hemorrhoidal node into ligator should be performed gradually and always under the visual control, not to let the dentate line to get into the latex ring. If you experience persistent pain, which can’t be relieved by analgesics immediately after ligation, and in cases when tissues of anal canal located distal from dentate line get into the ligature, the latex ligature should be cut with thin scissors through the lumen of anoscope and removed from the rectum.
In some cases after the procedure of ligation the patient may experience thrombosis of external hemorrhoids. The occurrence of this complication typically is due to the fact, that this procedure is performed in patients with mixed form of hemorrhoids, in the absence of boundaries between external and internal nodes. In most cases of thrombosis of hemorrhoids it’s possible to manage with conservative measures.
In the presence of diseases such as anal fissure and chronic paraproctitis, the procedure of ligation should be delayed until cure.
In about one case out of a hundred after ligation, a rectal bleeding requiring emergency measures is possible. Most often, this bleeding occurs because of an inaccurate choice of indications for the procedure of ligation (ligation of unexpressed hemorrhoids when the mass of the hemorrhoid may not be sufficient to hold the ligature – it can jump of during straining) or due to non-compliance of medical recommendations by patient to limit physical activity, normalization of bowel movement, nutrition and hygiene.
The cause of bleeding may also be performing of ligation with a single latex ring. While straining due to too much tension may occur rupture of the latex ring and bleeding developed. So it is advisable to perform the ligation only with two latex rings, especially in patients with large hemorrhoidal nodes.
Bleeding can also occur after stool at the first day after the procedure. Therefore, before the procedure it is necessary to prepare the colon with the same care as for hemorrhoidectomy and patients to should be warn about the undesirability of a stool at the first day after the manipulation.
The results of treatment allow us to consider the ligation with latex rings effective and radical method of treatment of hemorrhoids.