we retrospectively reviewed the results of dha performed between april 2010 and april 2011 at our institution .
the research and ethics committee of kunimoto hospital approved this study , and all patients provided written informed consent before participation .
the following inclusion criteria were applied : failure of nonoperative management , second- to fourth - grade hemorrhoids according to goligher 's classification , with mixed hemorrhoids including at least 1 large external hemorrhoid or hemorrhoids in an acute stage , such as thrombosed external hemorrhoids and strangulated hemorrhoids .
dha was performed under caudal epidural anesthesia , in the prone jackknife position , with the buttocks taped widely apart .
a fusiform incision was placed into the anal skin overlying the external pile ( fig .
we were careful to avoid cutting into the muscle sphincter below the hemorrhoidal vessels ( fig .
after dissection of the external pile to its pedicle , 2 - 0 vicryl ( ethicon , new jersey , usa ) was used to ligate the pile , which was excised at the dentate line . a running stitch using 3 - 0 monocryl ( ethicon , new jersey , usa )
a fusiform excision made in the anal skin overlying the external pile ( b ) .
cutting into the muscle sphincter below the hemorrhoidal vessels should be avoided ( c ) .
after dissection of the external pile to its pedicle , 2 - 0 vicryl is used to ligate the pile , which is excised at the dentate line .
the surgeon inserted a z - type proctoscope ( arakawa seisakujo , tokyo , japan ) with a distally opening window .
alta solution ( zione ; mitsubishi tanabe pharma co , osaka , japan ) was injected through a 25-gauge injection needle mounted on a 5-ml syringe according to a 4-step injection procedure as described previously .
briefly , alta was injected into 4 parts of the pile : submucosa at the superior pole of the pile , submucosa in the central part of the pile , mucous lamina propria in the center of the pile , and submucosa at the inferior pole of the pile .
the last part of the alta procedure was omitted for mixed hemorrhoids because these would be resected by distal hemorrhoidectomy .
the efficacy of dha was evaluated as the disappearance rate of prolapse , rate of postoperative pain , and rate of constipation at 28 days after surgery .
from april 2010 to april 2011 , we performed dha on 72 patients ( 38 men , 34 women ; median age , 54 years ; range , 2782 years ) .
overall , 8 patients had grade ii hemorrhoids , 59 had grade iii hemorrhoids , and 5 had grade iv hemorrhoids .
dha was performed for 1 hemorrhoid in 55 patients , 2 hemorrhoids in 16 patients , and 3 hemorrhoids in 1 patient .
the mean total injection dose of alta was 16 ml ( range , 625 ml ) .
postoperative complications included hemorrhage in 1 patient ( 1.4% ) , pyrexia in 1 ( 1.4% ) , and rectal ulcer in 1 ( 1.4% ) , respectively .
hemorrhages occurred at the distal hemorrhoidectomy site after 3 operative days and required stitching of the bleeding area .
rectal ulcers developed at the site of the alta injections a month after surgery , but they healed completely within a month of treatment with hemorrhoidal suppositories . at 28 days after dha , the disappearance rate of prolapse was 100% .
although spontaneous pain was not noted , pain during defecation and constipation were observed in 2 patients each ( 2.8% ) .
no prolapse recurrence after dha was observed during the median follow - up period of 6 months ( range , 136 months ) .
our data showed that dha is safe and effective , proving the combined effects of the safety of alta and curability of hemorrhoidectomy , for the management of mixed hemorrhoids .
ligation and excision ( le ) is the prevailing hemorrhoidectomy method whereby external and internal piles are selectively resected in a mass .
it is important to avoid excessive excision of the anal epithelial layer or mucous membranes because excessive excision may lead to complications such as postoperative pain , hemorrhage , prolonged healing , and anal stricture . unlike le , alta injection requires neither dissection of submucosa nor excision of any anoderm .
it can be performed in a short time , and there is very low risk of postoperative pain and complications . however , according to a study on recurrence after alta injection , the most frequent recurrence pattern was external pile recurrence ; therefore , it can not be used for treating external hemorrhoidal diseases , including mixed hemorrhoids or thrombosed external hemorrhoids .
furthermore , concomitant anal diseases such as skin tags and anal polyps are contraindications for treatment with alta injection .
in contrast , le has been the treatment of choice for various types of hemorrhoids .
therefore , dha ensures applicability by distal hemorrhoidectomy ; furthermore , the procedure is designed such that it minimizes complications .
first , almost the entire anoderm can be preserved by administering alta injection instead of performing le .
second , the extent of excision in distal hemorrhoidectomy is less than that in le ; as a result , alleviation of postoperative pain and prevention of hemorrhage from the edge of the wound can be expected .
postoperative secondary hemorrhage rarely arises from the vascular pedicle because the sites of ligation and excision are more distal than those in le and because alta injection causes a sclerosing effect on the internal piles .
significant complications of alta injection are rare , but misplacement of the injection may result in mucosal ulceration or necrosis , pyrexia , and prostatitis . in conclusion , dha was quick and easy to perform with a good short - term outcome , and it was associated with a low rate of complications .
 aluminum potassium sulfate and tannic acid injection ( alta ) is a useful and less - invasive treatment for internal hemorrhoids . 
 however , it is not a treatment option for external hemorrhoidal diseases , including mixed hemorrhoids . 
 distal hemorrhoidectomy with alta injection involves surgical resection of external piles , followed by injection therapy on internal piles . 
 we report technical details and the short - term results of this procedure in patients with mixed hemorrhoids . 
 seventy - two patients with mixed hemorrhoids treated between 2010 and 2011 were included . 
 the main outcome measures were the short - term response and complication rates . at 28 days after surgery , the disappearance rate of prolapse was 100% . 
 three patients ( 4% ) had postoperative complications , all minor in nature . no prolapse recurrence was observed within a median follow - up period of 6 months . 
 distal hemorrhoidectomy with alta injection appears to be a promising treatment option for patients with mixed hemorrhoids . 
Patients and Methods
Results
Discussion