Rubber-Band Ligation of Hemorrhoids
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For the majority of patients with hemorrhoids, outpatient treatment is feasible and sufficient. [1] Rubber-band ligation is one of the most common outpatient treatments available for patients with hemorrhoids. In this procedure, a rubber band is applied to the base of the hemorrhoid to hamper the blood supply to the hemorrhoidal mass. The hemorrhoid will then shrink and fall off within 2-7 days.
Rubber-band ligation is readily performed in an ambulatory setting. The procedure causes less pain and has a shorter recovery period than surgical hemorrhoidectomy. Its success rate is between 60% and 80%. [2, 3, 4]
A number of prospective studies have found rubber-band ligation to be a simple, safe, and effective method for treating symptomatic first-, second-, and third-degree hemorrhoids as an outpatient procedure with significant improvement in quality of life. [2, 3, 4, 5, 6] Hemorrhoid ligation has a limited morbidity, good results, long-term effectiveness, and good patient acceptance. It has been found to be safe even for patients with cirrhosis and portal hypertension and for patients on anticoagulation threrapy. [3, 4]
Hemorrhoid ligation is performed for first-degree, second-degree, and some cases of third-degree hemorrhoids when the patient complains of bleeding or prolapse of hemorrhoids. [7] Band ligation may also be considered for bleeding in severely anemic patients with fourth-degree hemorrhoids who are unfit for surgery.
Rubber-band ligation is contraindicated for the following:
Clinically, patients who have hemorrhoids usually present with bleeding, prolapse, pain (with thrombosis or ulceration), perianal mucous discharge, or pruritus. The complications of hemorrhoids are thrombosis, infection with inflammation, ulceration, and anemia.
Internal hemorrhoids are classified into four grades, as follows:
The initial treatment for symptomatic first- and second-degree hemorrhoids with a short history of bleeding, prolapse, or itching and pain is directed toward controlling constipation with dietary measures such as a high-fiber diet, sitz bath, stool softeners, laxatives, and various topical creams. [2, 3]
When medical treatment fails, ambulatory treatment is advised. Ambulatory treatments for hemorrhoids include injection sclerotherapy, rubber-band ligation, cryosurgery, infrared coagulation, and ultrasonic Doppler-guided transanal hemorrhoidal artery ligation (HAL). [8, 9, 10] Surgical treatment includes open or closed hemorrhoidectomy and stapled hemorrhoidopexy.
A proctosigmoidoscopy or anoscopy is always performed before any treatment for hemorrhoids is considered. In patients older than 40 years, polyps and other colonic pathology may be present; therefore, colonoscopy is advised in these patients before they are treated for hemorrhoids. A colonoscopy or barium enema should be always performed before any treatment for hemorrhoids is considered in the following cases [3] :
It is now widely accepted that piles are nothing more than a sliding downwards of part of the anal canal lining. [2] It is therefore obvious that treatment measures have to address reduction of the prolapse as well as reduction of blood flow to the hemorrhoid mass. The principle of outpatient treatment is to fix the mucosa above the prolapsing hemorrhoid. Preceding lateral internal sphincterotomy under local anesthesia may be done simultaneously for patients with high sphincter tone associated with first-degree hemorrhoids.
Because of the risk of hemorrhage, rubber-band ligation is absolutely contraindicated in patients on anticoagulant therapy. Patients taking aspirin should stop the medication at least 14 days before the procedure. [2]
The rubber rings must be applied on an insensitive area well above the dentate line to avoid postprocedural pain.
The clinician should carefully examine the patient for anorectal complains before embarking on rubber-band ligation. Failure to recognize a septic process in this region may lead to fatal sepsis with extensive cellulitis and gangrene after the procedure.
The multicenter HubBLe trial compared the outcomes of rubber-band ligation with those of HAL in 370 patients aged 18 years or older who presented with second- or third-degree hemorrhoids, including some who had previously undergone band ligation. [11] The primary outcome was recurrence at 1 year; the secondary outcomes were recurrence at 6 weeks; hemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness.
The 1-year recurrence rate was 30% for HAL and 49% for rubber-band ligation; however, when multiple band ligations were performed, the recurrence rate fell to 37.5%. [11] Symptom scores, complication rates, EQ-5D-5L scores, and continence scores did not differ significantly between the two groups, and patients who underwent HAL were found to experience more pain in the early postoperative period. HAL was more expensive and was judged unlikely to be cost-effective.
Guttenplan M. The Evaluation and Office Management of Hemorrhoids for the Gastroenterologist. Curr Gastroenterol Rep. 2017 Jul. 19 (7):30. [Medline].
Corman ML. Hemorrhoids. Brown B, McMullan E, LaPlante MM. Colon and Rectal Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 1: 177-244/8.
Bernal JC, Enguix M, López García J, García Romero J, Trullenque Peris R. Rubber-band ligation for hemorrhoids in a colorectal unit. A prospective study. Rev Esp Enferm Dig. 2005 Jan. 97 (1):38-45. [Medline]. [Full Text].
El Nakeeb AM, Fikry AA, Omar WH, Fouda EM, El Metwally TA, Ghazy HE, et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008 Nov 14. 14 (42):6525-30. [Medline]. [Full Text].
Forlini A, Manzelli A, Quaresima S, Forlini M. Long-term result after rubber band ligation for haemorrhoids. Int J Colorectal Dis. 2009 Sep. 24(9):1007-10. [Medline].
Reese GE, von Roon AC, Tekkis PP. Haemorrhoids. BMJ Clin Evid. 2009 Jan 29. 2009:0415. [Medline]. [Full Text].
Lu LY, Zhu Y, Sun Q. A retrospective analysis of short and long term efficacy of RBL for hemorrhoids. Eur Rev Med Pharmacol Sci. 2013 Oct. 17 (20):2827-30. [Medline].
Wallis de Vries BM, van der Beek ES, de Wijkerslooth LR, et al. Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation. Dig Surg. 2007. 24(6):436-40. [Medline].
Roka S, Gold D, Walega P, et al. DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study. Eur Surg. 2013 Feb. 45(1):26-30. [Medline]. [Full Text].
Scheyer M, Antonietti E, Rollinger G, Lancee S, Pokorny H. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol. 2015 Jan. 19 (1):5-9. [Medline].
Brown S, Tiernan J, Biggs K, et al. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technol Assess. 2016 Nov. 20 (88):1-150. [Medline]. [Full Text].
Sajid MS, Bhatti MI, Caswell J, Sains P, Baig MK. Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis. Updates Surg. 2015 Mar. 67 (1):3-9. [Medline].
Patel S, Shahzad G, Rizvon K, Subramani K, Viswanathan P, Mustacchia P. Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin. World J Clin Cases. 2014 Apr 16. 2 (4):86-9. [Medline].
Pradeep Saxena, MBBS, MS Professor, Department of General Surgery, All India Institute of Medical Sciences, India
Pradeep Saxena, MBBS, MS is a member of the following medical societies: Association of Colon and Rectal Surgeons of India, Association of Surgeons of India
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
The author gratefully acknowledges the contributions of Dr. Ashish Kumar Dwivedi, Resident Surgical Officer, Dr. Sandeep Prajapati, Resident Surgical Officer, and Dr. Narayan Das Kewalani, Department of Surgery, Gandhi Medical College and Hamidia Hospital, for their help with the development and writing of this article.
Rubber-Band Ligation of Hemorrhoids
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