Articles on Rubber Band Ligations

The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids.

Aigner F, Bodner G, Conrad F, Mbaka G, Kreczy A, Fritsch H.

Institute of Anatomy, Histology and Embryology, Leopold-Franzens-University Innsbruck, Muellerstr. 59, A-6010 Innsbruck, Austria. felix.aigner@uibk.ac.at

Am J Surg. 2004 Jan; 187(1): 102-8.

BACKGROUND: The hemorrhoidal artery ligation has been used for submucosal ligation of hemorrhoidal arteries by means of an ultrasonographic transducer since 1995. The success of this technique depends on the submucosal course of these arteries. Our investigation deals with branches of the superior rectal artery which pierce the rectal wall where they cannot be reached by this method. METHODS: The branching patterns were investigated by means of 5 macroscopic preparations of adult pelves, histological section series of 35 fetal and 3 adult pelves impregnated in epoxy-resin, and transperineal color Doppler ultrasound of 7 proctologic patients and 28 volunteers. RESULTS: Additional branches of the superior rectal artery coursing in outer layers of the rectal wall were shown entering the rectal wall just above the levator ani muscle to supply the internal hemorrhoidal plexus (corpus cavernosum recti). CONCLUSIONS: The terminal course of the branches of the superior rectal artery is not only applied to the rectal submucosa. We have shown that additional branches may be detected by ultrasonography and should be taken into account by the operating surgeon.

Ano-rectal physiological changes after rubber band ligation and closed haemorrhoidectomy.

Bursics A, Weltner J, Flautner LE, Morvay K.

First Department of Surgery, Semmelweis University, Budapest, Hungary.

Colorectal Dis. 2004 Jan; 6(1): 58-61.

OBJECTIVE: The effect of treatment for haemorrhoids on ano-rectal physiology was studied in a prospective longitudinal follow-up study. METHODS: Thirty-six consecutive patients having II-III degree (Group I, 18 patients) or IV degree (Group II, 18 patients) haemorrhoids were studied. Group I underwent rubber band ligation while Group II underwent closed scissors haemorrhoidectomy. RESULTS: Patients in Group I had significantly lower maximum basal pressure (P < 0.05) and also significantly lower maximum squeeze pressure (P < 0.05) compared to Group II before treatment. Both basal and squeeze pressures dropped after haemorrhoidectomy (P < 0.001) whereas they remained unchanged after rubber band ligation (P > 0.1). The volume of first sensation was higher in Group II before treatment (P < 0.001) and remained so after treatment. Rectal compliance was higher (P < 0.005) in Group I before treatment. It increased significantly in both groups (P < 0.05, Group I; P < 0.001, Group II) after treatment. CONCLUSIONS: The results show a significant increase in anal pressures in constantly prolapsing (IV degree) haemorrhoids. Most of the physiological differences observed between the two groups were abolished after treatment. This suggests that these may be a consequence rather than a cause of haemorrhoids.

Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids.

Su MY, Chiu CT, Wu CS, Ho YP, Lien JM, Tung SY, Chen PC.

Digestive Therapeutic Endoscopy Center, Department of Gastroenterology, Lin-Kou Medical Center, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan, ROC.

Gastrointest Endosc. 2003 Dec; 58(6): 871-4.

BACKGROUND: This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of patients with symptoms caused by internal hemorrhoids. METHODS: A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients). The severity of the hemorrhoids was classified by using the grading system of Goligher. RESULTS: All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8 to 24 months). The mean number of band ligations per session was 2.86. The mean number of treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients (95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered uneventfully. CONCLUSIONS: Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for patients with symptoms caused by internal hemorrhoids.

Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids and mucosal prolapse.

Chew SS, Marshall L, Kalish L, Tham J, Grieve DA, Douglas PR, Newstead GL.

Colorectal Unit, Department of Surgery, Prince of Wales Hospital, Sydney, Australia.

Dis Colon Rectum. 2003 Sep; 46(9): 1232-7.

PURPOSE: Rubber band ligation is a common office procedure for symptomatic hemorrhoids. The aim of the study was to assess our short-term and long-term results of combined sclerotherapy and rubber band ligation in the management of hemorrhoids and incomplete mucosal prolapse. METHODS: Data on 6,739 patients who had previous combined sclerotherapy and rubber band ligation by the senior authors (GLN and PRD) were retrieved from the database dating between January 1976 and June 2000. These patients either had hemorrhoids or incomplete mucosal prolapse. Furthermore, questionnaires were sent to a random sample of 2,400 patients. Telephone interviews were performed for 600 of the nonrespondents. RESULTS: Of 6,739 patients (3,683 males; mean age, 46.7 years) in the database, 4,686 (70 percent) received the procedure once, and 2,053 (30 percent) received the procedure more than once. There were 5,689 patients (84 percent) who had their procedures performed consecutively within a planned period, and only 1,050 patients (16 percent) had repeat procedures after a period of more than 12 months from their last treatments. Thus, the recurrence rate was 16 percent. The overall complication rate was 3.1 percent, with minor bleeding being the major complaint. With regard to the questionnaire, 44 percent responded. The mean follow-up period was 6.5 (range, 1-11) years. There were patients who had residual symptoms of bleeding (19 percent), itch (21 percent), and lump (20 percent). However, 58 percent of patients who replied were asymptomatic. With satisfaction scores ranging from +3 to -3 (+3 indicating complete satisfaction and -3 indicating complete dissatisfaction), 90 percent scored >/=1, 9 percent scored 0 or less, and 1 percent did not specify a score. Hemorrhoidectomy was required in 7.7 percent of the responders. Of 600 phone interviews with the nonrespondents, 152 responded to the questionnaires. Although there was less satisfaction from the phone respondents, which may have accounted for the initial nonresponse, no statistical difference was detected in residual symptoms. CONCLUSIONS: Combined triple sclerotherapy and rubber band ligation is an effective treatment for early hemorrhoids and incomplete mucosal prolapse, with low rates of recurrence, complications, and hemorrhoidectomy, and it can be repeated easily.

Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study.

Bursics A, Morvay K, Kupcsulik P, Flautner L.

First Department of Surgery, Semmelweis University, 1082 Budapest, Hungary.

Int J Colorectal Dis. 2003 Jul 5

BACKGROUND AND AIMS. Doppler-guided hemorrhoid artery ligation is a new approach for treating hemorrhoids. Early and 1-year follow-up results of the procedure are presented and compared with those of closed scissors hemorrhoidectomy in a prospective randomized study. PATIENTS AND METHODS. Sixty consecutively recruited patients were randomized into two groups: group A ( n=30) was treated with standardized closed scissors hemorrhoidectomy and group B ( n=30) with Doppler-guided hemorrhoid artery ligation. The follow-up period was 11.7+/-4.6 months. RESULTS. The average need for minor analgesics was 11.7+/-12.6 doses in group A and 2.9+/-7.7 in group B. Patients in group A spent 62.9+/-29.0 hours in hospital postoperatively and those in group B 19.8+/-41.8 hours. Return to normal daily activities took 24.9+/-24.5 days in group A and 3.0+/-5.5 days in group B. Neither the disappearance (26 vs. 25 patients) nor the recurrence of preoperative symptoms (5 vs. 6 patients) differed significantly between the two groups. CONCLUSION. Both procedures were effective in treating hemorrhoids. The 1-year results of Doppler-guided hemorrhoid artery ligation do not differ from those of closed scissors hemorrhoidectomy. Doppler-guided hemorrhoid artery ligation seems to be ideal for 1-day surgery, and it fulfills the requirements of minimally invasive surgery.

Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.

Perez Vicente F, Fernandez Frias A, Arroyo Sebastian A, Serrano Paz P, Costa Navarro D, Candela Polo F, Ferrer Riquelme R, Oliver Garcia I, Lacueva Gomez FJ, Calpena Rico R.

Unidad de Coloproctologia. Hospital Universitario de Elche. Alicante, Spain. faperez@airtel.net

Rev Esp Enferm Dig. 2003 Feb; 95(2): 110-4, 105-9. [Article in English, Spanish]

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.

A comparison of the simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately, for the treatment of haemorrhoids: a prospective randomized trial.

Kanellos I, Goulimaris I, Christoforidis E, Kelpis T, Betsis D.

4th Department of Surgery, Aristotle University of Thessaloniki, Antheon 1, GR 55236, Panorama, Thessaloniki, Greece. ik@hol.gr

Colorectal Dis. 2003 Mar; 5(2): 133-8.

OBJECTIVE: To compare simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately for the treatment of 2nd degree haemorrhoids. PATIENTS AND METHODS: Between 1993 and 1996, 255 patients that suffered from 2nd degree haemorrhoids were divided into 3 groups of 85 patients, each to receive either simultaneous sclerotherapy for smaller and rubber band ligation for larger piles (SCL/RBL) in one session, or sclerotherapy (SCL), or rubber band ligation (RBL), respectively. After a period of 4 years all patients were examined and their symptoms were recorded. RESULTS: The patients of the SCL group developed significantly fewer complications after treatment compared to the other two methods (P < 0.001), which did not differ from each other. After the SCL/RBL treatment, significantly more patients were symptom free (46%) than after SCL (8%), P < 0.001. There was no significant difference between the SCL/RBL (46%) and the RBL (31%) groups (P = 0.217), although the combined treatment seemed to be more effective than rubber band ligation. Only 10% of the patients of the SCL/RBL group needed additional sessions 6-24 months after the initial treatment compared to 30% of the patients of the SCL group (P = 0.001). However, there was no significant difference between SCL/RBL and RBL (17%) groups (P = 0.151). CONCLUSION: The combination of sclerotherapy and rubber band ligation for treatment of 2nd degree haemorrhoids is significantly more efficient than sclerotherapy on its own.

A prospective randomised study of local anaesthetic injection after multiple rubber band ligation of haemorrhoids.

Gokalp A, Baskonus I, Maralcan G.

Department of General Surgery, Faculty of Medicine, University of Gaziantep, Turkey.

Chir Ital. 2003 Mar-Apr; 55(2): 213-7.

One hundred and forty-two patients with second and third degree internal haemorrhoids were randomised to rubber band ligation only (n = 72) or rubber band ligation + local anaesthetic injection (n = 70). Pain was assessed by the patients at intervals of 6 hours and 1, 2, 3 and 4 days after banding. Other symptoms, complications, analgesic requirements and patient satisfaction were also recorded for 10 days following the treatment. There was a significant reduction in pain at 60 minutes and 6 hours after the procedure in the rubber band ligation plus local anaesthetic injection patients compared with the rubber band ligation only group (P < 0.05), but there was no reduction in pain when local anaesthetic was used compared with rubber band ligation only on days 1, 2, 3 and 4 days after ligation. On day 10 after banding, there was no difference between the two groups with respect to symptoms such as nausea, feeling of heaviness and/or tenesmus, fainting; complications, analgesic consumption or overall patient satisfaction. Bupivacaine injection after multiple rubber band ligation may be useful in reducing pain during the first 6 hours of the postbanding period.

Long-term results of endoscopic hemorrhoidal ligation: two different devices with similar results.

Su MY, Tung SY, Wu CS, Sheen IS, Chen PC, Chiu CT.

Digestive Therapeutic Endoscopic Center, Dept. of Gastroenterology, Lin-Kou Medical Center, Chang-Gung Memorial Hospital, Chang-Gung University, Tao-Yuan, Taiwan.

Endoscopy. 2003 May; 35(5): 416-20.

BACKGROUND AND STUDY AIMS: To evaluate the efficacy of two different endoscopic hemorrhoidal ligation (EHL) devices for symptomatic internal hemorrhoid. PATIENTS AND METHODS: From November 2000 to February 2001, 218 consecutive patients with symptomatic internal hemorrhoids were enrolled. A total of 109 patients were treated with an EHL device 9 mm in diameter (group A); the rest were treated with a device 13 mm in diameter (group B). The patients' clinical presentations were rectal bleeding and prolapse. The severity of the hemorrhoid was classified using Goligher's grading. RESULTS: All patients were treated for one session, and were followed from 19 to 24 months (mean 22.4 months). The number of band ligations averaged 2.59 in group A and 1.68 in group B. Most patients had their hemorrhoids reduced by at least one grade (82.8 % in group A and 90.8 % in group B). Rectal bleeding was controlled in 108 patients (99.1 %) in group A and 109 patients (100 %) in group B, while rectal prolapse was reduced in 93 patients (85.3 %) in group A and 99 patients (90.8 %) in group B. Eleven patients in group A and 12 in group B experienced anal pain after treatment, and eight patients in group A and six in group B had mild bleeding. The patients' subjective satisfaction rates were 90.8 % in group A and 93.6 % in group B. The 1-year recurrence rates were 3.9 % in group A and 2.3 % in group B. CONCLUSIONS: Both EHL devices can effectively treat symptomatic internal hemorrhoids. A device with a smaller diameter requires more band ligations, but appears equivalent with regard to treatment outcome and complications.

Multiple hemorrhoidal ligation: a prospective, randomized trial evaluating a new technique.

Armstrong DN.

Georgia Colon & Rectal Surgical Clinic, Atlanta 30342, USA.

Dis Colon Rectum. 2003 Feb; 46(2): 179-86.

PURPOSE: A modified anoscope was developed, with lateral apertures at the left lateral, right anterior, and right posterior quadrants, to enable synchronous exposure and ligation of all three internal hemorrhoids. Results were compared with those for conventional multiple ligation. METHODS: Postligation pain, complications, and outcomes were compared between synchronous ligation with the new anoscope (synchronous group) and three-quadrant ligation with a conventional anoscope with similar overall dimensions (conventional group). RESULTS: Twenty-five patients were prospectively randomized to each group. Postligation pain and analgesic requirements were recorded up to 28 days, and postligation complications and outcomes were evaluated for a minimum of 6 months. Narcotic requirements were lower in the synchronous group, but this difference did not achieve statistical significance (P > 0.05, Student's t-test). Secondary hemorrhage occurred in 1 patient (4 percent) in the conventional group but resolved spontaneously. The synchronous group experienced significantly less pain during the ligation procedure and for 2 days afterward (P < 0.01, Wilcoxon's test). External hemorrhoidal thrombosis developed in 4 percent of the synchronous group and 12 percent of conventionally treated patients, all of whom responded to conservative treatment. Repeat ligation was required less often in the synchronous group (16 percent) than with conventional ligation (28 percent). Surgery (completion hemorrhoidectomy for external thrombosis) was necessary in one patient (4 percent) in each group. Anal stenosis developed in one patient in the synchronous group. CONCLUSION: The new anoscope provides improved exposure of all three internal hemorrhoids and permits optimal placement of the rubber bands; this may account for the decreased postligation pain and lower repeat ligation rates. Synchronous hemorrhoidal ligation is a less painful method of multiple hemorrhoidal ligation and may improve outcomes compared with conventional multiple ligation.

Massive life-threatening lower gastrointestinal hemorrhage following hemorrhoidal rubber band ligation.

Odelowo OO, Mekasha G, Johnson MA.

Division of Gastroenterology, Department of Medicine and Department of Surgery, Howard University Hospital, Washington, DC, USA. oodelowo@hotmail.com

J Natl Med Assoc. 2002 Dec; 94(12): 1089-92.

Hemorrhoids are common, and a significant proportion of patients who have hemorrhoids experience symptoms such as bleeding, pain and itching. Endoscopic hemorrhoidal ligation is a safe and effective technique indicated for the treatment of grade 1 to 3 hemorrhoids, with a high success and low complication rate. Complications, when they occur, are minor and may include painful thrombosed prolapsed hemorrhoids, slippage of bands, minor rectal bleeding and chronic longitudinal ulcer. Rare, potentially life-threatening complications are massive hemorrhage and pelvic sepsis. A case of massive, life-threatening lower gastrointestinal hemorrhage following endoscopic hemorrhoidal rubber-band ligation is presented. Our patient ingested aspirin intermittently following the procedure. In a study documenting complications after hemorrhoidal band ligation, two of three individuals requiring transfusion for massive hemorrhage were taking aspirin on a regular basis. The risk of massive hemorrhage after hemorrhoidal rubber band ligation is probably increased by ingestion of nonsteroidal anti-inflammatory drugs. It may be wise to withhold such drugs soon after the procedure, if feasible.

[Endoscopic hemorrhoidal ligation from the rectum]

Shioda Y, Onda M, Sakuma T, Hori M, Takasaki H, Hasegawa H.

Department of Surgery, Shioda Hospital, Chiba, Japan.

J Nippon Med Sch. 2002 Oct; 69(5): 451-5. [Article in Japanese]

Endoscopic hemorrhoidal ligation with a rubber band was carried out on 40 patients with internal hemorrhoids. All the patients were treated in the outpatient ward. Seven patients complained of mild to moderate aches in the early postoperative days, which were easily controlled by medication. One week after the treatment, no patient complained of pain. None of the patients had any postoperative bleeding. The results of this treatment were classified as good (no complaint or symptoms after the treatment), fair (at least some improvement), or poor (no change or worse than before the treatment). Twenty-nine of the 40 patients were classified as good, and the remaining 11 patients were fair. No patients were classified as poor. EHL is a harmless and painless procedure and is easily performed in the outpatient ward. When internal hemorrhoids of operative indication are detected by colonoscopy, EHL can be easily and simultaneously carried out.

Comparative study between multiple and single rubber band ligation in one session for bleeding internal, hemorrhoids: a prospective study.

Chaleoykitti B.

Department of Surgery, Phramongkutklao Hospital, Bangkok, Thailand.

J Med Assoc Thai. 2002 Mar; 85(3): 345-50.

OBJECTIVE: The aim of this study was to compare the cessation of bleeding and the complications between multiple and single ligation using high ligation technique. MATERIAL AND METHOD: All first-visit patients with bleeding internal hemorrhoids were studied and randomly divided into multiple and single ligation groups. High ligation technique was used. Patients visited the clinic in the second week and were invited to visit the clinic or completed questionnaires after one year. RESULTS: 109 patients were included in the study. 61 patients had multiple ligation and 48 patients had single ligation. The cessation of bleeding in one week occurred in 96.7 per cent of patients in the multiple group and 79 per cent of patients in the single group (p = 0.004). There were no differences between the multiple group and single group concerning postligation pain and tenesmus (6.5% vs 2%, p = 0.532), urinary hesitancy and frequency (6.5% vs 4%, p = 0.904), and rebleeding in one year (27.9% vs 34%, p = 0.710). No major complications such as massive bleeding and pelvic sepsis were noted. CONCLUSIONS: Multiple ligation of bleeding internal hemorrhoids in one session can stop bleeding better than single ligation with no more complications.

Rubber band ligation of haemorrhoids in the out-patient clinic.

Kumar N, Paulvannan S, Billings PJ.

Department of Surgery, Wrexham Maelor Hospital, UK. nkumar1402@hotmail.com

Ann R Coll Surg Engl. 2002 May; 84(3): 172-4.

Rubber band ligation (RBL) is an effective treatment for symptomatic haemorrhoids but carries significant morbidity. We performed a prospective study of 98 consecutive patients treated by RBL in the out-patient clinic. Immediate, intermediate (within 2 weeks) and late (within 2 months) complications were recorded. Immediate complications occurred in 66 (67.3%) patients. Pain was the predominant symptom in 50 patients (51%). Fifteen (15.3%) patients had vasovagal attacks and 1 (1%) had bleeding. Twenty-five patients (25.5%) were unable to perform normal activities on the day of RBL. One patient needed hospital admission for control of pain. Seventy four (75.5%) patients would have RBL if they needed further treatment for haemorrhoids. Symptomatic cure was achieved in 71 patients (72.4%). RBL is an effective treatment but with significant complications. Patients should be adequately warned, especially of pain and vasovagal attacks.