Background
Approximately one in three Europeans suffers from haemorrhoids, painful piles or anal prolapse at least once in his life time. Symptomatic haemorrhoids are cause by arterio-venous high pressure zone with vascular hyperplasia combined with an inflammatory process at the level of the ano-rectal canal. An efficient and safe treatment for moderate to severe haemorrhoids is the “Barron” rubber band ligation.
Haemorrhoid ligation is one of the most common outpatient treatments available for patients suffering from symptomatic haemorrhoids. The procedure consists in applying a rubber band to the base of the haemorrhoid to strangulate the blood supply to the prolapsing haemorrhoidal tissue. The haemorrhoid will than shrink and falls off within 2-7 days. Rubber band ligation are usually performed in an ambulatory setting in an outpatient clinic. The procedure causes less pain and has a shorter recovery period than any other form of treatment foremost following open surgical procedures. If indication and technique are well followed, the success rate is quite high and range between 60% and 80%.
A number of prospective studies have found rubber band ligation to be a simple, safe, and effective outpatient procedure treating symptomatic first-, second-, and third-degree haemorrhoids with significant improvement in quality of life. Haemorrhoid ligation has a limited morbidity, good results, long-term effectiveness, and good patient acceptance. It is safe during pregnancy and even so for patients in poor health as in liver disease, portal hypertension and even for patients on anticoagulation treatment.
Overview
Internal haemorrhoids are classified into four grades, as follows:
- First degree – Veins of anal canal increase in number and size, and they bleed on defaecation
- Second degree – Haemorrhoids prolapsed outside the anal canal but reduce spontaneously (see the image below)
- Third degree – Haemorrhoids protrude outside anal canal and require manual reduction
- Fourth degree – Irreducible haemorrhoids that remain constantly prolapsed
Indications
Haemorrhoid ligation is performed for first-degree, second-degree, and some cases of third- and fourth degrees haemorrhoids when the patient complains of bleeding or haemorrhoidal prolapse. Band ligation may also be considered for bleeding in severely anemic patients with fourth-degree haemorrhoids who are unfit for surgery.
Contraindications
Haemorrhoid ligation is relatively contraindicated for the following:
- Patients using anticoagulants
- Any infection or septic process in the anorectal region (eg, perianal abscess, proctitis, or colitis)
- Acute thrombosis of haemorrhoids.
- In presence of large grade IV haemorrhoids where surgery may offer faster results
- Hypertrophied anal papilla where surgery offers better results
- Chronic anal fissure (surgical treatment is more appropriate)
Band ligation should not be done if there is insufficient tissue to be pulled inside the band ligator drum
Technical considerations
Best practices
Clinically, haemorrhoids usually present with bleeding, prolapse, pain (in presence of thrombosis or ulceration), perianal mucous discharge, or pruritus. The complications resulting from non-treated haemorrhoids are thrombosis, infection with inflammation, ulceration, and anaemia.
Second-degree haemorrhoids.
The initial treatment for symptomatic first- and second-degree haemorrhoids with a short history of bleeding, prolapse, or itching and pain is directed toward controlling painful stool evacuation with dietary measures such as a high-fibre diet, sitz bath, stool softeners, suppositories, laxatives, and various topical creams.
When medical treatment fails, ambulatory treatment is advised. Ambulatory treatments for haemorrhoids include injection sclerotherapy, rubber band ligation, cryosurgery, infrared coagulation, and ultrasonic Doppler-guided transanal arterial ligation. Surgical treatment includes open or closed haemorrhoidectomy and stapled haemorrhoidopexy.
Procedural planning
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 primordial before any treatment is envisaged. A colonoscopy or barium enema should be always performed before any treatment for haemorrhoids is considered in the following cases:
- If there is suspicion of colonic disease based on patient’s symptoms and clinical evaluation
- When haemorrhoids do not appear to be the main cause of bleeding
- When bleeding is continuous even after hemorrhoid ligation
It is now widely accepted that piles are nothing more than a sliding downwards of part of the anal canal lining. It is therefore obvious that treatment measures have to address reduction of the prolapse as well as reduction of bloodflow to the haemorrhoid tissue. The principle of outpatient treatment is to fix the mucosa above the dentate line. Praeceding lateral internal sphincterotomy under local anaesthesia may be done simultaneously for patients with high sphincter tone associated with first-degree haemorrhoids.
Complication prevention
Because of the risk of haemorrhage, rubber band ligation is relatively contraindicated in patients on anticoagulant therapy. Patients taking aspirin should stop the medication at least 7 days before the procedure. In patients under coumarin who cannot stop only one rubber band should be placed per treatment.
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 recommanding rubber band ligation.
Failure to recognise an inflammatory process in this region may lead to complications.
Periprocedural Care
Patient education and consent
Formal consent should always be obtained before placement of rubber bands to treat haemorrhoids because some complications have been reported in randomized controlled trials.
Patients should be advised that there is a recurrence rate of about 20-25% in 5 years.
Stool softeners and bulk agents should be prescribed, and the patient should avoid straining for bowel movements.
The patient should be warned about the possibility of bleeding after the procedure and after 1-2 weeks when the rubber rings are dislodged. If the patient thinks that bleeding is severe or persistent, he or she should contact the surgeon.
In cases of pain or fever, the patient should come back for consultation. A sitz bath may be advised to keep the anal area clean and hygienic to prevent infections and reduce pain. The patient should be advised to avoid heavy lifting or strenuous activities for 3-4 days.
Equipment
Equipment for haemorrhoid ligation includes the following:
- Barron hemorrhoidal ligator with rubber rings/bands (see the image below)
- Haemorrhoid-grasping forceps if not iusing suction
- Proctoscope/anoscope
- Light source (torch)
- Gauge piece
- Artery forceps
Barron haemorrhoidal ligator with loading cone and grasping forceps.
Patient preparation
A proctoclysis enema is given just before the procedure. For lubrication and local anesthesia, 5% lidocaine jelly is applied locally in the anal canal. The patient should be in the left lateral position with buttocks projecting well over the operating table.
Monitoring and follow-up
A single treatment can achieve satisfactory results. If the symptoms of bleeding and prolapse due to hemorrhoids are not relieved, further band ligation or other conservative treatment may be tried. If the symptoms are not controlled after three sessions, haemorrhoidectomy may be considered.
Technique
Procedure
Usually, one or two haemorrhoids are ligated at a time. Any remaining haemorrhoids may be ligated after a period of 4-6 weeks.
A Barron haemorrhoidal ligator with a suction device is used. The ligator has a drum at one end over which rubber bands are loaded. It is connected with a 30-cm shaft to the handle, which has a trigger to release the bands and a suction hole to suck to haemorrhoidal tissue.
A loading cone is screwed over the drum of the Barron hemorrhoidal ligator. Two rubber rings/bands are slipped to load the ligator (see the first image below). The hemorrhoid-grasping forceps is then passed through the drum of the ligator and is now ready to grasp the hemorrhoid (see the second image below).
Loaded rubber rings on drum of Barron hemorrhoidal ligator.
Loaded band ligator ready for use.
A proctoscope/anoscope is inserted into the anal opening. The haemorrhoids are visualized, and the most prominent hemorrhoid is addressed first. The assistant holds and maintains the position of the anoscope, while the operator
holds the preloaded Barron band ligator with the grasping forceps. The internal hemorrhoid is grasped with the forceps about 1 cm proximal to the dentate line and maneuvered into the drum of the ligator (see the image below).
If the patient complains of pain, a more proximal point should be selected for band ligation.
Grasping forceps holding the hemorrhoid.
The hemorrhoid is pulled taut through the drum of the ligator (see the first image below). The ligator is then pushed up against the base of the hemorrhoid, and the trigger is released to apply two rubber rings/bands to the base of the hemorrhoid (see the second image below). The process is repeated for other haemorrhoids.
Hemorrhoid held taut, with drum of ligator pushed against base of hemorrhoid and trigger released.
Rubber bands applied on hemorrhoid.
Alternatively, a suction hemorrhoid ligator may be used. This instrument draws the hemorrhoidal mass into the drum through suction; therefore, the grasping forceps is not required. After the pile mass has been adequately drawn into the drum by means of suction, the trigger is released to apply the rings to the base of the hemorrhoid.
Multiple pile masses may be ligated, but more than one banding session spaced over 3-4 weeks may be required.
Barron band ligation for hemorrhoids.
Complications
Most complications of the procedure are minor and self-limiting; they can be managed on an outpatient basis.
Complications of hemorrhoid ligation include the following:
- Pain (32%)
- Vasovagal symptoms (dizziness and fainting)
- Bleeding (1-5%)
- External hemorrhoid thrombosis (2-3%)
- Ulceration
- Infection
- Sepsis
- Fournier’s Gangrene
Some discomfort in the anal region may be felt for a few days and is usually relieved by sitz baths and analgesics. In case of severe pain, removal of the rings may be required. The rubber ring can be removed with a stitch-cutter.
Early (24 hours) and late haemorrhage (1-2 weeks after the procedure) may be significant, and patients should be advised to keep a watch on the amount of blood loss. If bleeding is observed, anoscopic examination should be done under adequate visualization and anaesthesia to suture the bleeding site. If the patient is pale, hypotensive with tachycardia, hospitalization is mandatory.
If thrombosis of the corresponding external hemorrhoid occurs after internal hemorrhoid ligation, incision or eventually excision of the thrombosed external hemorrhoid may be required.
The clinician should carefully examine the patient for anorectal complains before performing a rubber band ligation. In order to avoid any infection, the rectum should be cleansed prior to the procedure with either one or two suppositories (ie Lecicarbon) or with an enema. Infections with sepsis have been reported following band ligation. Such patients may present with fever, anorectal pain, perineal pain, scrotal swelling, difficulty in micturition, cellulitis, and sometimes frank gangrene. Failure to recognise a septic process in this region may lead to fatal sepsis with extensive cellulitis and gangrene after the procedure.
