Internal Hemorrhoid Banding

  • Author: Assaad M Soweid, MD, FACG, FASGE; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
 
Updated: Mar 21, 2016
 

Background

Endoscopic hemorrhoid band ligation (HBL) is an important advancement in the treatment of symptomatic internal hemorrhoids. This procedure is simple, safe, and effective. Multiple rubber bands can be applied in one session, and further bands can be applied in subsequent sessions if a single session fails to completely eradicate the internal hemorrhoids. The treatment success rate is high, while the long-term recurrence rate is low.

Symptomatic hemorrhoids in adults is considered one of the most prevalent anorectal disorders. Hemorrhoids of different grades can be found in more than 80-90% of patients undergoing sigmoidoscopy or colonoscopy. Hemorrhoids are either internal or external depending on the localization above or below the dentate line.[1]

Internal hemorrhoids may be classified into four grades on the basis of the Goligher system, as follows[1] :

  • Grade I hemorrhoids protrude into the anal canal but do not prolapse
  • Grade II hemorrhoids prolapse with straining or defecation but reduce spontaneously (see the image below)
  • Grade III hemorrhoids prolapse and usually require manual reduction
  • Grade IV hemorrhoids are prolapsed and cannot be reduced and are thus at risk of strangulation and thrombosis
Grade II internal hemorrhoids. Grade II internal hemorrhoids.

Grade I, II, and III hemorrhoids are managed nonsurgically, whereas grade IV hemorrhoids require surgical intervention.

Stiegman and Goff were the first to propose the technique of elastic band ligation for the treatment of esophageal and gastric varices using a gastroscope,[2, 3] and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one to a gastroscope and a larger one to a colonoscope.

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Indications

Patients with symptomatic internal hemorrhoids in whom conservative management has failed or who request a nonsurgical therapeutic modality are candidates for HBL.[4] In addition, patients who cannot tolerate surgery, given the risk of anesthesia, may be advised to undergo banding instead of hemorrhoidal surgery.

HBL also provides an alternative therapeutic modality in patients at a higher risk of bleeding (cirrhosis and uremia). A significant advantage of HBL is that it can be performed repeatedly, if needed, with further sessions for patients whose symptoms persist after the first session.[5, 6]

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Contraindications

Contraindications for HBL include the following[7] :

  • Acute thrombosis
  • Active proctitis or colitis
  • Significant rectal prolapse
  • Perirectal abscess
  • Rectal malignancy
  • Coagulopathy
  • Immunosuppression

HBL is contraindicated in patients who are receiving anticoagulants or who have a bleeding disorder, as well as those with concurrent anorectal sepsis.[8]

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Technical Considerations

Preparation includes conscious or deep sedation. Internal hemorrhoids should be graded to achieve optimal management results.

Patients should be asked about their medications prior to the procedure (mainly antithrombotics and antiplatelets) to avoid the risk of early and late bleeding following band ligation.

Misapplication of the band below the dentate line should be avoided; otherwise, severe anal pain may ensue. In some cases, thrombosis is caused by leftover hemorrhoids distal to the rubber band, and therefore ligation must be applied close to the dentate line.[7] Sepsis and hemorrhage may result from ulceration and sloughing after banding.[9]

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Outcomes

The success rate of HBL is in the range of 70-97%.[1] Favorable outcomes depend on the banding technique, the internal hemorrhoid grade, and the timing of the follow-up.[7]

Band ligation vs other techniques

Other endoscopic nonoperative techniques used for the treatment of symptomatic internal hemorrhoids include sclerotherapy, cryotherapy, and infrared coagulation.[10]

HBL using video-endoscopic anoscopy compared favorably with traditional banding via anoscopy.[7, 11] The ability to perform band ligation in the clinic makes this technique a popular treatment option for internal hemorrhoids.[4] In addition, the rubber bands used for this procedure are inexpensive and are easy to deploy.

In a meta-analysis of 18 prospective randomized trials performed by MacRae and McLeod, band ligation was the most effective among office-based procedures, with a lower recurrence rate.[11]  In a meta-analysis of 23 studies, several internal hemorrhoidal treatment modalities were compared, and it was concluded that band ligation was superior to sclerotherapy, which demonstrated good short-term but poor long-term benefits.[11]  With cryosurgery, patient satisfaction was less, and local complications were more frequent. A cap-assisted endoscopic sclerotherapy approach has been described, which is reported to be convenient, safe, and effective.[12]

Compared to infrared coagulation, band ligation causes more pain but has a lower recurrence rate.[13, 14]  In a study by Gupta et al, 80 patients with grade II bleeding internal hemorrhoids were prospectively randomized to undergo HBL ligation (n=44) or radiofrequency ablation (RFA; n=36). Patients in the RFA group had longer procedure times and higher recurrence rates, but earlier return to work (2 days vs 5 days). Pain and tenesmus were more severe with band ligation.

Historical evolution of internal HBL

Stiegman and Goff were the first to propose the technique of elastic band ligation for the treatment of esophageal and gastric varices using a gastroscope,[2, 3] and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one to a gastroscope and a larger one to a colonoscope.

In 1997, following band ligation, 95% of internal hemorrhoids were downgraded by more than one point, as reported by Trowers et al.[15] Afterward, the retroflexion manoeuver was introduced by Berkelhammer and Moosvi,[16] with excellent results noted in more than 80% of cases (the highest success rates were in patients with grade II internal hemorrhoids).

Long-term outcome and efficacy of endoscopic HBL for symptomatic internal hemorrhoids

Su et al enrolled a total of 759 consecutive patients (415 males, 344 females) to assess the long-term outcome of endoscopic HBL for the treatment of symptomatic internal hemorrhoids. The clinical presentations were bleeding per rectum (n=593) and mucosal prolapse (n=166). All patients underwent the procedure in outpatient clinics. The mean follow-up period was 55.4 months. The average number of bands used ranged from 2.35 to 2.69. Bleeding was controlled in 98% of patients; 82.5% reported reduction in the prolapse. Anal pain was reported in 93 patients, bleeding in 48. The mean recurrence rate was 3.7% at 1 year, 6.6% at 2 years, and 13% at 5 years; 93.6% of patients were satisfied with the procedure.[1]

Flexible gastroscopy vs rigid proctoscopy

Forty-one patients (20 men, 21 women) were enrolled in a study comparing rigid proctoscopy (n=19) with flexible gastroscopy (n=22) by Cazemier et al.[17] The median age was 52 years. Twenty-nine patients had grade I, nine had grade II, and three had grade III internal hemorrhoids. A median of four bands were used with the rigid scope, whereas six were used in the flexible endoscope group. Three versus 10 patients reported pain postligation when using a rigid proctoscope as compared with a flexible gastroscope. No sphincter defects were reported with this technique.[17, 18]

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Contributor Information and Disclosures
Author

Assaad M Soweid, MD, FACG, FASGE Associate Professor of Clinical Medicine, Endosonography and Advanced Therapeutic Endoscopy, Director, Endoscopy-Bronchoscopy Unit, Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Lebanon

Assaad M Soweid, MD, FACG, FASGE is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Lara B Younan, MD Fellow in Gastroenterology, American University of Beirut

Disclosure: Nothing to disclose.

Mohammed H Saad, MD Resident Physician, Department of Internal Medicine, Good Samaritan Hospital of Baltimore

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

References
  1. Su MY, Chiu CT, Lin WP, Hsu CM, Chen PC. Long-term outcome and efficacy of endoscopic hemorrhoid ligation for symptomatic internal hemorrhoids. World J Gastroenterol. 2011 May 21. 17(19):2431-6. [Medline]. [Full Text].

  2. Saeed ZA. The Saeed Six-Shooter: a prospective study of a new endoscopic multiple rubber-band ligator for the treatment of varices. Endoscopy. 1996 Sep. 28(7):559-64. [Medline].

  3. Van Stiegmann G, Goff JS. Endoscopic esophageal varix ligation: preliminary clinical experience. Gastrointest Endosc. 1988 Mar-Apr. 34(2):113-7. [Medline].

  4. BLAISDELL PC. Office ligation of internal hemorrhoids. Am J Surg. 1958 Sep. 96(3):401-4. [Medline].

  5. Su MY, Chiu CT, Wu CS, Ho YP, Lien JM, Tung SY, et al. Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids. Gastrointest Endosc. 2003 Dec. 58(6):871-4. [Medline].

  6. Fukuda A, Kajiyama T, Arakawa H, Kishimoto H, Someda H, Sakai M, et al. Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids. Gastrointest Endosc. 2004 Mar. 59(3):380-4. [Medline].

  7. Jensen SL, Harling H, Arseth-hansen P, Tange G. The natural history of symptomatic haemorrhoids. Int J Colorectal Dis. 1989. 4(1):41-4. [Medline].

  8. Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World J Gastroenterol. 2015 Aug 21. 21 (31):9245-52. [Medline]. [Full Text].

  9. Scarpa FJ, Hillis W, Sabetta JR. Pelvic cellulitis: a life-threatening complication of hemorrhoidal banding. Surgery. 1988 Mar. 103(3):383-5. [Medline].

  10. MacRae HM, Larissa KF, McLeod RS. A meta-analysis of hemorrhoidal treatments. Semin Colon Rect Surg. 2002. 13:77-83.

  11. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg. 1997 Feb. 40 (1):14-7. [Medline].

  12. Zhang T, Xu LJ, Xiang J, He Z, Peng ZY, Huang GM, et al. Cap-assisted endoscopic sclerotherapy for hemorrhoids: Methods, feasibility and efficacy. World J Gastrointest Endosc. 2015 Dec 25. 7 (19):1334-40. [Medline].

  13. Gupta PJ. Radiofrequency coagulation versus rubber band ligation in early hemorrhoids: pain versus gain. Medicina (Kaunas). 2004. 40(3):232-7. [Medline].

  14. Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009 Aug. 104 (8):2057-64. [Medline].

  15. Trowers EA, Ganga U, Rizk R, Ojo E, Hodges D. Endoscopic hemorrhoidal ligation: preliminary clinical experience. Gastrointest Endosc. 1998 Jul. 48(1):49-52. [Medline].

  16. Berkelhammer C, Moosvi SB. Retroflexed endoscopic band ligation of bleeding internal hemorrhoids. Gastrointest Endosc. 2002 Apr. 55(4):532-7. [Medline].

  17. Cazemier M, Felt-Bersma RJ, Cuesta MA, Mulder CJ. Elastic band ligation of hemorrhoids: flexible gastroscope or rigid proctoscope?. World J Gastroenterol. 2007 Jan 28. 13(4):585-7. [Medline].

  18. Wehrmann T, Riphaus A, Feinstein J, Stergiou N. Hemorrhoidal elastic band ligation with flexible videoendoscopes: a prospective, randomized comparison with the conventional technique that uses rigid proctoscopes. Gastrointest Endosc. 2004 Aug. 60(2):191-5. [Medline].

  19. Kwok HC, Noblett SE, Murray NE, Merrie AE, Hayes JL, Bissett IP. The use of local anaesthesia in haemorrhoidal banding: a randomized controlled trial. Colorectal Dis. 2013 Apr. 15(4):487-91. [Medline].

  20. Subramaniam D, Hureibi K, Zia K, Uheba M. The development of Fournier's gangrene following rubber band ligation of haemorrhoids. BMJ Case Rep. 2013 Nov 28. 2013:[Medline].

  21. Ramzisham AR, Sagap I, Nadeson S, Ali IM, Hasni MJ. Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids. Asian J Surg. 2005 Oct. 28 (4):241-5. [Medline]. [Full Text].

  22. Dickey W, Garrett D. Hemorrhoid banding using videoendoscopic anoscopy and a single-handed ligator: an effective, inexpensive alternative to endoscopic band ligation. Am J Gastroenterol. 2000 Jul. 95(7):1714-6. [Medline].

  23. Wechter DG, Luna GK. An unusual complication of rubber band ligation of hemorrhoids. Dis Colon Rectum. 1987 Feb. 30(2):137-40. [Medline].

 
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Grade II internal hemorrhoids.
Endoscopic view via the banding cap prior to banding.
Endoscopic view of post-banding of the internal hemorrhoids.
Post-band ligation with retroflexed view.
Grade II internal hemorrhoids
 
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