Internal Hemorrhoid Band Ligation

Endoscopic hemorrhoid band ligation (HBL) is an important advance in the treatment of symptomatic internal hemorrhoids.[1, 2] 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.[3] Hemorrhoids are either internal or external, depending on the localization above or below the dentate line.[4]

Internal hemorrhoids may be classified into four grades on the basis of the Goligher system, as follows[4] :

• 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 I, grade II, and select grade III hemorrhoids are managed nonsurgically, whereas grade IV and many grade III hemorrhoids require surgical intervention.[5]

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,[6, 7] and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one with a gastroscope and a larger one with a colonoscope.

Patients with symptomatic internal hemorrhoids in whom conservative management has failed or who request a nonsurgical therapeutic modality are candidates for HBL.[8] 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 higher risk for 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.[9, 10]

Contraindications for HBL include the following[11] :

• 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.[12]

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

Patients should be asked about their medications (mainly antithrombotics and antiplatelets) before the procedure so as to minimize the risk of early and late bleeding after HBL.

Misapplication of the band below the dentate line should be avoided; if it is not, 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.[11] Sepsis and hemorrhage may result from ulceration and sloughing after banding.[13]

The success rate of HBL is in the range of 70-97%.[4] Favorable outcomes depend on the banding technique, the internal hemorrhoid grade, and the timing of the follow-up.[11]

Band ligation vs other techniques

Other endoscopic nonoperative techniques used for the treatment of symptomatic internal hemorrhoids include sclerotherapy, cryotherapy, and infrared coagulation.[14]

HBL using video-endoscopic anoscopy compared favorably with traditional banding via anoscopy.[11, 15] The ability to perform band ligation in the clinic makes this technique a popular treatment option for internal hemorrhoids.[16] 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.[15]  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.[15]  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.[17, 1]

Compared with infrared coagulation, band ligation causes more pain but has a lower recurrence rate.[18, 19]  In a study by Gupta et al, 80 patients with grade II bleeding internal hemorrhoids were prospectively randomized to undergo HBL (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 vs 5 d). Pain and tenesmus were more severe with band ligation.

The multicenter HubBLe Trial compared hemorrhoidal artery ligation (HAL) with rubber band ligation (RBL) for symptomatic second- and third-degree hemorrhoids.[20]  At 1 year, HAL resulted in fewer recurrences, but the recurrence rate was similar to that of repeat RBL. The two treatments did not differ significantly with respect to symptom scores, complications, European Quality of Life-5 Dimensions (5-level version; EQ-5D-5L), or continence score. Patients in the HAL group had more pain in the early postoperative period. HAL was found to be more expensive and unlikely to be cost-effective in terms of incremental cost per quality-adjusted life year (QALY). 

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,[6, 7] and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one for a gastroscope and a larger one for a colonoscope.

In 1997, following band ligation, 95% of internal hemorrhoids were downgraded by more than one point, as reported by Trowers et al.[21] Afterward, the retroflexion manoeuver was introduced by Berkelhammer and Moosvi,[22] 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 male, 344 female) to assess the long-term outcome of endoscopic HBL for the treatment of symptomatic internal hemorrhoids (mean follow-up, 55.4 mo).[4] The clinical presentations were bleeding per rectum (n = 593) and mucosal prolapse (n = 166). All patients underwent the procedure in outpatient clinics. 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.

Flexible gastroscopy vs rigid proctoscopy

Cazemier et al enrolled 41 patients (20 men, 21 women; median age, 52 y) in a study comparing rigid proctoscopy (n = 19) with flexible gastroscopy (n = 22).[23]  Twenty-nine patients had grade I internal hemorrhoids, nine had grade II, and three had grade III. A median of four bands were used in the rigid scope group, whereas six were used in the flexible endoscope group. Three patients reported postligation pain with rigid proctoscopy versus 10 who reported pain with flexible gastroscopy. No sphincter defects were reported with this technique.[23, 24]

Patients should be informed about the risks and benefits of hemorrhoid band ligation (HBL), including the risks of conscious sedation (eg, desaturation, cardiovascular events). Patients should be educated regarding the possibility of symptom recurrence. The patient’s informed consent should be obtained (including the possible need for blood transfusion). Elements of informed consent include the risks and benefits, alternatives, confidentiality, and expectations and length of the procedure.

Patients are kept on NPO (nil per os) status after midnight the day of the procedure, and bowel preparation instructions are given to the patient.

Equipment includes a gastroscope, flexible sigmoidoscope, colonoscope, or anoscope with forceps applicator, and the set of rubber bands (six- or 10-shooter variceal ligator).[6]

Patients should receive bowel cleansing preparations (as used before a regular colonoscopy). In the procedure room, the standard pre-endoscopy preparations (intravenous line, blood pressure, cardiac monitoring, oxygen supplementation) should be done as per guidelines from the American College of Gastroenterology (ACG) or the American Society for Gastrointestinal Endoscopy (ASGE).

Anesthesia

HBL can be performed after premedication with midazolam, pethidine, or both. Sometimes, depending on the patient tolerability, propofol can be used. A randomized, controlled trial by Kwok et al found local anesthetic injection at the time of banding to be safe and effective.[25]  A study by Behrenbuch et al found that local anesthesia for HBL led to decreases in immediate postoperative recovery time and use of opioid analgesia.[26]

Positioning

The patient should be positioned in the left lateral decubitus position for endoscopic HBL.

Patients undergoing HBL should be monitored for immediate postprocedural pain. Patients should also be instructed to watch for symptoms of fever, chills, hematochezia, purulent rectal discharge, and urinary retention for the first few days after HBL. Clinicians should be vigilant in following high-risk patients who still suffer from other conditions after the procedure.[27]

Follow-up for around 7-10 days after banding is requested to exclude the possibility of delayed hemorrhage.

Hemorrhoid band ligation (HBL) can be performed in an office setting and may not require anesthesia.[16] Technically, it can be performed in an antegrade and/or retroflexed position by using disposable single or multishot devices.[10]  An endoscope is used to grasp hemorrhoidal tissue, and elastic bands are then applied.[28] Submucosal scarring prevents subsequent hemorrhoidal tissue formation.[9]

Grade I, grade II, and select grade III internal hemorrhoids can be treated with office-based procedures such as infrared coagulation, sclerotherapy, and HBL; HBL is generally the most popular and effective office-based treatment.[5, 29] Grade III and grade IV can be treated surgically, especially if thrombosed.

Once the symptomatic internal hemorrhoids have been identified, a forceps applicator can be used to apply the rubber bands down to the neck of the hemorrhoids, 5 mm above the dentate line, to avoid thrombosis.[28]

An alternative technique involves the use of an endoscopic suction ligator.[28] The bands are deployed by suction via the biopsy channel of the endoscope. That fewer treatment sessions are needed but adequate ligation is still achieved suggests the efficacy of this technique. A single-handed nonendoscopic ligating device (KilRoid, Astra Tech, AB, Molndal, Sweden) is currently used and has shown excellent results.[30]

Another available technique is the vacuum suction band ligator,[28] in which the ligator is attached to wall suction. The advantage of this technique is that it can be performed without assistance; the operator can hold the ligator to apply the rubber bands with one hand and the anoscope with the other.[30]

Traditionally, a reusable rigid banding device and an anoscope had been used. Various newer single-shot and multishot disposable devices became available for endoscopic HBL, including the Steigmann-Goff banding device (C.R. Bard, Inc, Murray Hill, NJ), CRH-O'Regan Disposable Hemorrhoid Banding System (CRH Medical Corp, Kirkland, WA), 4 Shooter (Cook Medical, Winston-Salem, NC), and Short Shot Hemorrhoidal Multiband Ligator (Cook Medical).

These ligating devices can be used to place rubber bands in the antegrade and/or retroflexed position.[10] Many experienced endoscopists prefer banding in the retroflexed position (see the images below) with a diagnostic endoscope because the dentate line is more easily identified in this position and treatments are better tolerated with the smaller-caliber endoscope.

Endoscopic view of post-banding of the internal hemorrhoids.

Post-band ligation with retroflexed view.

Grade II internal hemorrhoids

Prolapsed internal hemorrhoids are first manually reduced and then visualized via the anoscope or endoscope. Protruding tissue is gently drawn into the banding device with a forceps (traditional device) or with suction (much as in variceal band ligation). If a patient experiences pain with suctioning, the band release should not be performed at that location, and an area farther above the dentate line should then be identified and resuctioned.

An average of three or four bands are placed during each session. Treatments are repeated at 4- to 6-week intervals until symptoms are controlled and all internal hemorrhoid segments are reduced to grade I or 0. Ulcerations are usually noted at the site of the previous band ligation after the banded hemorrhoidal tissue sloughs off.

Pain is the most frequent complication following HBL.[31] It has been reported in approximately 8% of patients and results from anal spasm or misapplication of bands below the dentate line.[32]  

Other potential complications include the following[13] :

• Hemorrhoidal thrombosis (hemorrhoids distal to the rubber band ligation site)
• Delayed hemorrhage (due to band dislodgment within 2-4 days or ulceration around 5-7 days after the procedure) ^[33]
• Localized infection or abscess (manifesting as persistent anorectal pain, fever, or foul-smelling rectal drainage)
• Sepsis
• Urinary retention