Experience of rubber band ligation for haemorrhoidal disease.
Objectives: To assess symptomatic relief in haemorrhoidal disease using rubber band ligation.
Settings and duration: Surgical unit, Hayatabad Medical Complex, Peshawar from July 2007 to June 2009.
Patients and Methods: All patients presenting with rectal bleeding or prolase underwent proctoscopy to determine the cause of bleeding. Only patients with 1st, 2nd and 3rd degree haemorrhoids (bleeding and prolapse) were selected for the study and they underwent rubber band ligation in two sessions, 6 weeks apart. Patients were followed in the OPD at 3 months and one year when their subjective and objective symptoms were noted followed by rectal examination and proctoscopy. Therapeutic response was assessed by symptomatic improvement in bleeding and prolapse of hemorrhoids and any complications.
Results: A total of 105 patients underwent rubber band ligation. There were 65(62%) males and 40(38%) females with a male to female ratio of 1.6:1. Age of the patients ranged from 21-65 years (+-2.4SD). Twenty three (21.9%) patients had 1st degree, 50(47.6%) had 2nd degree and 32(30.5%) had 3rd degree haemorrhoids. Forty-eight patients (45.7%) presented with prolapse, 33(31.4%) had both bleeding and prolapse and 23(21.9%) had bleeding only. At 3 months of follow up rubber band ligation cured 76(72.4%) patients, improved 13(12.4%) and failed in 7(6.7%) patients. At one year follow up, recurrence of bleeding and prolapse occurred in 16(15.2%) patients having 3rd degree haemorrhoids. Overall success was achieved in 89(84.8%) cases. Complications were seen in 20(19.1%) patients which were of mild to moderate nature and no serious/ life threatening complications were noted.
Conclusions: Rubber band ligation is a rapid and safe non operative procedure for treating 1st, 2nd and early 3rd degree haemorrhoids on out patient basis.
Key words: Haemorrhoids, rectal bleeding, prolapse, rubber band ligation, ambulatory surgery.
Haemorrhoids are a common cause of perianal complaint and affect 1-10 million people in North America and in Europe1. Its prevalence is estimated between 25-40% in USA2,3. A patient may have haemorrhoid but without any symptoms, while, many have haemorrhoids with symptoms. Sir Edward Hughes (1983) had recommended definitive treatment for those patients who have haemorrhoids with symptoms4.
Haemorrhoids are treated by operative and non operative approaches. Operative methods (haemorrhoidectomy) are not very popular in patients due to its painful nature and unpleasant experience along with need for anaesthesia and hospitalization. A number of non operative methods are practiced for non prolapsing and early prolapsing haemorrhoids, these include Barron elastic band ligation, infrared coagulation, injection sclerotherapy and cryotherapy3. All these procedures are convenient, safe and effective outdoor procedures and if the symptoms can be controlled by these procedures, haemorrhoidectomy can be avoided2.
Rubber band ligation is a simple and safe procedure which is performed in outpatient department and leads to resolution of symptoms and effectively cures haemorrhoids2,5,6. It also prevents progression to total rectal prolapse3. Although it is claimed that 50-100% of the 2nd and 3rd degree haemorrhoids can be managed by rubber band ligation3, the success rate depends on case selection. Rubber band ligation works well for patient with 2nd degree internal haemorrhoids but less well for patients with 3rd degree external haemorrhoids7. Ideally not more than 2 haemorrhoids should be banded at each session with a lapse of at least 3 weeks between each treatment2,8. To avoid perianal pain and discomfort; (one of the major complication of banding), bands should be applied at least 1.5-2 cm above the dentate line9-11.
The local experience of haemorrhoidal banding is being shared in 1st 2nd and 3rd degree haemorrhoids.
Patients and Methods
This study was done in surgical unit of Hayatabad Medical Complex, Peshawar from July 2007 to June 2009 where all patients presenting with rectal bleed or prolapse underwent rectal examination and proctoscopy. Only cases with 1st, 2nd and 3rd degree haemorrhoids were included in the study. Patients with
4th degree haemorrhoids or history of previous haemorrhoidectomy, sclerotherapy or cryotherapy were excluded from the study along with patients with haemorrhoidal complications such as complete prolapse, gangrene, thrombosis and associated fissures or fistula, perianal abscess or colitis.
History was taken to exclude other causes of rectal bleeding. Banding was done without anaesthesia and following application of bands, one ml of 2% lignocaine was injected into the strangulated mass to prevent slippage of band and pain. A maximum of 2 haemorrhoids were dealt in one session and patients were sent home with an advice to avoid straining at stool for 2- 3 days and to report immediately in case of sever pain or bleeding. They were prescribed stool softeners e.g. syruplactulose two times a day, tablet diclofenic sodium 50mg twice day and tablet metronidazole 400mg three times a day for 3 days.
Patients were advised to visit OPD at 6th week, 3rd month and one year after the procedure. At 6 weeks, subjective and objective symptoms (bleeding and prolapse) were noted along with 2nd session of banding.
At 3 months and one year, the success of the treatment was assessed by noting the occurrence of bleeding and prolapse through proctoscopy.
A total of 105 patients underwent rubber band ligation who were followed in OPD for one year. There were 65(62%) males and 40(38%) females whose ages ranged from 21 to 65 years (+-2.4SD). Majority of patients presented with prolapse followed by both bleeding and prolapse (Table-1).
Table 1: Presenting symptoms. (n =105)
Symptoms###No of Cases###Percentage
Twenty three (21.9%) patients had 1st degree haemorrhoids, 50(47.6%) had 2nd and 32(30.5%) patients had 3rd degree haemorrhoids. At 3 months followup, rubber band ligation either cured or improved bleeding in all 23 patients with 1st degree haemorrhoids. It cured bleeding and prolapse in 47(44.7%) patients with 2nd degree haemorrhoids and none of these cases showed any recurrence on follow up. Out of 32 patients with 3rd degree haemorrhoids, 16(15.2%) patients either got cured or improved, 7(6.7%) patients showed no improvement (2 had persistent bleeding and 5 had prolapse), 9(8.9%) patients showed initial improvement but 6 had recurrence of prolapse and 3 had bleeding (Table-2). Both these failed and recurrence groups were advised surgery. The over all success rate of banding was 84.8% (89 cases either cured or improved).
Table 2: Results of rubber band ligation. (n = 105)
Degree of###No of###Cured Improved Failed Recurrence
###(100%) (72.4%) (12.4%) (6.7%) (8.6%)
In 22(21%) patients, the 2 session of banding was done as not all haemorrhoids were banded in the firstsession and in 8(7.6%) patients bands had slipped, therefore, 2nd session of banding was done at 1st follow up i.e. 6 weeks.
In this study 28 out of 38(73.3%) patients who presented with bleeding were cured, 6(15.8%) got improved, while 4(10.5%) patients had failure of the procedure (2 cases) or recurrence of symptoms (2 cases). Similarly 49(73.1%) out of 67 patients with prolapse were cured, 7(10.4%) improved and 11(16.4%) had either failure of the procedure (6 cases) or recurrence of symptoms (5 cases) (Table-3).
Table 3: Effects of rubber band ligation on bleeding and prolapse. (n = 105)
Symptoms###No of###Cured###Improved Failed Recurrence
###(100%)###(73.3%) (12.4%)###(7.6%) (6.7%)
Post band ligation complications mild to moderate pain or discomfort (enough to restrict routine activities) was reported in 3(2.9%) cases and 2(2%) had sever pain. Four (3.8%) patients had post ligation mild bleeding and 3(2.9%) patients over the age of 55 years had lower urinary tract symptoms which were relieved with conservative management. In 8(7.6%) patients, bands had slipped. Complete healing was seen within 14 days. The overall complication rate was 19.1%.
Haemorrhoids may present with bleeding, prolapse, pain, discharge and itching. Symptomatic 1st and 2nd degree haemorrhoids usually respond to conservative outpatient care9, which includes stool softeners and rubber band ligation. These patients do not experience any change in their life style and usually get good results without any serious complication4. Haemorrhoidal grading is used to classify their size and is also used as a guide to therapeutic response. The diagnosis of haemorrhoidal disease is made by anoscopy12 or proctoscopy. In the management of haemorrhoids, surgery is considered as the last resort because it is a painful procedure2 which, interferes with normal anatomy.
In our study, 48(45.7%) cases presented with prolapse, 33(31.4%) had combined bleeding and prolapse and 23(21.9%) had bleeding only and almost similar figures were reported by others2. Male predominance as noted in the present study was also reported by othersl,2,9,13. In the present study, 2nd degree haemorrhoids (47.6%) were more common than 3rd degree haemorrhoids (38.5%) and these figures are comparable to 52% and 30% for 2nd and 3rd degree haemorrhoids respectively reported by Bernal et al12.
In the present study, at one year followup 72.4% patients were cured,12.4% improved, giving an overall success rate of 84.8%. While the procedure failed in 6.7% patients. These results are comparable to 82% to 92% success reported by others2,9,14-16. For only 2nd degree haemorrhoids, a 55% symptomatic improvement has been reported by Savioz et al17 while, according to Al-Ghaniem et al symptomatic haemorrhoids can be best dealt with rubber band ligation which is more efficacious and safer18. The failure rate of rubber band ligation (6.7%) was mostly seen in patients having large 3rd degree haemorrhoids with associated skin tags. This failure rate is comparable to 8% reported by Zafar2. For large 3rd degree haemorrhoids with sufficient skin component, rubber band ligation has limited value and trimming surgery of skin tags is recommended under local anaesthesia2.
Many surgeons perform banding in one session as it is safe and economical2,9,19 and improves patient's satisfaction if bleeding is the predominant symptom20, but some surgeons recommend that banding should be performed in more than one session to reduce post operative pain and oedema2,7. Placement of 4 or more bands are associated with higher complications12.
In this study, recurrence of symptoms was seen at one year follow up in 8.6% patients having 3rd degree haemorrhoids. Recurrence rate of other studies ranges between 10-12%2,13, while an acceptable recurrence rate is between 9-22% with 2-7% cases requiring subsequent haemorrhoidectomy15. A five year follow up showed recurrence rate of 23%16. Recurrence is common unless the patients alter their dietary habits. Low recurrence rate of 9% was reported in patients with normal bowel habits in contrast to 85% seen in those with constipation21.
In this study, pain occurred in 4.7% patients and this figure is less than 25% reported by Wehrmann T et al22. Mild bleeding figures (3.8%) seen in the present study are comparable to 2.8% reported by others12. In our study, 2.9% patients had urinary disturbances including urinary retention while another study reported 20% post operative urinary retention23. In this study, only 2% patients had severe pain which was relieved with injection diclofenac sodium (75mg). Use of 1ml of 2% Lignocaine in each haemorrhoidal mass to reduce pain was practiced by us and also recommended by others18.
In the present study, the overall complication rate of rubber band ligation was 19.1% while others reported complication rates between nil to13.8%9,13,24-26. The high complication rate in the present series could be due to the inclusion of cases of band slippage, this complication rate was 52% in another study2.
Rubber band ligation is a useful procedure in pregnancy and in patients not fit for surgery2, those having bleeding disorders and portal hypertension2,13. A prospective clinical trial showed rubber band ligation to cure or improve prolapse and bleeding as effectively as haemorrhoidectomy2 while, many surgeons found rubber band ligation superior to sclerotherapy and infrared coagulation and claimed good results with banding in selected cases of 4th degree haemorrhoids13.
The present study showed rubber band ligation to be a convenient, safe, effective and economical method for treating symptomatic 1st, 2nd and small 3rd degree haemorrhoids which do not respond to medical treatment.
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16. Gupta PJ, Radiofrequency coagulation versus band ligation in early haemorrhoids: pain versus gain. Medicina (Kaunas) 2004; 40: 232-7.
17. Savioz D, Roche B, Glauser T, Dobrinov A, Ludwig C, Marti MC. Rubber band ligation of haemorrhoids: relapse as a function of time. Int J Colorectal Dis 1998; 13: 154-156.
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19. Law WL, Chu KW. Tripple rubber band ligation for haemorrhoids: prospective randomized trail of the use of local anaesthetic injection. Dis Colon Rectum 1999; 42: 363-6.
20. Watson NFS, Liptrott S, Maxwell-Armstrong CA. A prospective audit of early pain and patient satisfaction following outpatient band ligation of haemorrhoids. Ann R Coll Surg Engl 2006; 88: 275-9.
21. Mattana C, Maria C, Pescatori M. Rubber band ligation of haemorrhoids and rectal mucosal prolapse in constipated patients. Dis Colon Rectum 1989; 32: 372-5.
22. Wehrmann T, Riphaus A, Feinstein J, Stergiou N. Hamorrhoidal elastic band ligation with flexible video- endoscopes. Gastrointest Endosc Dis 2004; 60: 191-5.
23. Uba AF, Obekpa PO, Ardill W. Open versus closed haemorrhoidectomy. Niger Postgrad Med J 2004; 11: 79-83.
24. Peres Vicente F, Fernandez Frias A, Arroyo Sebastian A, Costa Navarro D, Candela Polo F, Calpena Rico R. Effectiveness of rubber band ligation in haemorrhoids and factors related to relaps. Rev Esp Enferm Dig 2003; 95: 110-4.
25. Chew SS, Marshall L, Kalish I, Tham J, Grieve DA, Douglas PR, et al. Short term and long trerm combined sclerotherapy and rubber band ligation of haemorrhoids and mucosal prolapse. Dis Colon Rectum 2003; 46: 1232-7.
26. Benzoni E, Milan E,Cerato F, Narisetti P, Bresadola V, Terrosu G. Second degree haemorrhoids: patient's satisfaction, immediate and long term results of rubber band ligation treatment. Minerva Chir 2006; 61: 119-24.
Corresponding Author: Ainul Hadi, Department of Surgery, Hayatabad Medical Complex Peshawar.
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|Publication:||Pakistan Journal of Medical Research|
|Article Type:||Clinical report|
|Date:||Sep 30, 2011|
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