Colonoscopic classification of internal hemorrhoids: usefulness in endoscopic band ligation

BACKGROUND: Bleeding is one of the main symptoms of internal hemorrhoids. However, the conventional Goligher's classification of internal hemorrhoids does not consider the severity of bleeding. We intended to establish a useful method for evaluating internal hemorrhoids using a colonoscope that reflected the severity of the symptoms. METHODS: Using a colonoscope in the retroflexed and forward viewing position, 104 patients with symptomatic internal hemorrhoids were evaluated based on the criteria of range, form and red color signs (RCS). Range was determined by the circumferential distribution of internal hemorrhoids and scaled from 0 to 4. Form was determined by size and scaled from 0 to 2. The presence of RCS was also evaluated. Symptoms were determined by interview and scaled from 0 to 3. Patients were treated by endoscopic band ligation (EBL) and were examined endoscopically before and 4 weeks after the treatment. RESULTS: Before the treatment, range, form and RCS were significantly correlated to bleeding (P < 0.01), and form was significantly correlated to prolapse (P < 0.05). The endoscopic classification scores at 4 weeks after EBL improved significantly (range from 3.25 +/- 0.05-0.56 +/- 0.08 [P < 0.01] and form from 2.81 +/- 0.04-0.56 +/- 0.07 P < 0.01). CONCLUSION: The new endoscopic classification of internal hemorrhoids proved to be closely correlated to symptoms, particularly bleeding, and thus highly useful in evaluating the effectiveness of the treatment.     

Retroflexed endoscopic band ligation of bleeding internal hemorrhoids

BACKGROUND: Elastic band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids, stages II-III. Usually, one or two bands are placed at a single session by using rigid instruments. The aim of this study was to assess the feasibility, tolerability, safety, and efficacy of multiple band ligation of internal hemorrhoids performed in one session by using a flexible endoscope with an attached band ligation device in the retroflexed position. METHODS: Eighty-three patients with chronically bleeding and/or prolapsing internal hemorrhoids were treated by retroflexed endoscopic band ligation. From 1 to 6 bands were placed in a single session. Bands were targeted at the apex and proximal body of the internal hemorrhoid so that final band placement was entirely proximal to the dentate line. Malpositioned bands were removed by using a novel method. Patients were followed prospectively to assess tolerance, complications, and efficacy. Retreatment was offered if the desired result was not achieved. RESULTS: A mean of 3.0 (SD 1.2) bands (range 1-6) were placed in a single session. Five percent of bands were malpositioned and removed. Patients were followed for 26 (17) months (range 1-52 months). An excellent result was achieved in 80% of patients with stage II hemorrhoids. Patients with stage II hemorrhoids were more likely to have an excellent result compared with patients with stage III hemorrhoids (80% vs. 54%, p < 0.01). Retroflexed endoscopic band ligation was well tolerated overall. The rate of major, nonfatal complications was 4%. CONCLUSIONS: Retroflexed endoscopic band ligation is a feasible, well-tolerated, effective, and safe for treatment of bleeding stage II internal hemorrhoids. A novel method of endoscopic band removal is described.     

Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids

BACKGROUND: Elastic band ligation is a well-established nonoperative method for treatment of internal hemorrhoids that give rise to symptoms. This study assessed the efficacy and safety of retroflexed endoscopic multiple band ligation, a procedure that involves extensive ligation of internal hemorrhoids, and the immediately proximal normal rectal mucosa, by means of a retroflexed endoscope. METHODS: Eighty-two patients with symptoms caused by internal hemorrhoids (15, stage I; 19, stage II; 47, stage III; 1, stage IV) were treated by retroflexed endoscopic multiple band ligation. Symptoms (prolapse, bleeding, pain with defecation) were graded from 0 to 3. Range and form of the internal hemorrhoids were evaluated endoscopically. Retroflexed endoscopic multiple band ligation was performed by using a flexible endoscope with an attached band ligation device in the retroflexed position. RESULTS: A mean of 8 bands (range 4-14) were placed per treatment session. Seventy-six patients were treated in a single session, 5 in two sessions, and one in 3 sessions. Symptom and endoscopic scores improved at 4 weeks after the retroflexed endoscopic multiple band ligation: bleeding, from 1.26 to 0.53 (p<0.01); prolapse, from 1.94 to 0.5 (p<0.01); pain, from 1.03 to 0.93 (p=0.67); Goligher classification, from 2.41 to 1.09 (p<0.01); range, from 3.25 to 0.56 (p<0.01); and form, from 2.81 to 0.56 (p<0.01). Long-term response (mean follow-up 12 months, range 3-40 months) was excellent for 89% of the patients, good for 9%, and poor for 2%. No major complication was noted. CONCLUSIONS: Retroflexed endoscopic multiple band ligation is a safe and effective method for treatment for patients with symptoms caused by internal hemorrhoids.     

Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids

PURPOSE: Rubber band ligation therapy for symptomatic hemorrhoidal disease has been used for many years and is a well-accepted treatment modality, but information on long-term outcome is limited. Our goals were to determine safety and long-term efficacy of this treatment.METHODS: A retrospective chart review of patients undergoing rubber band ligatures for symptomatic internal hemorrhoids in a single practice was conducted. Information on presenting symptoms, number of bands applied, response to therapy, complications encountered, length of follow-up, interval to recurrent symptoms when applicable, and subsequent therapy were documented. Supplemental information was obtained from telephone follow-up. Outcome was categorized as success or failure, in which success was defined as: permanent relief of symptoms for follow-up period; marked improvement in symptomatology with rare manifestation of bleeding (1/month); symptom relief for a limited period of time (100 days), and failure was defined as: modest improvement (decreased but not relief of symptoms); or no improvement in symptoms.RESULTS: A total of 805 patients underwent 2,114 rubber band ligatures. Most common presenting symptoms were bleeding in 731 patients (90.8 percent) and prolapsing in 382 patients (47.5 percent). The median number of bands placed was two (range, 1–17). The median time between bandings was 4.7 (range, 1.1–35.6) weeks. Median follow-up time was 1,204 (range, 14–9,571) days. Excluding 104 patients lost to follow-up (never returned after initial treatment), success was obtained in 70.5 percent (494/701) and failure in 29.5 percent (207/701) of patients. Success rates were similar for all degrees of hemorrhoids. Hemorrhoidal disease requiring the placement of four or more bands was associated with a trend in higher failure rates and greater need for subsequent hemorrhoidectomy. Complications per treatment series included bleeding (2.8 percent), thrombosed external hemorrhoids (1.5 percent), and bacteremia (0.09 percent). Higher bleeding rates were encountered with the use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin. Time to recurrence was less with subsequent treatment courses. Treatment of recurrent symptoms with rubber band ligation resulted in success rates of 73.6, 61.4, and 65 percent for first, second, and third recurrences respectively. This resulted in a cumulative success rate of 80.2 percent for this method of treatment.CONCLUSIONS: Rubber band ligatures are safe and effective therapy for symptomatic internal hemorrhoids. It can be used to treat all degrees of hemorrhoids with similar effectiveness. The likelihood of success is lower if more than four bands are needed to eliminate symptoms. The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin is associated with higher bleeding rates. Rubber band ligatures for recurrence of symptoms is effective; however, time to recurrence is less with subsequent treatments.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Videoanoscopy: Useful technique in the evaluation of hemorrhoids

Background and Aim:  Rigid proctoscopy, the gold standard for detecting hemorrhoids, has become a neglected procedure in the era of flexible endoscopy. Evaluation of hemorrhoids is often done with the retroflexed fiberoptic colonoscope. The aim of this study was to evaluate the technique of videoanoscopy in comparison with retroflexion of colonoscope in the rectum to detect hemorrhoids and to correlate objective findings of hemorrhoids and their relation to bleeding.
Methods:  In total, 544 patients were screened and 358 patients were evaluated by the technique of videoanoscopy and retroflexion of colonoscope in the rectum. The video images of both the procedures were independently analyzed by two observers for the presence or absence of hemorrhoids. The videoanoscopy images were also analyzed for number of columns of hemorrhoids, size and presence of red-color sign.
Results:  Videoanoscopy detected hemorrhoids in a significantly higher number of subjects when compared with retroflexion of colonoscope in the rectum by both observers ( P  < 0.05). The average kappa value was 0.637 and 0.779 for retroflexed colonoscopy and videoanoscopy, respectively. Red-color sign was present in 80.5% of patients with bleeding compared with only 30.3% in the non-bleeding group. The majority (71%) of patients in the bleeding group had larger hemorrhoids. Red-color sign and size of hemorrhoidal columns correlated with bleeding ( P  < 0.05).
Conclusion:  Videoanoscopy is a simple technique with increased sensitivity to detect hemorrhoids compared with intrarectal retroflexion of colonoscope and yields valuable objective information about the presence and condition of hemorrhoids. It should be performed as an extension of standard colonoscopy.     

内痔消化内镜下套扎治疗的现状与发展

消化内镜下内痔套扎治疗已成为内痔治疗的常用方法。与肛门镜下套扎相比,消化内镜下套扎具有良好的视野,显著提高了对解剖标志的辨识能力,有助于选择更合理、更精准的治疗位点,从而提高疗效,减少并发症。与内镜下硬化治疗相比,套扎治疗对内痔脱垂效果更好,复发率更低,但是术后疼痛发生率较高。本文介绍了内痔内镜下套扎治疗的现状,并介绍了肛直线、齿状线等肛管表面解剖标志的内镜下辨识要点,以及套扎手术流程和团队的经验体会。     

软式内镜下透明帽辅助硬化术治疗内痔出血的临床观察

目的探讨经软式内镜下透明帽辅助硬化术治疗内痔出血的临床疗效及安全性。 方法回顾性分析2018年8月至2019年10月黑龙江省双鸭山市双矿医院收治的经软式内镜下透明帽辅助硬化术治疗的56例内痔出血患者的临床资料,观察其首次硬化治疗止血成功率、术中及术后肛门疼痛情况、患者满意度等情况。 结果首次硬化治疗止血成功率为89.2%(50/56),术后6个月观察,达到痊愈标准的41例、好转14例,总有效率达98.2%(55/56)。疼痛情况：治疗时：无疼痛42例(64.6%)、轻微疼痛12例(21.4%)、剧烈疼痛2例(3.5%)。术后48 h：无疼痛53例(94.6%)、排便痛3例(5.3%)、持续疼痛0例。患者满意度情况：非常满意42例(75%)、满意11例(19.6%)、不满意2例(3.5%)、非常不满意1例(1.7%)。 结论软式内镜下透明帽辅助硬化术治疗内痔出血具有首次治疗成功率高、安全可靠、患者满意度高等优势,值得临床广泛推广应用。     

Severe complication of rubber band ligation of internal hemorrhoids

In light of recent reports describing severe and even fatal complications, the authors would like to report good results in two patients with massive edema and one with localized necrosis following rubber band ligation of internal hemorrhoids, which were recognized early and treated aggressively. The potential for severe complications emphasizes the need for determining other causes of rectal symptoms before ligation of hemorrhoids is undertaken     

Complications of rubber band ligation of symptomatic internal hemorrhoids

In a prospective study, 512 patients undergoing hemorrhoidal band ligation over a seven-year period were followed up to focus on complications. Thirteen patients (2.5 percent) were hospitalized: six with delayed massive rectal bleeding, three with urinary retention, pain, and fever (one developed perianal abscess), and three others with severe pain due to prolapsed thrombotic hemorrhoids (one developed difficulty in urination). One patient developed perianal abscess and perianal fistula two months after ligation. Twenty-four patients (4.6 percent) suffered from minor complications: 11 patients had painful thrombosed hemorrhoids; five experienced slippage of bands; three had mild bleeding; two developed band-related mucosal ulcer; one experienced each time, after two subsequent ligations, priapism lasting several hours; and difficulty in urination and tender induration above the dentate line occurred in two other patients. Rubber band ligation is, in effect, a miniature hemorrhoidectomy and has been considered, until recent reports of fatalities associated with this procedure, as an effective, safe, and efficient method of treating symptomatic second-degree and third-degree hemorrhoids. We conclude that the ability to handle complications that occur secondary to the rubber band ligation and, thereby, prevent sepsis and the low rate of major complications in our study justify reliance on this method of treating symptomatic hemorrhoids.     

内镜下硬化剂注射术及套扎术治疗Ⅱ度内痔的临床研究

目的通过比较内镜下硬化剂注射术及套扎术治疗Ⅱ度内痔的临床疗效及安全性,从而为临床上Ⅱ度内痔治疗方案的选择提供指导意见。 方法回顾性分析2019年1月至2020年7月期间,于保定市第一中心医院行内镜下硬化剂注射术或套扎术治疗的Ⅱ度内痔患者的临床资料,按照内镜下术式的不同,将纳入的患者分为硬化组和套扎组,比较两组患者临床疗效及术后并发症发生情况的差异。 结果共纳入患者35例,其中硬化组27例、套扎组8例。临床疗效方面：硬化组中,痊愈14例、好转10例、无效3例,痊愈率51.85%,治疗有效率为88.89%;套扎组中,痊愈6例、好转2例,痊愈率75%,治疗有效率为100%;两组患者痊愈率及治疗有效率的差异均无统计学意义(P>0.05)。术后并发症方面：硬化组术后并发症发生率为11.11%(3/27),其中1例出现肛门疼痛和发热,1例出现肛门疼痛,1例出现少量便血;套扎组术后并发症发生率为25%(2/8),其中1例出现肛门疼痛和便血,1例出现肛门疼痛。两组患者术后并发症发生情况的差异无统计学意义(P>0.05)。 结论内镜下硬化剂注射术与套扎术治疗Ⅱ度内痔均具有较好的临床疗效,有待大样本研究进一步证实。     

Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions

BACKGROUND: The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition. METHODS: Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. Endoscopic band ligation was performed by using less than 200 mBar negative pressure in suctioning the target lesion into the ligation cap just before band release. Mean follow-up was 18 months (range 6-31 months). OBSERVATIONS: Endoscopic band ligation achieved hemostasis in a single session in all patients. No adverse events occurred except for mild abdominal pain in two patients. Mortality was null, and no patient required further blood transfusion during the 40 days after endoscopic band ligation. No patient with Dieulafoy's lesion had further bleeding, whereas bleeding recurred in 6 of 14 (43%) patients with angiodysplasia during long-term follow-up. CONCLUSIONS: Endoscopic band ligation is safe and effective for treatment of acutely bleeding small bowel vascular lesions. Although endoscopic band ligation is definitive therapy for Dieulafoy's lesion, long-term efficacy in the treatment of GI bleeding from angiodysplasia is limited.     

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

AIM:To assess the long-term outcome of endoscopic hemorrhoid ligation (EHL) for the treatment of symptomatic internal hemorrhoids.METHODS:A total of 759 consecutive patients (415 males and 344 females) were enrolled.Clinical presentations were rectal bleeding (593 patients) and mucosal prolapse (166 patients).All patients received EHL at outpatient clinics.Hemorrhoid severity was classified by Goligher's grading.The mean follow-up period was 55.4 mo (range,45-92 mo).RESULTS:The number of band ligations aver...     

Triple rubber band ligation for hemorrhoids

PURPOSE: Rubber band ligation is a common office procedure for hemorrhoids. Triple rubber band ligation in a single session has been shown to be a safe and economical way of treating hemorrhoids. However, postligation discomfort after triple rubber band ligation is not uncommon. The aim of this study was to evaluate the effectiveness of local anesthetic injection to the banded hemorrhoidal tissue in reducing postligation discomfort. METHODS: Patients attending an outpatient clinic for symptomatic hemorrhoids suitable for triple rubber band ligation were randomly assigned to two groups. In the treatment group rubber band ligation was performed at three columns of hemorrhoids, and 1 to 2 ml of 2 percent lignocaine was injected into the banded hemorrhoidal tissue. In the control group triple rubber band ligation was performed in a similar manner, but local anesthetic was not given. Patients were followed up by telephone at the second week and in the clinic after six weeks. RESULTS: From April to August 1996, 101 patients entered the trial and were treated with triple rubber band ligation. Sixty-two patients were randomly assigned to the local anesthetic injection group and 39 to the control group. Overall good to excellent results occurred in 89 percent of patients, and there was no difference between the two groups. Postligation pain occurred in 26 and 20 percent of patients in the treatment and control groups, respectively (P>0.05). Postligation tenesmus occurred in 32 and 41 percent of patients in the treatment and control groups, respectively (P>0.05). No patients suffered from septic complications or bleeding that required transfusion. CONCLUSION: Triple rubber band ligation in a single session is a safe, economical, and effective way of treating symptomatic hemorrhoids. Postligation pain and tenesmus occurred in 24 and 37 percent, respectively. Discomfort was usually tolerable. Local anesthetic injection to the banded hemorrhoidal tissue did not help to reduce postligation discomfort.     

内镜下三种微创方案治疗内痔的疗效及安全性评价

为了评价内镜下内痔治疗的安全性和有效性, 对中国科学技术大学附属第一医院2018年1月—2020年6月行内镜下治疗且有完整随访资料的166例Ⅰ～Ⅲ度内痔病例进行了回顾性总结, 其中单纯硬化组35例、单纯套扎组104例、套扎联合硬化组27例。结果显示:3组术后均未出现严重并发症, 单纯套扎组和套扎联合硬化组术后肛门疼痛发生率[分别为35.6%(37/104)和33.3%(9/27)]和肛门坠胀感发生率[分别为70.2%(73/104)和70.4%(19/27)]均较高, 但一般均可耐受或经简单处理后缓解;出院前, 3组的患者满意度均达90%以上, 手术接受程度均达95%以上;3组术后3个月时的治疗有效率均在90.0%以上, 术后12个月时的治疗有效率均有不同程度下降, 其中单纯硬化组的治疗有效率最低[74.3%(26/35)], 其他2组的治疗有效率仍能维持在85.0%以上。由此可见, 内镜下微创治疗内痔是一种安全有效的治疗方法, 具有有效改善症状、患者术后满意度和手术接受程度高等特点。     

New device for rubber band ligation of hemorrhoids

We describe a new accessory for rubber band ligation of hemorrhoids. By using the new instrument it is possible to abscind the elastic band applied to the base of the hemorrhoidal node without entailing traumatic interventions. Of a total of 62 elastic ligatures, this device was used in the last 18 procedures, and provided excellent results. This instrument enables the surgeon to carry out the technique in a more accurate way and, if necessary, rectify “dangerous mistakes” that can occur while accomplishing the procedure itself.     

Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids

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.     

内痔的内镜治疗进展

痔疮是肛门最常见疾病之一，患病率极高，严重影响患者生活质量。近年来，随着内镜技术的快速发展，以内镜下内痔套扎、硬化治疗为代表的内镜微创治疗逐渐兴起，具有操作简单、安全有效、创伤小、恢复快等优势，深受广大医师和患者的欢迎。本文对这一类技术的现状和展望进行综述。     

An unusual complication of rubber band ligation of hemorrhoids

Rubber band ligation of hemorrhoids has had a low incidence of complications until recently, when five deaths resulted from bacterial septicemia or toxemia. The case presented describes a severe soft-tissue infection following banding successfully treated with antibiotics, surgical debridement, and hyperbaric oxygen.