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.     

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.     

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.     

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.     

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.     

RPH治疗混合痔合并直肠粘膜内脱垂临床研究

目的观察自动痔疮套扎术(RPH)治疗混合痔合并直肠粘膜内脱垂患者的临床效果与传统外剥内扎术比较有何种优点。 方法观察手术时间、术中出血量、改善排便困难、术后并发症和平均住院日等情况,比较RPH治疗的98例混合痔合并直肠粘膜内脱垂患者与传统外剥内扎术治疗的98例混合痔合并直肠粘膜内脱垂患者的临床疗效。 结果RPH组在手术时间、手术出血量、改善排便困难、术后创面疼痛、出血、水肿,平均住院日等方面均显著优于对照组(P<0.05)。 结论RPH对混合痔合并直肠粘膜内脱垂患者具有疗效显著,手术简便、出血少、术后并发症少,术后恢复快、能有效改善排便困难症状,易于推广等优点。     

Rubber band ligation of hemorrhoids: relapse as a function of time

Rubber band ligation is a well established treatment of internal second-degree hemorrhoids. Up to now, the long-term results (>5 years) of this method have not been assessed. The aim of this study was to determine the long-term success rate of rubber band ligation in patients with a first episode of second-degree hemorrhoids not responding to medical treatment (local cream with laxative). A total of 92 patients who were treated between 1979 and 1997 for second-degree hemorrhoids responded to a questionnaire. The need for complementary conservative (sclerotherapy, cryotherapy or rubber band ligation) or surgical treatment was considered indicative of relapse. The collected data were analyzed according to the Kaplan-Meier method. The average follow-up time was 5.6 years. There were 21 patients who suffered a relapse. The probability of successful treatment was 0.77 (range: 0.67–0.88) after 5 years and 0.68 (range: 0.5–0.86) after 10.6 years. We conclude that rubber band ligation represent an efficient long-term treatment for second-degree hemorrhoids. Approximately two thirds of the patients are cured after 5 years and more than a half after 10 years. Accepted: 5 June 1998     

Local injection of bupivacaine after rubber band ligation of hemorrhoids

PURPOSE: The aim of this study was to determine if local injection of bupivacaine after hemorrhoidal banding causes a decrease in pain and in the incidence of associated symptoms. METHODS: After hemorrhoidal banding, patients were randomly assigned to receive a local injection of bupivacaine with 1:200,000 epinephrine, an injection of normal saline, or no injection, just superior to each band. Pain was graded by the patient and by the study nurse within 30 minutes, and any associated symptoms were recorded. At intervals 6, 24, and 48 hours postbanding, the patient recorded pain, limitation of activities, and analgesic requirements. Associated symptoms while at home were recorded. RESULTS: Of 115 patients studied, 42 received bupivacaine injection, 42 received normal saline injection, and 31 received no injection. In patients receiving bupivacaine compared with no injection, within 30 minutes postbanding there was a significant reduction in pain graded by the patient (P = 0.000002) and by the nurse (P = 0.000005) and a significant reduction in incidence of nausea (P = 0.01) and shaking (P = 0.008). However, in the bupivacaine group compared with the other two groups, at the intervals of 6, 24, and 48 hours postbanding there was no sustained reduction in the severity of pain and no reduction in analgesic requirements or limitation of normal activities. In the week after banding, there was no difference between groups in symptoms of nausea, shaking, lightheadedness, urinary retention, or bleeding. CONCLUSIONS: Bupivacaine injection may be useful for reducing pain and associated symptoms long enough to tolerate a trip home from the outpatient department but does not show a sustained effect.     

Rubber band ligation of three primary hemorrhoids in a single session

Rubber band ligation was used in 221 patients with first or second-degree hemorrhoids. All three primary hemorrhoids were ligated at a single out-patient session without anesthesia. Nineteen patients were lost to follow up. For the 202 patients under review, the follow up period ranged from three to 39 months with a mean of 18.4 months and median of 17 months. Excellent or good results were obtained in 183 patients (90.6 per cent). Moderate to severe pain was noticed by 58 patients (28.7 per cent). Further banding was required in 28 patients (13.9 per cent) and hemorrhoidectomy in six patients (3 per cent). The overall complication rate resulting from the treatment procedure was 3.5 per cent.