Rubber band ligation of symptomatic hemorrhoids: an old solution to an everyday problem.

PURPOSE: The aim of this prospective study is to present the results of rubber band ligation (RBL) in 2635 consecutive patients with 2nd, 3rd, and 4th degree symptomatic hemorrhoids, the pain risk factors, and the applicability of the method in patients with liver cirrhosis and portal hypertension. METHODS: A total of 1256 patients with 2nd, 1159 with 3rd, and 220 with 4th degree hemorrhoids were included in the study. Fifty-seven patients with hemorrhoids had liver cirrhosis and portal hypertension. RBL was performed using St Marks', McGinvey, and suction ligators. Single ligation was done in 178 patients, while 2457 patients had synchronous multiple ligations, in one (272), two (1289), and three (896 patients) sessions. RESULTS: After the end of treatment, 86.8% of our patients were asymptomatic and 84.5% remained asymptomatic 2 years later. A total of 593 patients had complications. Thirty required hospitalization, while pain was the most frequent complication (16.16 %). Multiple banding, young age, male sex, and external hemorrhoids were pain risk factors. RBL proved to be safe in 57 patients with coagulation disorders due to cirrhosis. Symptomatic recurrence was detected in 327 out of 2110 patients (15.49%), with repeat RBL in 219 cases and surgery in 108 cases. CONCLUSION: RBL is a safe, effective method for treating symptomatic 2nd and 3rd degree hemorrhoids. It can also be applied in selected cases of 4th degree hemorrhoids and patients with cirrhosis and portal hypertension.

Case report of a successful non-operative management of postoperative bleeding from pseudoaneurysm of the gastroduodenal artery, following gastric surgery.

INTRODUCTION: Post operative pseudoaneurysm of the gastroduodenal artery is a very rare entity. Rupture of the pseudoaneurysm can be treated by embolism of the artery. PRESENTATION OF CASE: A 71 years old male with a perforated pyloric ulcer was treated with controlled external duodenal fistula. Due to postoperative bleeding a subtotal gastrectomy was performed. A second episode of bleeding occurred and rupture of a pseudoaneurysm of the gastroduodenal artery was diagnosed by computed angiography and treated by embolism of the artery. Three days later the duodenal stump was ruptured and a new controlled external duodenal fistula was surgically created. The patient died 6 weeks later due to multiple organ failure. DISCUSSION: Pseudoaneurysm is the result of self-contained ruptures of one or more layers of the vascular wall. Computed angiography is the golden standard to identify pseudoaneurysms (100% sensitivity). Early suspicion for the presence of a pseudoaneurysm is crucial, as when the rupture actually occurs, the mortality rate is remarkably high. Endovascular approach is a minimally invasive procedure with high success rates (70-100%) and significantly lower morbidity and mortality rates. Surgical is reserved in case of bleeding recurrence. The fact that is particularly interesting in this patient is the timing of the formation of the pseudoaneurysm, considering the fact that 48 h earlier the gastroduodenal artery appeared normal. CONCLUSION: There are no guidelines regarding the treatment of the pseudoaneurysm of the gastroduodenal artery. It seems reasonable to treat them immediately after diagnosis because a possible rupture of the aneurysm has an extremely high mortality.