Ischemic Polypectomy Through Detachable Snare and Rubber Band Ligation in Peutz-Jeghers Syndrome.

Endoscopic polypectomy is essential for the prevention of Peutz-Jeghers syndrome-associated complications, including intussusception, intestinal obstruction, and malignant transformation. Conventional polypectomy is the preferred approach, but it can be challenging to achieve in patients with Peutz-Jeghers syndrome because of the high polyp burden and polyps located in areas with difficult endoscopic access. This case report highlights 2 different techniques of ischemic polypectomy and its advantage compared with conventional polypectomy in this subset of patients.

Development of a low-cost simulator for training in hemorrhoidal ligation

Introduction: Rubber band ligation is a minimally invasive outpatient hemorrhoid treatment with low cost, low complication rates, and rapid realization. It is performed with the aid of an anoscope and uses a rubber ring that surrounds the hemorrhoidal nipple, causing compression of the vascular structures of the tissue, leading to necrosis and remission of the hemorrhoid. No device for training this essential procedure for treating this pathology has been identified in the literature. Therefore, we aim to develop a low-cost simulator for training hemorrhoidal rubber ligation. Methods: The model was constructed using PVC pipe wrapped in neoprene fabric. Hemorrhoidal nipples and the pectineal line were also simulated using fabric and sewing threads. The procedure is performed with conventional anoscope and ligature forceps. Conclusion: The device in question is a low-cost simulation model designed to train the skills required to perform a rubber band ligation and review the basic anatomy of the anal canal during anoscopy. Given these qualities, the model can be used for academic training due to its low cost and simplicity of application. (AU)

Sclerobanding in the treatment of second and third degree hemorrhoidal disease in high risk patients on antiplatelet/anticoagulant therapy without suspension: a pilot study.

Introduction: Around 20% of population in western countries is under anticoagulant treatment. However, there is paucity of evidence about the treatment of HD in patients under anticoagulant/antiplatelet therapy, although both suspension and continuation in the perioperative period may increase the risk of severe complications. The aim of this pilot study was to confirm the feasibility and safety of sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy), an office-based procedure, for the treatment of second-and third-degree HD in patients under anticoagulant/antiplatelet therapy without suspension. Materials and methods: Patients affected by second-third-degree haemorrhoids unresponsive to conservative treatment and under anticoagulant/antiplatelet were enrolled between November 2019 and October 2021. Postoperative complications, readmission, mortality and reintervention during the follow-up were evaluated. Results: Fifty-one patients were recruited, 23 female (45.1%) and 28 male (54.9%), with an average age of 65 years ± 11.4 SD (range 42-90). Twenty-seven patients (52.9%) had II-degree haemorrhoidal disease, and 24 (47.1%) had grade III-degree. The most frequently taken medications were dual antiplatelet therapy (51%) and new oral anticoagulants (NOACs) (21.6%). The mean follow-up was 23 months. No intraoperative complications were recorded. The rate of complications in the first postoperative month was 13.7%, represented by mild complications: 6 cases of moderate to severe pain and 1 case (2%) of thrombosis of a residual haemorrhoidal nodule, all regressing after conservative therapy. No severe complications were reported. Postoperative complications were not statistically significantly associated with the number of nodules treated (1, 2, or 3), the disease grade (2nd vs. 3rd) or the specific anticoagulant/antiplatelet regimen. During follow-up, 2 patients (4%) required a new procedure for recurrent bleeding: one an infrared photocoagulation as outpatient, and another a haemorrhoidectomy after 3 months. No cases of intraoperative or postoperative mortality occurred. Conclusions: Sclerobanding is a safe and effective technique in treating intermediate-grade haemorrhoidal disease in patients at high risk on anticoagulant/antiplatelet therapy. Sclerobanding is repeatable, usually does not require anaesthesia, and is cost-effective. Observational multicentre studies with a larger number of patients and controlled clinical trials will be needed to confirm these results.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease.

PURPOSE: The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores. METHODS: This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications. RESULTS: A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%). CONCLUSION: Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Treatment of haemorrhoids: rubber band ligation or sclerotherapy (THROS)? Study protocol for a multicentre, non-inferiority, randomised controlled trial.

INTRODUCTION: Haemorrhoidal disease (HD) is a common condition with significant epidemiologic and economic implications. While it is possible to treat symptomatic grade 1-2 haemorrhoids with rubber band ligation (RBL) or sclerotherapy (SCL), the effectiveness of these treatments compatible with current standards has not yet been investigated with a randomised controlled trial. The hypothesis is that SCL is not inferior to RBL in terms of symptom reduction (patient-related outcome measures (PROMs)), patient experience, complications or recurrence rate. METHODS AND ANALYSIS: This protocol describes the methodology of a non-inferiority, multicentre, randomised controlled trial comparing rubber band ligation and sclerotherapy for symptomatic grade 1-2 haemorrhoids in adults (> 18 years). Patients are preferably randomised between the two treatment arms. However, patients with a strong preference for one of the treatments and refuse randomisation are eligible for the registration arm. Patients either receive 4 cc Aethoxysklerol 3% SCL or 3 × RBL. The primary outcome measures are symptom reduction by means of PROMs, recurrence and complication rates. Secondary outcome measures are patient experience, number of treatments and days of sick leave from work. Data are collected at 4 different time points. DISCUSSION: The THROS trial is the first large multicentre randomised trial to study the difference in effectivity between RBL and SCL for the treatment of grade 1-2 HD. It will provide information as to which treatment method (RBL or SCL) is the most effective, gives fewer complications and is experienced by the patient as the best option. ETHICS AND DISSEMINATION: The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers, location AMC (nr. 2020_053). The gathered data and results will be submitted for publication in peer-reviewed journals and spread to coloproctological associations and guidelines. TRIAL REGISTRATION: Dutch Trial Register NL8377 . Registered on 12-02-2020.

HEmoRhoidal disease management with Band ligation versus polidocanol Sclerotherapy: a systematic review and meta-analysis (the HerBS Review).

PURPOSE: Symptomatic internal hemorrhoids affect up to 40% of people in Western society. Patients with grade I-III hemorrhoids, who fail lifestyle and medical management, may benefit from office-based procedures. As per the American Society of Colon and Rectum Surgeons (ASCRS), rubber band ligation (RBL) is the first-line office-based treatment. Polidocanol sclerotherapy is a relatively new approach for these patients. The aim of this systematic review is to compare the efficacy of RBL and polidocanol sclerotherapy with the treatment of symptomatic grade I-III internal hemorrhoids. METHODS: The systematic review was completed by searching MEDLINE, Embase, and CENTRAL databases from inception to August 2022 for prospective studies comparing RBL and polidocanol sclerotherapy or evaluating the efficacy of polidocanol sclerotherapy alone for adult (> 18 years) patients with grade I-III internal hemorrhoids. Treatments were evaluated for therapeutic success and post-procedure morbidity. RESULTS: Of 155 citations obtained, 10 studies (3 comparative and 7 single-arm studies) and 4 abstracts (2 comparative and 2 single arm) were included in the study. The patients undergoing sclerotherapy had a 93% (151/163) therapeutic success rate compared to 75% (68/91) in the RBL group (OR 3.39, 95% CI 1.48-7.74, p < 0.01). The post-procedure morbidity was 8% (17/200) in the sclerotherapy group and 18% (23/128) in the RBL group (OR 0.53, 95% CI 0.15-1.82, p = 0.31). CONCLUSION: This study highlights that polidocanol sclerotherapy may be associated with higher therapeutic success in patients with symptomatic grade I-III internal hemorrhoids. Further evaluations in the form of randomized trials are required to evaluate patient populations, which may benefit more from sclerotherapy.

Efficacy of two endoscopic rubber band ligation methods for symptomatic hemorrhoids: a randomized controlled trial.

BACKGROUND: Endoscopic rubber band ligation (ERBL) is considered an effective nonsurgical treatment for symptomatic grade I to III hemorrhoids; however, it is unclear whether ligation of hemorrhoids or simultaneous ligation of hemorrhoids and proximal normal mucosa (combined ligation) is safer and more effective. This controlled, open-label, and prospective study aimed to evaluate the efficacy and safety of both methods for symptomatic grade I to III hemorrhoids. METHODS: Seventy patients with symptomatic grade I to III hemorrhoids were randomly assigned to the hemorrhoid and combined ligation groups (35 in each group). Patients were followed up at 3, 6, and 12 months to assess symptom improvement, complications, and recurrence. The primary outcome was overall therapeutic success rate (complete resolution and partial resolution rates). The secondary outcomes included recurrence rate and efficacy for each symptom. Complications and patient satisfaction were also assessed. RESULTS: Sixty-two patients (31 in each group) completed the 12-month follow-up; 42 (67.8%) experienced complete resolution, 17 (27.4%) experienced partial resolution, and 3 (4.8%) experienced no change in overall efficacy. The rates of complete resolution, partial resolution, and no change in the hemorrhoid ligation and combined ligation groups were 71.0 and 64.5%, 22.6 and 32.3%, and 6.5 and 3.2%, respectively. No significant differences in overall efficacy, recurrence rate, or efficacy for each symptom (including bleeding, prolapse, pain, anal swelling, itching, soiling, and constipation) were observed between groups. No life-threatening events requiring surgical intervention occurred. The incidence of postoperative pain was higher in the combined ligation group (74.2% vs. 45.2%, P = 0.02). No significant differences between groups in terms of incidences of other complications or patient satisfaction were observed. CONCLUSION: Both methods achieved satisfactory therapeutic effects. No significant differences in efficacy and safety of the two ligation methods were observed; however, combined ligation resulted in a higher incidence of postprocedural pain.

Hemorrhoid Disease: A Review on Treatment, Clinical Research and Patent Data.

BACKGROUND: Hemorrhoid disease (HD) is an anal-rectal ailment that is commonly painful or may be painless and causes rectal bleeding with or without prolapsing anal tissue. It is generally associated with bleeding, prolapse, pruritus, and discomfort, which results in a diminished quality of life and well-being. OBJECTIVE: To highlight the recent developments in terms of safety, clinical efficacy, and marketed formulation for the effective management of hemorrhoids. METHOD: Reported literature available on Scopus, PubMed, Science Direct, Clinicaltrails.gov, and from many reputed foundations has been studied to summarize the recent development and clinical studies for the management of hemorrhoids. RESULTS AND CONCLUSION: The high incidence of hemorrhoids obliges the development of new molecules; therefore, safe and efficient drugs to confer protection against hemorrhoids are urgently needed. This review article mainly focuses on the newer molecules to overcome hemorrhoids and also emphasizes various studies carried out in the past.

Comparison of the long-term efficacy and safety of multiple endoscopic rubber band ligations in a single session for varying grades of internal hemorrhoids.

BACKGROUND: There is no consensus on the number of ligation bands for varying grades of internal hemorrhoids (IH) in a single session of endoscopic rubber band ligation (ERBL). AIMS: The aims of this study were to investigate this issue. METHODS: Patients with IH were treated with ERBL. The primary endpoint was no hemorrhoid symptoms 6 weeks after ERBL. The secondary endpoints were postoperative complications and recurrence. RESULTS: One hundred twenty-three eligible patients met the inclusion criteria, and 3 patients were excluded. The average bands were 3.9 ± 1.1, and grade II hemorrhoids required significantly fewer bands than grade III hemorrhoids (3.45 ± 0.85 vs 4.35 ± 1.06, P = 0.000). 78.8% of patients achieved the primary endpoint. The efficacy of grade II hemorrhoids was higher than that of grade III hemorrhoids (87.8% vs 69.2%). The incidence of postoperative complications was not significantly correlated with the grade of hemorrhoids (P = 0.201) and the number of bands (P = 0.886). The median follow-up time was 14.3 ± 7.9 (1.3-30.9) months. The overall recurrence rate was 25.0%, with grade III significantly higher than grade I-II (32.8% vs 14.6%, P = 0.027). For grade III hemorrhoids, the recurrence rate was lower with more than 4 bands of ligation than with less than 4 bands (26.5% vs 53.3%). CONCLUSIONS: The average ERBL treatment of IH requires nearly four bands, and grade II hemorrhoids require less banding than grade III hemorrhoids, while the efficacy was better. Increasing the number of bands improves the treatment efficacy for grade III IH, which could be a strategy to reduce the recurrence rate without increasing postoperative complications.

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial.

BACKGROUND: Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events. METHODS: This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no). RESULTS: At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events. CONCLUSIONS: LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

A comparative study of rubber band ligation versus BANANA-Clip in grade 1 to 3 internal hemorrhoids.

PURPOSE: Rubber band ligation (RBL) for grade 1 to 3 internal hemorrhoids is a well-established modality of choice. But RBL is also a kind of surgical treatment; it is not free from complications (e.g., delayed bleeding [DB], rectal stenosis). This study aimed to investigate the results of the comparative treatment of RBL and BANANA-Clip (BC; Endovision). METHODS: Study participants were 632 consecutive patients with grade 1 to 3 internal hemorrhoids attended to Department of Colorectal Surgery at Wellness Hospital between January 2010 and May 2019. We retrospectively reviewed the incidence rate of complications, including DB between RBL and BC. RESULTS: There were 304 male and 328 female patients, whose ages ranged from 15 to 84 years, with a mean age of 45.7 years. The common symptom and cause of treatment was prolapse (70.1%). The number of ligated sites was 1.49±0.57 in the RBL group and 1.99±0.77 in the BC group. RBL showed a significantly higher incidence of DB (3.5%) compared to BC (0%) (P=0.001). The 1-year success rate was 95.9% in the RBL group and 99.7% in the BC group (P=0.005). CONCLUSION: In our study, BC was more reliable in treating grade 1 to 3 internal hemorrhoids with higher success rates and less post-ligation complications, especially DB, compared to RBL.

Office-Based Procedures in the Management of Hemorrhoidal Disease: Rubber Band Ligation versus Sclerotherapy - Systematic Review and Meta-Analysis.

Introduction: The most frequently used office-based procedures in hemorrhoidal disease (HD) are rubber band ligation (RBL) and sclerotherapy. Few studies have been published comparing the various types of instrumental therapy. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of sclerotherapy and RBL. Methods: Three online databases were searched. Efficacy (control of symptoms, prolapse, bleeding and pain, patients' satisfaction, and disease recurrence) and safety (complications, such as pain and bleeding) were the assessed outcomes. Pooled relative risks (RR) were computed for each outcome using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I2. Results: Six RCTs and three cohort studies were included. Control of prolapse and bleeding was significantly higher with RBL (93.1% RBL vs. 66.4% sclerotherapy, RR 1.34, 95% CI 1.12-1.60 and 89.1% RBL vs. 78.7% SCL, RR 1.17, 95% CI 1.02-1.34, respectively). Both techniques had similar results in terms of pain relief, overall control of symptoms, and risk of recurrence at 3 months. Although patient satisfaction was significantly higher with RBL (77.8% RBL vs. 46.7% sclerotherapy, RR 1.59, 95% CI 1.01-2.50), post-procedural pain was significantly higher with this technique (24% RBL vs. 14% sclerotherapy, RR 1.74, 95% CI 1.32-2.28). There was no significant difference regarding post-procedure bleeding (11.1% RBL vs. 8.7% sclerotherapy, RR 1.29, 95% CI 0.86-1.94). In the subgroup analysis, according to the HD grade, post-procedure pain was higher with RBL only in HD grade II (vs. HD grade I-III). Conclusions: RBL performs better than sclerotherapy in controlling HD symptoms, specifically prolapse and bleeding, although post-procedural pain is a frequent complication. Recurrence is similar with both procedures. While waiting for the publication of results with sclerotherapy with new sclerosants, RBL remains the office-based treatment of choice in HD.

Contexto/Objetivos: Os tratamentos instrumentais mais frequentemente realizados na doença hemorroidária (DH) são a laqueação elástica (LE) e a escleroterapia. Existem poucos estudos publicados que comparem os vários tipos de tratamento instrumental. O objetivo desta revisão sistemática e meta-análise foi comparar a eficácia e a segurança da escleroterapia e da LE. Métodos: A pesquisa foi feita em três bases de dados. A eficácia (controlo dos sintomas, do prolapso, da hemorragia e da dor, satisfação dos doentes e recorrência da DH) e a segurança (complicações, tais como dor e hemorragia) foram os resultados avaliados. Os riscos relativos (RR) foram calculados para cada resultado, com recurso a um modelo de efeitos aleatórios, e a heterogeneidade foi avaliada pelo teste Q de Cochran e I2. Resultados: Foram incluídos seis estudos clínicos randomizados e três estudos de coorte. O controlo do prolapso e da hemorragia foi significativamente mais elevado com a LE (93,1% LE VS 66,4% escleroterapia, RR 1,34, 95% CI 1,12-1,60 e 89,1% LE VS 78,7% escleroterapia, RR 1,17, 95% CI 1,02-1,34, respetivamente). Ambas as técnicas tiveram resultados semelhantes em termos de alívio da dor, controlo global dos sintomas e risco de recidiva aos 3 meses. Embora a satisfação dos doentes fosse significativamente maior com LE (77,8% LE VS 46,7% escleroterapia, RR 1,59 95% CI 1,01-2,50), a dor pós-procedimento foi significativamente maior com esta técnica (24% LE VS 14% escleroterapia, RR 1,74, 95% CI 1,32-2,28). Não houve diferença significativa na hemorragia pós-procedimento (11,1% LE VS 8,7% escleroterapia, RR 1,29, 95% CI 0,86-1,94). Na análise de subgrupos, de acordo com o grau da DH, a dor pós-procedimento foi mais elevada com a LE apenas na DH grau II (VS DH graus I-III). Conclusões: A LE tem melhores resultados do que a escleroterapia no controlo dos sintomas, mais concretamente na resolução do prolapso e da hemorragia hemorroidária, embora a dor pós-procedimento seja uma complicação mais frequente com a LE. A recorrência é semelhante em ambos os procedimentos. Enquanto se aguarda a publicação dos resultados de estudos com novos esclerosantes, a LE deverá ser considerado o tratamento instrumental de primeira linha na DH.

Outcomes of Rubber Band Ligation in Haemorrhoids Among Outdoor Patients.

BACKGROUND: Out of all anorectal diseases, haemorrhoids are the most common benign disease. Haemorrhoids can be treated by various treatment modalities like medical, surgical, and instrumental. Instrumental treatment comprises rubber band ligation, sclerotherapy, and infrared and laser therapy. Out of these modalities, the rubber band ligation technique is the least invasive with a reduced rate of complications and without the need for hospitalization. Hence, the current study was conducted to evaluate the outcomes with respect to the effectiveness of rubber band ligation in grade II and III internal haemorrhoids along with the magnitude and pattern of post-procedural complications. METHODS: This is a prospective observational study, conducted on a sample of 100 patients who presented to our outdoor patient's department and were diagnosed with haemorrhoids, either grade II or III. All enrolled study patients having haemorrhoids were banded with rubber band by Barron Ligator (Precise, Canada) with local anaesthetic agent xylocaine jelly in a single session. All patients were followed on the 10th day, 1st month, and 6th month after the procedure to assess symptomatic improvement. The endpoint of this study is to know the effectiveness of rubber band ligation in different clinical parameters such as post-ligation pain or discomfort, the requirement of analgesic, any complication, and time off work. RESULTS: Out of 100 patients 17 patients had grade II and 83 patients had grade III haemorrhoids. Among them, 89% were symptomatically relieved after rubber band ligation whereas the rest 11% of patients had residual symptoms. CONCLUSION: Thus, we conclude that rubber band ligation for grade II and III haemorrhoids is simple, safer, easy-to-perform daycare procedure with lesser requirements of analgesics and without any need for anaesthesia.

Rubber band ligation of hemorrhoids: is the procedure effective for the immunocompromised, hemophiliacs and pregnant women?

Background: Rubber band ligation (RBL) is an effective, well-established, non-surgical option for symptomatic grade II-III hemorrhoid treatment. However, few reports exist about the benefit and risks of RBL in high-risk patients. We herein evaluated the effectiveness and safety of RBL in hemophiliac, human immunodeficiency virus (HIV)-positive and pregnant patients vs. other patients. Methods: We retrospectively evaluated the effectiveness of RBL, during the period 2001-2021, in 3 distinct patient categories deemed high-risk and thus not suitable for anesthesia and/or surgical management of their hemorrhoids: hemophiliacs, HIV-positive patients, and pregnant women. These were compared to matched controls, selected from our outpatient pool, who had no major comorbidities and who had opted for RBL as the primary method of treatment. Results: There were 3 study groups (44 with hemophilia, 29 HIV-positive patients, and 45 pregnant women) and controls respectively matched for grade, sex and age (2 for each one in the study groups). Hemophilia patients needed up to 6 RBL sessions for relief of symptoms (3.22 sessions/patient) compared to controls, who needed up to 4 sessions (1.88 sessions/patient, P<0.001); in the other 2 groups there was no difference. There were 3 minor complications: one minor bleeding in a hemophilia patient, a thrombosis in an HIV-positive patient, and severe rectal pain in a control patient. Patients were followed-up for at least 1 year. Conclusion: RBL is a safe and effective procedure in hemophiliacs, HIV-positive patients and pregnant women, with low complication rates for grade I-III hemorrhoids, similar to those in healthy matched controls.

Massive gastrointestinal bleeding after endoscopic rubber band ligation of internal hemorrhoids: A case report.

BACKGROUND: Rubber band ligation (RBL) using rigid anoscope is a commonly recommended therapy for grade I-III symptomatic internal hemorrhoids. Severe complications of RBL include pain, hemorrhage and sepsis. Flexible endoscopic RBL (ERBL) is now more commonly used in RBL therapy but few severe complications have been reported. Here we report on a case of massive bleeding after ERBL. CASE SUMMARY: A 31-year-old female was admitted to the department of gastroenterology with a chief complaint of discontinuous hematochezia for 2 years. No previous history, accompanying diseases or drug use was reported. Physical examination and colonoscopy showed grade II internal hemorrhoids. The patient received ERBL therapy. Five days after ligation, the patient presented with mild hematochezia. On days 7 and 9 after ligation, she presented with a large amount of rectal bleeding, dizziness and weakness. Emergency colonoscopy revealed active bleeding and an ulcer in the anal wound. The patient received two sessions of hemoclipping on days 7 and 9 to treat the bleeding. No further bleeding was reported up to day 15 and she was discharged home. Although the hemorrhoid prolapse disappeared after ERBL, she was dissatisfied with the subsequent complications. CONCLUSION: ERBL therapy is an effective treatment for symptomatic internal hemorrhoids with satisfactory short and long-term recovery. Pain and anal bleeding are the most frequently reported postoperative complications. Coagulation disorders complicate the increased risk of bleeding. Although rarely reported, our case reminds us that those patients without coagulation disorders are also at risk of massive life-threatening bleeding and need strict follow-up after ligation.

Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study.

BACKGROUND: Massive, delayed bleeding (DB) is the most common major complication of Rubber Band Ligation (RBL) for internal hemorrhoids caused by premature band slippage. In this study we modified conventional RBL to prevent early rubber band slippage and evaluated its clinical efficacy and safety. METHODS: Study participants were consecutive patients with grade II or III internal hemorrhoids treated with RBL at Ningbo Medical Center of Lihuili Hospital from January 2019 to December 2020. Postoperative minor complications such as pain, swelling, anal edema, prolapse recurrence and major complications like DB were retrospectively reviewed. RESULTS: A total of 274 patients were enrolled, including 149 patients treated with modified RBL and 125 treated with conventional RBL. There was no statistically significant difference between the two groups at baseline. Five cases of postoperative DB have been observed in the conventional RBL group, compared to none in the modified ones, with a significant difference (P < 0.05). Within three months after surgery, 8 cases in the modified RBL group experienced a recurrence rate of 5.4%, whereas 17 patients in the conventional RBL group experienced a recurrence rate of 13.6%. The difference was statistically significant (P < 0.05). The VAS score, edema, and incidence of sensation of prolapse between the two groups were not significantly different at 3 and 7 days after surgery (P < 0.05). There were also no significant differences in HDSS and SHS scores between the two groups after surgery (P > 0.05). CONCLUSION: Modified RBL may be associated with a lower rate of complications, especially with lower DB rate in comparison with standard RBL. Further studies in larger samples and different design are necessary to confirm these results.

The use of topical anaesthetic in the banding of internal haemorrhoids: a feasibility study for a randomised control trial.

INTRODUCTION: Rubber band ligation (RBL) is a procedure commonly performed in colorectal clinics for internal haemorrhoids. Overall, 90% of patients experience pain following RBL. We aimed to complete a feasibility randomised control trial assessing the role of topical anaesthetic before RBL of internal haemorrhoids. METHODS: We performed a prospective, single-centre, single blinded, randomised (1:1) control feasibility trial. Patients presenting with symptomatic haemorrhoids suitable for banding were randomised to undergo the procedure with local anaesthetic or without (control). Pain scores and vasovagal symptoms were assessed at 0 minutes, 30 minutes, 4 hours and 72 hours after the procedure. Primary outcome measures were recruitment rate, participant retention rate and patient and surgeon acceptability. Secondary outcome measures were pain scores up to 72 hours, vasovagal episodes, new use of analgesia and adverse outcomes. RESULTS: In total, 35 patients (18 topical anaesthetic, group A; 17 no anaesthetic gel, group B) were recruited. Mean recruitment rate was 11.7 participants per month. Thirty-three (94%) participants remained in the study until completion, with two patients lost to telephone follow-up. The treatment was acceptable for 35 (97%) eligible patients. One patient declined enrolment. The treatment was acceptable to all surgeons (100%). There was a significant difference in median pain scores of -2 (95% CI -4.0 to -1.0, p=0.0006) at the 30-minute time point only. There was no significant difference in vasovagal symptoms (p=0.10) or new analgesia use (p=0.85). CONCLUSION: We have shown that a phase III clinical trial is feasible for assessing the role of topical anaesthetic before RBL of internal haemorrhoids. We have demonstrated excellent patient recruitment and retention as well as patient and surgeon acceptability.

Hemorrhoidectomy versus rubber band ligation in grade III hemorrhoidal disease: a large retrospective cohort study with long-term follow-up.

PURPOSE: Standard therapy for grade III hemorrhoids is rubber band ligation (RBL) and hemorrhoidectomy. The long-term clinical and patient-reported outcomes of these treatments in a tertiary referral center for proctology were evaluated. METHODS: A retrospective analysis was performed in all patients with grade III hemorrhoids who were treated between January 2013 and August 2018. Medical history, symptoms, reinterventions, complications, and patient-reported outcome measurements (PROM) were retrieved from individual electronic patient files, which were prospectively entered as standard questionnaires in our clinic. RESULTS: Overall, 327 patients (163 males) were treated by either RBL (n=182) or hemorrhoidectomy (n=145). The median follow-up was 44 months. The severity of symptoms and patient preference led to the treatment of choice. The most commonly experienced symptoms were prolapse (83.2%) and blood loss (69.7%). Hemorrhoidectomy was effective in 95.9% of the cases as a single procedure, while a single RBL procedure was only effective in 51.6%. In the RBL group, 34.6% received a second RBL session. Complications were not significantly different, 11 (7.6%) after hemorrhoidectomy versus 6 (3.3%) after RBL. However, 4 fistulas developed after hemorrhoidectomy and none after RBL (P<0.05). The pre-procedure PROM score was higher in the hemorrhoidectomy group whereas the post-procedure PROM score did not significantly differ between the groups. CONCLUSION: Treatment of grade III hemorrhoids usually requires more than one session RBL whereas 1-time hemorrhoidectomy suffices. Complications were more common after hemorrhoidectomy. The patient-related outcome did not differ between procedures.

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.

Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: The aim of this study was to review clinical outcome of haemorrhoidectomy and rubber band ligation in grade II-III haemorrhoids. METHODS: A systematic review was conducted. Medline, Embase, Cochrane Library, Clinicaltrials.gov, and the WHO International Trial Registry Platform were searched, from inception until May 2018, to identify randomised clinical trials comparing rubber band ligation with haemorrhoidectomy for grade II-III haemorrhoids. The primary outcome was control of symptoms. Secondary outcomes included postoperative pain, postoperative complications, anal continence, patient satisfaction, quality of life and healthcare costs were assessed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Three hundred and twenty-four studies were identified. Eight trials met the inclusion criteria. All trials were of moderate methodological quality. Outcome measures were diverse and not clearly defined. Control of symptoms was better following haemorrhoidectomy. Patients had less pain after rubber band ligation. There were more complications (bleeding, urinary retention, anal incontinence/stenosis) in the haemorrhoidectomy group. Patient satisfaction was equal in both groups. There were no data on quality of life and healthcare costs except that in one study patients resumed work more early after rubber band ligation. CONCLUSIONS: Haemorrhoidectomy seems to provide better symptom control but at the cost of more pain and complications. However, due to the poor quality of the studies analysed/it is not possible to determine which of the two procedures provides the best treatment for grade II-III haemorrhoids. Further studies focusing on clearly defined outcome measurements taking patients perspective and economic impact into consideration are required.