Indian Journal for the Practising Doctor

Wani NA, Fazilli A, Bhat GH, Mir IS

Dr Nazir A Wani, M.S. (Lecturer), Dr Anjum Fazili, M.S. (Lecturer), Dr Gh. Hassan Bhat, M.S. (Assistant Prof.), Dr Iqbal Saleem Mir, M.S. (Lecturer), Department of Surgery, Government Medical College, Srinagar (J&K), India.

ISSN: 0973-516X

Abstract

A study was conducted in the SMHS hospital, Srinagar, over a period of one year, for evaluation of rubber band ligation as a treatment of hemorrhoids on outpatient basis. Fifty cases were subjected to this treatment, majority (70%) of whom were grade 2 and in the age range of 18 to 70 years with 32% in the 21-30 year age group. The results of treatment were excellent or good in 90% cases, fair in 4% and poor in 4%, with failure after completion of treatment in 2% of cases. Moreover, the benefits of this method of treatment were far better than other modalities of treatment.

Key words: Rubber band ligation, Hemorrhoids, Digital rectal examination, Sigmoidoscopy.

Introduction

The common man calls them piles, the autocracy call them hemorrhoids, the French call them figs what does it matter so long as you cure them (John of Andre,1370).

Man has been tormented by hemorrhoids since antiquity. It is also among the earliest conditions recorded in the medical history as a cause of perpetual discomfort of humans, affecting young and old, rich and poor alike. The exact prevalence of hemorrhoids in general population is not known, since many patients, with few or no symptoms, do not seek surgical advice. However, Buie¹ reported a prevalence of 52% in a large series of patients examined proctoscopically at the Mayo clinic. The exact figure probably approaches 75% of the adult population. The methods of treatment have varied from conservative treatment with dietary modifications, stool softeners, laxatives to the injection therapy, laser, rubber band ligation, maximal anal dilatation, cryotherapy and surgery(Hemorrhoidectomy). The latter is a painful procedure, needs hospitalization, and anaesthesia, and has a lot of postoperative complications. Injection therapy showed good results only in cases of first degree and early second degree hemorrhoids. Maximal anal dilatation needed anesthesia and could land the patient into distressing complications like anal prolapse and incontinence in the elderly². Cryotherapy requires specialized equipment and has drawbacks of causing troublesome, profuse, offensive discharge from the treated area, lasting for several weeks and necessitating frequent change of dressings or sanitary towels³.The method of rubber band ligation, introduced by Baron,⁴ has many advantages like outpatient procedure, and no requirement of expensive equipment and anesthesia. It also does not affect the routine work of the patient and is well tolerated. In view of the great prevalence of this problem in general public, considering the other modalities of treatment and usefulness of rubber band ligation technique, it was felt worthwhile to study this method and evaluate its results in our patients.

Material and Methods

The study was conducted for a period of one year on fifty patients with symptomatic hemorrhoids who reported in the surgical OPD of SMHS Hospital, Srinagar. The patients were examined clinically in detail to rule out any associated diseases like fissure, fistula, stricture, abscess etc. Each patient was subjected to digital rectal examination (DRE) and proctoscopic examination. After noting the size, site, number and appearance of hemorrhoids, the patients selected for the study were subjected to rigid sigmoidoscopy up to 25 to 30 cm to rule out any higher up cause of hemorrhoids. Fifty patients with primary hemorrhoids were selected for rubber band ligation therapy. Out of these 35 patients had second degree piles, 6 first degree piles, 7 third degree hemorrhoids, while 2 cases had advanced third degree without external pile masses. Baseline routine investigations like hemoglobin, cell counts and urine examination were done in all patients.

The equipment used consisted of band ligator, pile holding forceps, loading cone, rubber bands and illuminating proctoscope. The patients were subjected to band ligation in the outpatient department using ordinary examination table. Patients were prepared by giving a tablet of laxative in the evening and proctoclysis enema in morning. Each patient was placed in the left lateral position and a rubber band was loaded on the ligator. No premedication or anesthesia was used. After DRE with xylocaine jelly lubricated finger, an illuminating proctoscopic was introduced in the rectum, its obturator was removed and hemorrhoidal area was clearly visualized. After localizing the pile mass a long Ellis forceps was then introduced through the speculum to apply traction at several different places on the hemorrhoidal area with two objectives:

1. To test the pain sensitivity as to know the site of pectinate line
2. To find the most redundant apex of the pile.

The forceps were removed and inserted through the cylinder of the ligator already loaded with a band, and both were then passed through the speculum. The previously redundant apex of the pile was grasped by forceps and pulled into the cylinder of the ligator, then the rod was pushed to release the rubber band over the neck of the hemorrhoid. The forceps was then removed. The ligated hemorrhoid assumed the shape of a miniature balloon tied at its neck. It became very quickly cyanotic and subsequently underwent necrosis and sloughed off. In the first session, the procedure was confined to only one or two of the three hemorrhoids routinely. Subsequent ligations were done at the interval of two weeks. Post procedure patients were occasionally given mild analgesics and laxatives and were advised to report after 2 weeks or earlier in case of any complications.

Results

Out of the 50 enrolled patients patients, 44 were males and 6 females with a male female ratio of 7.3:1. Thirty four patients were from rural and 16 from urban areas. The patients fell in the age range 18 to 70 years with a mean of 44.2 years; the commonest age group was between 21- 30 years (32%).

The symptoms were bleeding per rectum (92%), something coming out per rectum, prolapse of the hemorrhoids (88%), perianal discomfort (64%) and constipation (68%). General examination revealed pallor in 42 cases being severe in 2 cases, severe hypertension in 2 cases, chronic obstructive lung disease in 1 case, hypertensive cardiovascular disease with chronic renal disease, thyroid adenoma and severe anemia in 1 case.12 cases were unfit for surgery under general or local anesthesia. DRE did not reveal any finding in 45 cases (90%) and slightly lax anal sphincter in 5 cases (10%) of older age group. Proctoscopic findings are summarized in table 1. Sigmoidoscopy was normal in all cases in the study group.

Table 1: Final case distribution as per DRE and Proctoscopy

S.No.	Grade	No.of cases	Sex Ratio	Age in years	Mean Age
1	I	6	6:00	24-25	32.5
2	II	35	30:05	18-70	41.83
3	III	07	06:01	30-60	46.57
4	IV	02	02:00	48-55	51.50

Among the laboratory investigations the most significant variation was noticed in hemoglobin values. Two cases, one each of grade III and IV hemorrhoids, who had bleeding per rectum for 17 years on average were severely anemic (one with Hb of 4.5 gms/dl). 40 cases that included, respectively, 33, 6 and 1 case of grade II,III,IV, had been bleeding, on average, for 6.5 years and were severely anemic (Hb 6-10gm / dl) and 8 cases, 6 of grade I and 2 of grade II, with bleeding per rectum for an average of 1.5 months, had a hemoglobin level ranging between 11 and 12 gms / dl.

The procedure was done without any premedication or anesthesia in the outpatient department using Baron's technique. Rubber band ligation of one pile mass was done in three cases and two pile masses (in first sitting) in 47 cases. Subsequent ligation of remaining hemorrhoids was done after an interval of 2-3 weeks.

Table II: Outcome of the procedure

S. no	Result of treatment	Grade (i)	Grade (ii)	Grade (iii)	Grade (iv)	Total cases	%
1.	Excellent	06	27	00	00	33	66
2.	Good	00	07	05	00	12	24
3.	Fair	00	00	02	00	02	04
4.	Poor	00	01	00	02	03	06
	Total	06	35	07	02	50	100

Discussion

Majority of patients in our study were under 70 years. Other investigators Hood and Williams,³ Barron⁴, Lou⁶ and Khubchandani⁷ have also conducted studies of the use of rubber band ligation on patients who fell more or less in the same age range i.e., 24-78 years, 25-71 years, 19-79 year and 21-85 years, respectively. Majority of cases in this study (80%) had already tried other forms of treatment. Of these, one patient had undergone injection therapy one year before without any relief in symptoms while the other had undergone hemorrhoidectomy 4 years before, had developed recurrence and was now fearful and unwilling to undergo same operative procedure again. In a study of 200 cases by Barron⁸, 6% had already received injection therapy and 7 percent had undergone hemorrhoidectomy. Salvati⁹ reported band ligation in 26% of the cases who had previously undergone injection therapy and in 9.8% of cases previously having undergone hemorrhidectomy. Rudd¹⁰ reported 3 patients who were particularly happy with the results of band ligation therapy having previously undergone hemorrhoidectomy and were glad that they had not to undergo the painful procedure again. These observations confirm the fact that hemorrhoids can recur even after expert surgical treatment and a large number of patients insist on undergoing band ligation rather than hemorrhoidectomy.

Six (12%) patients in this study who were considered as poor anesthetic and poor surgical risks for operative procedures on account of such diseases as hypertensive cardiovascular disease with chronic renal disease and severe anemia in one case, severe hypertension in 2 cases, severe anemia in 2 cases and COPD in one case were safely taken up for this procedure and all got benefited. Barron⁸ had done rubber band ligation on 12 patients with severe heart disease, 3 cases with advanced Parkinsonism, some with inoperable cancer, severe diabetes and many others who were diagnosed as poor surgical risk and all obtained relief by this method of treatment.

Lee¹¹ also described the procedure in cardiac patients and during senility and infirmity when the patients were unfit for radical excision treatment. The usefulness of this procedure in the poor risk elderly patients and in those with recurrent hemorrhoids after surgical treatment has also been commented by Salvati⁹. Jones and Schofield¹² stated that the use of Lords procedure should be abandoned in patients of older age group because of the risk of such complications as prolapse and fecal incontinence, while the use of rubber band because of its safety has been advocated at this age.

This study revealed that majority of patients (76%) had no loss of time from work due to postligation discomfort. Only one patient (2%) had significant loss of time (one week) due to perianal hematoma. 11(22%) patients, who had mild discomfort, stayed at their home for 24 hours post ligation. Thus, it was concluded that practically no loss of time occurred in this procedure therefore making it a suitable and satisfying one.

Barron⁴ reported that only 5% of patients absented themselves from work following ligation. The majority of them were tense, nervous and apprehensive individuals. The average loss of time in this study was two days. Hood and Williams³ reported an average loss of time from work of 1-2 days duration. Lau⁶ advised one and a half days rest in all cases after ligating them on Saturday, allowing to attend the office of Monday. It is thus apparent that the time lost from work in this procedure is far less than that lost after routine hemorrhoidectomy (7-10 days after discharging from hospital). Excellent results, post treatment were achieved in 33(66%) patients. None of them reported with recurrence till 6 months from the time of completion of the treatment. Good results were achieved in 12(24%) patients. They had occasional residual bleeding but no prolapse. This was due to residual hemorrhoids which were dealt with by conservative treatment if small or by band ligation if big. It was thus concluded that one must deal effectively with residual hemorrhoid tags as they can otherwise give rise to recurrent symptoms later. Fair results were achieved in 2(4%) cases. Both of them belonged to grade III hemorrhoids and needed religation. Lau⁶ also required further band ligation in 13.9% of patients to ameliorate or relieve their symptoms. He reported excellent results in 28.2%, fair results in 6.4% and poor results in 3% patients. Groves¹³ reported excellent results in 66% patients and good results in 25% patients. Poor results were seen in3(6%) patients. They included one patient of grade II hemorrhoids and 2 patients of grade IV hemorrhoids.

Apart from pain during procedure in one case and premature slipping of both bands in another, the other post-ligation complications were secondary hemorrhage in 6(12%), pruritis ani in 2(4%) and perianal hematoma in one case. Minor secondary hemorrhage was noticed between 7 and 14 days postligation following sloughing of ligated hemorrhoids. Bleeding stopped spontaneously in all cases without any need of hospitalization, blood transfusion or surgical intervention.

Barron⁸ reported bleeding following ligation of hemorrhoids in 4 out of 200(2%) cases; one of them had to be hospitalized for blood transfusion and ligation of the remaining hemorrhoids. In another study of 400 cases in 1964, he reported bleeding from ligature site in one case. Salvati9 reported hemorrhage following ligation in 9(1.8%) out of which 5 patients had to be hospitalized for treatment. Lau⁶ reported 5(2.5%) cases in his study who developed bleeding after sloughing of the ligated hemorrhoids between 7th and 14th day postligation and out of these 2 patients required transfusion. None of the cases in this study developed infection following band ligation of hemorrhoids. There was no evidence of thrombosis in this study, although Salvati reports this complications in 3% of cases and Rudd in 3.75% of cases. 4 cases in our study who had combined internal and external hemorrhoids were treated by ligating the internal hemorrhoids alone. In two of them 50% reduction in the size of external hemorrhoids was seen and in the other two cases external hemorrhoids persisted. Although these skin tags could be easily excised under local anesthesia in those 2 patients but it was not required. Rudd also treated combined interno-external hemorrhoids by ligating the internal hemorrhoids alone and in all cases in our study the external hemorrhoids cleared up following the treatment. Keeping in view the excellent and good results of 90% patients in this study, our results are comparable to other studies and are definitely better than those of the Lord's procedure. In addition, rubber band ligation saves money and time and avoids load on hospital beds which is of particular importance in a general hospital like ours.

To sum up the advantages of rubber band ligation procedure are that it is practically painless, no expensive hospitalization is required, there is no loss of work hours, almost no danger of hemorrhage and other complications like incontinence and stenosis. Thus the procedure is economically beneficial for treatment of hemorrhoids in a society like ours, where poor people will be benefited as no money or mandays are lost and where busy office going people and businessmen can save time, as little or no time is wasted. Of late our hospital has now picked this procedure of treatment and results are really encouraging.

Complications

1. Pain during procedure: 49 (98%) cases experienced no pain during procedure while one patient had severe pain which necessitated the use of parenteral narcotic analgesics and immediate removal of the bands. The patient was a nervous female and procedure had to be abandoned.

2. Slipping of bands: In one patient of grade IV disease without external hemorrhoids the rubber band slipped, the patient refused the procedure in the second sitting and opted for hemorroidectomy. The ligated hemorrhoids got separated within two weeks in 96% cases and 4% took longer time.

3. Post-procedure discomfort: 12 cases which included 6 cases each of grade I and II hemorrhoids experienced no discomfort at all. 26 patients of grade II hemorrhoids had minimal discomfort requiring no analgesia lasting for 12 hours only. 11 patients (3, 6 and 2 patients of grade II,III and IV hemorrhoids respectively) had felt discomfort lasting 24 hours requiring analgesics. The discomfort occurred only after first ligation. Subsequent post ligation periods were painless.

The majority of patients (76%) had no loss of time from work. 11(22%) patients returned to work after 24 hours and only one case had significant loss of time from work i.e., one week because of perianal haematoma. At 2 weeks after banding of the last primary hemorrhoid, each patient was asked about relief/ persistence of symptoms, assessment being made on the basis of two cardinal symptoms i.e., bleeding and prolapse.

The results were considered as:

1. Excellent — when the patients were completely asymptomatic
2. Good — when there were minimal symptoms
3. Fair — when there was slight improvement in symptoms
4. Poor — when symptoms were persistent or became worse.

References

1. Buie,L.A: Practical Proctology.1960: 2nd ed; pg.737-740.
2. Bates. Rectal prolapse after anorectal dilatation in elderly. Br Med J 1972:2,505
3. Hood T R and Williams J A. Anal dilatation versus rubber band ligation for internal hemorrhoids; Am.J.Surg,1971:122;545-547
4. Barron J: Office ligation treatment of hemorrhoids Dis. Colon and Rectum 1963:6;109-111.
5. Wrobliski,D.E; Corman,M.L; Veidenheimer M.C and Coller J.A; Long term evaluation of rubber band ligation in hemorrhoidal diseases. Dis Colon and Rectum 1980,23;478-480
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