|Year : 2018 | Volume
| Issue : 1 | Page : 108-113
Rubber band ligation for bleeding hemorrhoids in hepatic patients
Ashraf A Zeineldin, Ahmed Gaber, Mohamed M. A. Shabana
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||19-Dec-2014|
|Date of Acceptance||12-Mar-2015|
|Date of Web Publication||14-Jun-2018|
Mohamed M. A. Shabana
12/1 Anas Ebn Malek St., New Damietta, Damietta
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the efficiency of rubber band ligation (RBL) in the treatment of symptomatic hemorrhoids in hepatic patients, versus surgical hemorrhoidectomy. Operative (time and blood loss) and postoperative (pain, bleeding, analgesic requirement, urinary retention, discharge, stenosis, fecal incontinence, wound healing and patient satisfaction) outcomes were evaluated.
The aim of this study was to compare the outcome of hemorrhoidectomy performed using RBL with surgical hemorrhoidectomy.
Patients and methods
Forty patients with liver disease and diagnosed with grade I, II, or III hemorrhoids were randomized equally to be subjected to either RBL (group A) or surgical conventional hemorrhoidectomy (group B). Operative details were recorded and patients recorded daily pain scores on a linear analog scale. Follow-up was carried out weekly for 2 months and monthly for 6 months to evaluate complications, return to normal activity, ongoing symptoms, and patient satisfaction.
Intraoperative blood loss was lower in group A, with a mean of 1.2 ± 1.6 ml (range 0–5 ml) versus 22.2 ± 6.58 ml (range 15–35 ml) in group B (P = 0.0001). Operative time was shorter in group A, with a mean of 9.00 ± 2.449 min (range 5–12 min) versus 24.100 ± 3.669 min (range 20–30 min) in group B (P < 0.001). There was significant difference in postoperative pain scores, analgesic requirement, especially during the first week, and wound healing between the two groups, which was remarkable in the RBL group. There was no difference between the two groups with respect to the degree of patient satisfaction or the number of postoperative complications.
RBL operation is recommended for the treatment of hemorrhoids in hepatic patients especially in the second and third stage, as it results in less blood loss, less postoperative pain, earlier wound healing, and earlier return to work.
Keywords: hemorrhoidectomy, hemorrhoids, rubber band ligation
|How to cite this article:|
Zeineldin AA, Gaber A, Shabana MM. Rubber band ligation for bleeding hemorrhoids in hepatic patients. Menoufia Med J 2018;31:108-13
|How to cite this URL:|
Zeineldin AA, Gaber A, Shabana MM. Rubber band ligation for bleeding hemorrhoids in hepatic patients. Menoufia Med J [serial online] 2018 [cited 2018 Dec 18];31:108-13. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/108/234236
| Introduction|| |
Hemorrhoids are the clinical manifestation of the downward disruption of normal functional structures known as the anal cushions. It is considered one of the most frequent diseases of the anal region with high prevalence and comprises nearly 50% of proctologic visits in a colorectal unit ,.
Portal hypertension is common in Egypt as a sequel to the high prevalence of hepatitis C virus and/or bilharziasis .
Hepatitis C virus infection is one of the major causes of chronic liver diseases. According to recent WHO estimates, the worldwide prevalence of hepatitis C virus infection is 2.2%, affecting 130 million people worldwide .
Internal hemorrhoids were reported to be common in patients with portal hypertension and liver cirrhosis (prevalence ranging between 21 and 36%) .
Cirrhotic patients have higher postoperative morbidity rates, which correlated with Child scores, especially in emergent situations. The increased risk may be related to anesthesia, operative stress, bleeding tendency, or postoperative sepsis due to hepatic and other organ dysfunctions .
First-degree, second-degree, and third-degree hemorrhoids can be treated by means of nonsurgical methods in the outpatient clinic, whereas severe prolapsed or circumferential hemorrhoids can be treated using a variety of surgical techniques (Milligan–Morgan) ,.
Nonsurgical methods aimed at tissue fixation include techniques such as sclerotherapy, cryotherapy, photocoagulation, and laser, whereas fixation with tissue excision can be performed with rubber band ligation (RBL) .
RBL is considered the most widely used procedure, and it offers the possibility to resolve hemorrhoidal disease without the need of hospitalization or anesthesia and with a lower incidence of complications ,.
Liver transplantation, in recent times, has become the ultimate solution for decompensating liver diseases such as chronic liver failure, acute liver failure, primary hepatic malignancy, and inborn errors of metabolism .
| Patients and Methods|| |
This is a prospective study, which included 40 patients admitted to the General Surgery Department, Menoufia University Hospital and Damietta Specialized Hospital from January 2013 to May 2014. All patients had liver disease and were diagnosed with first, second, or third degree bleeding hemorrhoids and were of Child classification A and B. Exclusion criteria were as follows: presence of thrombosis and strangulated hemorrhoids, patients previously operated for hemorrhoids, pregnant women, presence of other anal pathologies, and chronic liver disease of Child classification C.
Patients were divided into two groups: group A included 20 patients who were treated with RBL, and group B included the other 20 patients who were treated with surgical hemorrhoidectomy (Milligan–Morgan technique).
All patients were preoperatively subjected to the following: full patient history, clinical examination (general examination: chest, heart, and abdomen and local examination or per rectal examination for the detection of hemorrhoids, its grading, complications, and presence of other associated anorectal disease), and routine investigations. Preoperative preparation: the patients were prepared with evacuation enema the night before surgery.
With the patients under local or spinal anesthesia and in the lithotomic position the operations were performed as follows: group A was treated with RBL and group B was treated with conventional hemorrhoidectomy. Operative time and blood loss were recorded in each case.
Early postoperative follow-up (1 week) included evaluation of 24 h postoperative pain using a visual analogue scale (ranging from 0 to 10), analgesic requirement, incidence of bleeding, and urine retention. Late follow-up of the patients (6 months) included healing time, time of discharge, anal stenosis, incontinence, recurrence, and patient satisfaction.
Data were collected, verified, tabulated, and then analyzed using SPSS (Statistical Package for the Social Science (SPSS, version 17; SPSS Inc., Chicago, Illinois, USA)) was used to obtain the final results.
The following tests were used: arithmetic mean, SD, and hypothesis 't'-test (Student's test) for quantitative values and the c 2-test for qualitative values expressed as proportions.
For all statistical comparisons, a P value more than 0.05 was considered nonsignificant, a P value less than 0.05 was considered significant, and a P value less than 0.01 was considered highly significant.
| Results|| |
As regards operative time, it was significantly shorter in the RBL group; the mean ± SD operative time was 9.00 ± 2.449 min (range 5–12 min) in group A, whereas in group B the mean operative time was 24.100 ± 3.669 min (range 20–30 min). There was statistically significant difference between the study groups as regards the operation time (P = 0.001) [Table 1].
|Table 1: Distribution of the studied groups as regards their operation time|
Click here to view
As regards operative blood loss, intraoperative blood loss was estimated by the number and the degree of soaking of the gauze. The RBL group (group A) showed significantly lower intraoperative blood loss with a mean of 1.2 ± 1.6 ml, whereas in group B the mean intraoperative blood loss was 22.2 ± 6.58 ml. There was statistically significant difference between the study groups as regards the operative blood loss (P = 0.001) [Table 2].
|Table 2: Distribution of the studied groups as regards amount of blood loss|
Click here to view
As regards postoperative pain, there were seven (35%) patients with postoperative pain in group A, whereas there were 20 (100%) patients with postoperative pain in group B. There was statistically significant difference between the study groups as regards postoperative pain. In group A, there were five (25.0%) patients with mild postoperative pain and two (10.0%) with moderate postoperative pain. In contrast, in group B there were six (30%) patients with mild postoperative pain, seven (35%) with moderate postoperative pain, and seven (35%) with severe postoperative pain. There was statistically significant difference between the study groups as regards postoperative pain degree (P = 0.001) [Table 3].
As regards postoperative bleeding, in group A, three (15%) patients had postoperative bleeding, whereas in group B nine (45%) patients had postoperative bleeding. There was statistically significant difference between the study groups as regards postoperative bleeding (P = 0.022). In group A, three (15.0%) patients had mild postoperative bleeding, whereas in group B two (10.0%) patients had mild postoperative bleeding, six (30.0%) had moderate postoperative bleeding, and one (5.0%) had severe postoperative bleeding [Table 4].
|Table 4: Comparison of the studied groups as regards postoperative bleeding and its degree|
Click here to view
In group A, four (20.0%) patients had postoperative urine retention, whereas in group B 11 (55.0%) patients had postoperative urine retention. There was statistically significant difference between the study groups as regards postoperative urine retention (P = 0.011). In group A, one (5.0%) patient had postoperative constipation, whereas in group B two (10.0%) patients had postoperative constipation. There was no statistically significant difference between the study groups as regards postoperative constipation (P = 0.55). In group A, 10 (50.0%) patients had postoperative discharge, whereas in group B 19 (95.0%) patients had postoperative discharge. There was statistically significant difference between the study groups as regards postoperative discharge (P = 0.001). The discharge in both groups was bloody at first and then mucoid. In group A, one (5.0%) patient had postoperative sepsis, whereas in group B six (30.0%) patients had postoperative sepsis. There was statistically significant difference between the study groups as regards postoperative sepsis (P = 0.04) [Table 5].
|Table 5: Comparison of the studied groups as regards postoperative complication|
Click here to view
As regards time of hospital stay, the mean time (±SD) of hospital stay was 8.6 ± 2.54 h in group A (range 5.00–14.00 h), whereas in group B the mean time (±SD) of hospital stay was 60.65 ± 41.93 h (range 20–144 h). There was statistically significant difference between the study groups as regards hospital stay (P = 0.002) [Table 6].
|Table 6: Comparison of the studied groups as regards time of hospital stay|
Click here to view
As regards time of wound healing, the mean time (±SD) in days was 16.85 ± 1.87 days (range 14–21 days), whereas in group B it was 31.00 ± 3.57 days (range 25–40 days). There was statistically significant difference between the study groups as regards wound healing (P = 0.003) [Table 7].
As regards patient satisfaction, there was a significantly higher patient satisfaction at 3 months postoperatively in the RBL group. The mean satisfaction score in group A at the third month postoperatively was 8.70 ± 1.67 (range 7–10), whereas it was 7.12 ± 1.3 (range 4–10) in group B (P = 0.036) [Table 8].
| Discussion|| |
External and internal hemorrhoid cushions are anatomical structures present from early embryonic life, which play an important role in accomplishing anal continence .
The presence of hemorrhoids is not in itself an indication for treatment. The method of treatment must be aimed at symptomatic relief and the correction of anatomic deformity. Both of the above are achieved by means of conservative or surgical methods. Hemorrhoids can be treated either by means of tissue fixation (sclerotherapy, cryotherapy, photocoagulation, and laser) or by fixation with tissue excision (RBL) .
Excision hemorrhoidectomy (Milligan–Morgan) remains the standard procedure in the operative management of hemorrhoids, but it is always associated with severe postoperative pain, longer hospital stays, and longer healing time .
Nowadays, RBL is one of the most widely used procedures, and it offers the possibility to resolve hemorrhoid disease without the need of hospitalization or general anesthesia and with low incidence of complication when compared with surgical hemorrhoidectomy .
This study was conducted to compare the results of RBL hemorrhoidectomy with conventional Milligan–Morgan hemorrhoidectomy.
In our study, there was no significant difference between the groups as regards the preoperative data. Therefore, the correlation between the two groups could reflect the actual difference between them. As regards the operative time, this study found highly significant shorter operative time in the RBL group (mean ± SD, 9.0 ± 2.44 min; range, 5–12 min) compared with the Milligan–Morgan group (mean ± SD, 24.1 ± 3.669 min; range, 20–30 min) (P = 0.001). This was in accordance with that reported by Benzoni et al. .
Moreover, this study found significant difference as regards intraoperative blood loss, with a mean intraoperative blood loss of 1.2 ± 1.6 ml (range 0–5 ml) in group A compared with 22.2 ± 6.58 ml (range 15–35 ml) in group B. This was in accordance with the results of Bursics et al. .
In our study RBL was performed under spinal or local anesthesia; local anesthesia is recommended with RBL as it significantly reduces the pain .
In our study, pain was present in all patients who underwent Milligan–Morgan hemorrhoidectomy. Report postoperative pain requiring repeated injection. Suggest that pain after Milligan–Morgan hemorrhoidectomy can be reduced by anal dilation and sphincterotomy ,.
In our study, postoperative pain occurred in 35% of cases in the RBL group. Law and Chu  reported pain in 32% of patients who underwent triple RBL. They reported pain in rubber banding below the dentate line. Gupta  compared RBL with infrared therapy. He reported that more pain was observed with RBL, but there was less chance of recurrence. Tichikow et al.  reported severe pain in 7.5% of cases and recommended injection of local anesthetic solution into the hemorrhoid bundle. Wehrmann et al.  reported pain in 25% of patients who underwent RBL.
In our study, postoperative bleeding occurred in three (15%) out of 20 patients from group A; however, in the Milligan–Morgan group (group B) postoperative bleeding occurred in nine (45%) patients, with mild bleeding in two (10.0%), moderate bleeding in six (30.0%), and severe bleeding in one (5.0%) patient. All of them responded to conservative measures. Sheikh and Ahmed reported bleeding in 25% of patients in the Milligan–Morgan group ,.
In our study, the RBL group had a mean hospital stay of 8.6 h, whereas in the Milligan–Morgan group the mean hospital stay was 60.65 h. Marques et al.  reported that the average hospital stay for RBL was 1–2 days, whereas in the Milligan–Morgan group it was 1–4 days.
Urinary retention in 55% of Milligan–Morgan group Uba et al. , reported that postoperative urine retention occurring in 20% of patient. In RBL group urinary retention occurring in 20% of patients. Su et al. , reported that postoperative retention of urine had occurred in 15% of patient.
Infection such as cellulites was observed in 30% of patients of the Milligan–Morgan group and in 0.5% of patients of the RBL group. Benzoni et al.  and Watson et al.  reported no infection in the RBL group.
Bat et al.  reported that one out of 512 patients developed perianal abscess in second-degree hemorrhoids, which was drained out, but 2 months later progressed into an anal fistula, which was treated by means of fistulectomy.
Komborozos et al.  reported that the complication rate after RBL was relatively low (4.2%) and that most of the complications were minor and self-limiting. Only 1.2% of the patients had severe complications that required hospitalization. Thomson  found that the majority of cases could be successfully managed by banding; 83% of patients followed up were symptom-free, or improved and did not need any medical treatment.
Peng et al. concluded that RBL and hemorrhoidectomy were both equally effective in controlling symptomatic prolapse, but RBL was associated with increased incidence of recurrent bleeding . O' Regan  reported excellent results with no bleeding using a disposable RBL device.
In the present series, 90 and 85% of patients of the Milligan–Morgan hemorrhoidectomy and RBL groups, respectively, showed good improvement. Linag et al.  reported that 96% of patients showed improvement after RBL, 91% of patients were asymptomatic, 6% of patients improved, and 3% of patients showed no improvement at all. Benzoni et al.  reported that from 1 to 3 years after initial procedure, 82.2% of patients are either symptom free, or improve and do not need any medical treatment. Su et al.  reported control of bleeding in 93% of patients and prolapse in 91% of patients after RBL. Longman and Thomson  reported that RBL results in less pain, bleeding, itching, and discharge. Many authors reported that recurrence rate may be as high as 68% at 4 or 5 years of follow-up and that symptoms usually respond to repeated ligation, but only 10% of such patients require excisional hemorrhoidectomy .
Fakuda et al.  found that RBL was successful as hemorrhoidectomy.
In our study there was significant difference as regards patient satisfaction between the RBL group and the Milligan–Morgan group . Longman and Thomson  in their study reported that 82% of patients with first-degree and second-degree hemorrhoids were satisfied, whereas 86% of patients with third-degree hemorrhoids were satisfied. Watson et al. , in their study of 183 cases of band ligation found that only 15% of cases were unsatisfied. Kumar et al.  reported patient satisfaction in 75.5% of 98 patients who underwent band ligation.
| Conclusion|| |
RBL is associated with shorter operative time, less intraoperative and postoperative bleeding, lower incidence of urine retention, milder postoperative pain, shorter time to healing, shorter hospital stay, and early return to work compared with Milligan–Morgan hemorrhoidectomy.
The RBL operation is recommended for the treatment of hemorrhoids in hepatic patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nakeeb A, Fikry A, Omar W, Fouda E, El Metwally T, Ghazy H, et al
. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008; 14
Bernal JC, Enguix M, Lopez Garcia J, Garcia Romero J. RBL for hemorrhoids in colorectal unit. Rev Esp Enferm Dig. 2005; 97
Strickland GT, Elhefni H, Salman T, Waked I, Abdel-Hamid M, Mikhail NN, et al
. Role of hepatitis C infection in chronic liver disease in Egypt. Am J Trop Med Hyg 2002; 67
A Ali, G El Deeb, A Allah Essa, N
Ahmed. Study of frequency of prediabetes in Egyptian patients with chronic hepatitis C virus infection. Menoufia Med J 2014; 27
Awad A, Solman H,, AboSaif S, Darwish A, Mosad S, Elfert A. A prospective randomised comparative study of endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosisResearch articleArab Journal of Gastroenterology, 2012; 13
Neeff H, Mariaskin D, Spangenberg HC, Hopt UT, Makowiec F. Preoperative mortality after non-hepatic general surgery in patients with liver cirrhosis. J Gastrointest Surg 2011; 15
(1):1-11. doi: 10.1007/s11605-010-1366-9.
Fazio VW. Early promise of stapling technique for haemorrhoidectomy. Lancet 2000; 355:768-769.
Rowsell M, Bello M. Circumferential mucosectomy (Stapled) versus convectional haemorrhoidectomy. Lancet 2000; 355
Vassilios A, Komborozos VA, Shrekas GJ, Pissiots CA. RBL symptomatic internal hemorrhoids. Dig Surg 2000; 17
Pezzullo A, Palladino E. RBL of hemorrhoid, 5 years follow-up. G Chir 2000; 21
Longman RJ, Thomson WH. A prospective study of outcome from rubber band ligation of piles. Colorectal Dis 2006; 8
MR ElKholy, HM Elshazly. Role of three-dimensional multidetector computed tomography angiography of hepatic vessels in the evaluation of living donors. Menoufia Med J 2014; 27
Corman ML. Hemorrhoids. In: Corman ML, editors. Colon and rectal surgery
. Philadelphia: Lippinocott Raven; 2005. 147–205.
Komborozos VA, Skrekkas GJ, Pissiotis CA. Rubber band ligation in symptomatic internal hemorrhoids result of 500 cases. Dig Surs 2000; 17
Palimento D, Picchoi M, Altasaaio U. Stapled & open haemorrhoidectomy: randomized control trial of early result. World J Surg 2007; 32
Benzoni E, Milan E, Cerato F, Narisetti P, Bresadola V, Terrosu G. Second degree haemorrhoids: patient's satisfaction, immediate and long-term results of rubber band ligation treatment. Minerva Chir 2006; 61
Bursics A, Weltner TCF, Lubowski DZ. Anorectal physiological changes after rubber band ligation and closed haemorrhoidectomy. Colorectal Dis 2004; 6
Gokalp A, Baskonus I, Maraican G. A prospective randomized study of local anesthesia injection after multiple rubber band ligation of hemorrhoids. Chir Italy 2006; 55
Wang JY, Chang-Chein CR, Chen JS. The role of laser in haemorrhoidectomy. Dis Colon Rectum 2006; 5
MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities: a meta-analysis. Diseases of the Colon and Rectum. 1995; 38
Law WL, Chu KW. Triple rubber band ligation for hemorrhoids: prospective, randomized trial of use of local anesthetic injection. Dis Colon Rectum 1999; 42
Gupta PJ. Infra red photocoagulation of early grades of hemorrhoids – 5-year follow-up study. Bratisl Lek Listy 2007; 108
Tichikow C, Hass PA, Fox TA. injection of a local anesthetic solution into haemorrhoidal bundle following rubber band ligation. Dis Colon Rectum 1992; 25
Wehrmann T, Riphaus A, Feinstein J, Stergiou N. Hemorrhoidal elastic band ligation with flexible videoendoscopes: a prospective, randomized comparison with the conventional technique that uses rigid proctoscopes. Gastrointest Endosc 2004; 60
Sheikh AR, Ahmed I. Comparative study of haemorrhoidectomy with rubber band ligation for 2nd and 3rd degree hemorrhoids. Pak J Med Sci 1998; 12
Lyer ES, King TM, Nicholls RJ. Complications of rubber bands Ligation Br. J Surg 2004; 60
Marques CF, Nahas SC, Sobrado CW, Kiss DR. Early result of the treatment of internal hemorrhoids disease by infrared coagulation and elastic banding a prospective randomized cross-over trial. Tech Coloproct 2006; 10
Uba AF, Obekpa PO, Ardill W. Open vs. closed haemorrhoidectomy. Niger Postgrad Med J 2004; 11
Su MY, Chiu CT Wu CS, Ho YP, Lien JM. Endoscopic haemorrhoidal ligation of symptomatic internal hemorrhoids. Gastrointestinal Endosc 2003; 58
Watson NF, Liptrott S, Maxwell-Armstrong CA. A prospective audit of early pain and patient satisfaction following outpatient band ligation of hemorrhoids. Ann R Coll Surg Engl 2006; 88
Bat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Complication of rubber band ligation of symptomatic internal hemorrhoids. Dis Colon Rectum 1999; 36
Thomson WHF. Haemorrhoidectomy for thromboses external hemorrhoids. Am Fam Physician 2006; 65
Peng BC, Jayne DG, Ho YH. Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Colon Rectum 2003; 46
O'Regan PJ. Disposable device and a minimally invasive technique for rubber band ligation of hemorrhoids. Dis Colon Rectum 1999; 42
Liang CL, King TM, Chen CH. Rubber band ligation in the management of hemorrhoids. Zhonghua Yi Xue Za Zhi (Taipei) 1993; 51
Fukuda A, Kajiyama T, Arakawa H, Kishimoto H, Someda H, Sakai M, et al
. Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids. Gastrointest Endosc 2004; 59
Kumar N, Paulvannan S, Billings PJ. Rubber band ligation of hemorrhoids in the out patient clinic. Ann R Coll Surg Engl 2003; 48
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]