Internal Hemorrhoid Band Ligation

Endoscopic hemorrhoid band ligation (HBL) is an important advance in the treatment of symptomatic internal hemorrhoids. ^{[1, 2]} This procedure is simple, safe, and effective. Multiple rubber bands can be applied in one session, and further bands can be applied in subsequent sessions if a single session fails to completely eradicate the internal hemorrhoids. The treatment success rate is high, while the long-term recurrence rate is low.

Symptomatic hemorrhoids in adults is considered one of the most prevalent anorectal disorders. Hemorrhoids of different grades can be found in more than 80-90% of patients undergoing sigmoidoscopy or colonoscopy. ^[3] Hemorrhoids are either internal or external, depending on the localization above or below the dentate line. ^[4]

Internal hemorrhoids may be classified into four grades on the basis of the Goligher system, as follows ^[4] :

• Grade I - Hemorrhoids protrude into the anal canal but do not prolapse
• Grade II - Hemorrhoids prolapse with straining or defecation but reduce spontaneously (see the image below)
• Grade III - Hemorrhoids prolapse and usually require manual reduction
• Grade IV - Hemorrhoids are prolapsed and cannot be reduced and are thus at risk of strangulation and thrombosis

Grade I, grade II, and select grade III hemorrhoids are managed nonsurgically, whereas grade IV and many grade III hemorrhoids require surgical intervention. ^[5]

Stiegman and Goff were the first to propose the technique of elastic band ligation for the treatment of esophageal and gastric varices using a gastroscope, ^{[6, 7]} and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one with a gastroscope and a larger one with a colonoscope.

Patients with symptomatic internal hemorrhoids in whom conservative management has failed or who request a nonsurgical therapeutic modality are candidates for HBL. ^[8] In addition, patients who cannot tolerate surgery, given the risk of anesthesia, may be advised to undergo banding instead of hemorrhoidal surgery.

HBL also provides an alternative therapeutic modality in patients at higher risk for bleeding (cirrhosis and uremia). A significant advantage of HBL is that it can be performed repeatedly, if needed, with further sessions for patients whose symptoms persist after the first session. ^{[9, 10]}

Contraindications for HBL include the following ^[11] :

• Acute thrombosis
• Active proctitis or colitis
• Significant rectal prolapse
• Perirectal abscess
• Rectal malignancy
• Coagulopathy
• Immunosuppression

HBL is contraindicated in patients who are receiving anticoagulants or who have a bleeding disorder, as well as those with concurrent anorectal sepsis. ^[12]

Preparation includes conscious or deep sedation. Internal hemorrhoids should be graded to achieve optimal management results.

Patients should be asked about their medications (mainly antithrombotics and antiplatelets) before the procedure so as to minimize the risk of early and late bleeding after HBL.

Misapplication of the band below the dentate line should be avoided; if it is not, severe anal pain may ensue. In some cases, thrombosis is caused by leftover hemorrhoids distal to the rubber band, and therefore ligation must be applied close to the dentate line. ^[11] Sepsis and hemorrhage may result from ulceration and sloughing after banding. ^[13]

The success rate of HBL is in the range of 70-97%. ^[4] Favorable outcomes depend on the banding technique, the internal hemorrhoid grade, and the timing of the follow-up. ^[11]

Band ligation vs other techniques

Other endoscopic nonoperative techniques used for the treatment of symptomatic internal hemorrhoids include sclerotherapy, cryotherapy, and infrared coagulation. ^[14]

HBL using video-endoscopic anoscopy compared favorably with traditional banding via anoscopy. ^{[11, 15]} The ability to perform band ligation in the clinic makes this technique a popular treatment option for internal hemorrhoids. ^[16] In addition, the rubber bands used for this procedure are inexpensive and are easy to deploy.

In a meta-analysis of 18 prospective randomized trials performed by MacRae and McLeod, band ligation was the most effective among office-based procedures, with a lower recurrence rate. ^[15]  Several internal hemorrhoidal treatment modalities were compared, and it was concluded that band ligation was superior to sclerotherapy, which demonstrated good short-term but poor long-term benefits. ^[15]  With cryosurgery, patient satisfaction was less, and local complications were more frequent. A cap-assisted endoscopic sclerotherapy approach has been described, which is reported to be convenient, safe, and effective. ^{[17, 1]}

Compared with infrared coagulation, band ligation causes more pain but has a lower recurrence rate. ^{[18, 19]}  In a study by Gupta et al, 80 patients with grade II bleeding internal hemorrhoids were prospectively randomized to undergo HBL (n = 44) or radiofrequency ablation (RFA; n = 36). Patients in the RFA group had longer procedure times and higher recurrence rates, but earlier return to work (2 vs 5 d). Pain and tenesmus were more severe with band ligation.

The multicenter HubBLe Trial compared hemorrhoidal artery ligation (HAL) with rubber band ligation (RBL) for symptomatic second- and third-degree hemorrhoids. ^[20]  At 1 year, HAL resulted in fewer recurrences, but the recurrence rate was similar to that of repeat RBL. The two treatments did not differ significantly with respect to symptom scores, complications, European Quality of Life-5 Dimensions (5-level version; EQ-5D-5L), or continence score. Patients in the HAL group had more pain in the early postoperative period. HAL was found to be more expensive and unlikely to be cost-effective in terms of incremental cost per quality-adjusted life year (QALY). 

Historical evolution of internal HBL

Stiegman and Goff were the first to propose the technique of elastic band ligation for the treatment of esophageal and gastric varices using a gastroscope, ^{[6, 7]} and that technique was also applied to treat symptomatic internal hemorrhoids. Two devices can be used: a smaller one for a gastroscope and a larger one for a colonoscope.

In 1997, following band ligation, 95% of internal hemorrhoids were downgraded by more than one point, as reported by Trowers et al. ^[21] Afterward, the retroflexion manoeuver was introduced by Berkelhammer and Moosvi, ^[22] with excellent results noted in more than 80% of cases (the highest success rates were in patients with grade II internal hemorrhoids).

Long-term outcome and efficacy of endoscopic HBL for symptomatic internal hemorrhoids

Su et al enrolled a total of 759 consecutive patients (415 male, 344 female) to assess the long-term outcome of endoscopic HBL for the treatment of symptomatic internal hemorrhoids (mean follow-up, 55.4 mo). ^[4] The clinical presentations were bleeding per rectum (n = 593) and mucosal prolapse (n = 166). All patients underwent the procedure in outpatient clinics. The average number of bands used ranged from 2.35 to 2.69. Bleeding was controlled in 98% of patients; 82.5% reported reduction in the prolapse. Anal pain was reported in 93 patients, bleeding in 48. The mean recurrence rate was 3.7% at 1 year, 6.6% at 2 years, and 13% at 5 years; 93.6% of patients were satisfied with the procedure.

Flexible gastroscopy vs rigid proctoscopy

Cazemier et al enrolled 41 patients (20 men, 21 women; median age, 52 y) in a study comparing rigid proctoscopy (n = 19) with flexible gastroscopy (n = 22). ^[23]  Twenty-nine patients had grade I internal hemorrhoids, nine had grade II, and three had grade III. A median of four bands were used in the rigid scope group, whereas six were used in the flexible endoscope group. Three patients reported postligation pain with rigid proctoscopy versus 10 who reported pain with flexible gastroscopy. No sphincter defects were reported with this technique. ^{[23, 24]}