Efficacy of rubber band ligation in third degree hemorrhoid

Dr Samir Shrestha Lecturer, Department of Surgery Patan Academy of Health Sciences Email: samir_shrestha99@yahoo.com CORRESPONDENCE


Introduction
Hemorrhoids are a common disease.It affects in various degrees in 50% of people over the age of fifty.1 Symptoms of hemorrhoids include bright red painless bleeding, mucous discharge, prolapse, itching and occasionally pain.RBL is a non resective treatment of hemorrhoid.In 1954, Blaisdel invented the first automatic ligator for hemorrhoids, which was modified by Barron in 1962.This has replaced hemorrhoidectomy in 45% of case.2Although it is not associated with the problems that follow the typical surgical treatment of hemorrhoid2, the method is not free of complications viz; pain, bleeding, mucus discharge, vasovagal episodes, urinary discomfort, fistula in ano etc and even deaths have been reported to occur in immunocompromised patients.
RBL has shown to be superior to the injection sclerotherapy and other treatment modality though it bears mild degree of morbidity.The disadvantage of this procedure is no pathological specimen is obtained; therefore some cases of anal cancer may be overseen.
Traditionally RBL has been used in treatment of 1st and 2nd degree hemorrhoids.Recently it has been used in 3rd degree hemorrhoids with greater efficacy.The aim of this study was to assess the outcome, effectiveness and complications RBL as out patient procedure for symptomatic 3rd degree hemorrhoids.

Method
This cross sectional study was conducted after being approved by Institutional Review Board in National Academy of Medical Sciences, Patan hospital & Shree Birendra Army hospital from January 2007 to December 2008 for a period of two years.This study was conducted by the senior surgical residents posted in the respective institution under the guidance.All patients scheduled to undergo band ligation during the study period who met the inclusion criteria (symptomatic third degree hemorrhoid -hemorrhoid that needs manual reduction after act of defecation) were enrolled after a written informed consent.Exclusion criteria of this study were external hemorrhoids, age (below 15 years and above 70 years), liver cirrhosis and portal hypertension, associated anorectal pathology(-anorectal abscess, fistula in ano, fissure in ano), diabetes, compromised cardiopulmonary status and 1st ,2nd and 4th degree hemorrhoid.Enrolled patients were explained about the procedure, its complications & Visual Analogue Scale for pain.The scale ranged from 1to10, with 1 being the mildest and 10 being the most severe pain.Preoperatively, a thorough history, physical examination and investigations were reviewed.Variables like pain during defecation, bleeding per rectaum, constipation, prolapse of hemorrhoidal venous cushion etc were studied.Rigid proctosigmoidoscopy was done at same setting in the OPD after soap water enema to assess the degree of hemorrhoid, its location and to rule out any associated bleeding & anorectal pathology prior intervevtion.After that RBL was performed with the help of assistant at OPD.The hemorrhoidal cushion was grasped with allies forcep and pulled caudally through proctoscope and loaded band was fired using Barron's gun, so as to stangulate the venous pedicle above the dentate line.At least two band were applied per setting.Patient were given stool softner and analgesic (on demand) after procedure.They were advised to follow up in one and six weeks respectively.Statistical analysis of the data was done using SPSS (Statistical Package for Social Sciences) for Windows version 11.5.Independent "t" test and Chi square test were used for statistical analysis.The 'p' value of less than 0.05 was regarded as significant with a confidence interval of 95%.
Efficacy of rubber band ligation in third degree hemorrhoid The percentage of bleeding in our study was 21%, slightly higher than other reported cases. 7Johanson and Rimm 8 in their metaanalysis showed that 6.6-14.3% of the patients undergoing RBL required additional treatment due to the recurrence of symptoms.Bayer et al 9 reported 2.1% failure of RBL and needed conventional hemorrhoidectomy.In our study, recurrent symptoms of discharge and mass protrusion was seen in 6.4% and mass protrusion in 17.7 % even with repeat RBL.These patients (24.2%) were considered as treatment failure and advised to undergo surgical hemorrhoidectomy.

Conclusion
Third degree hemorrhoids can be treated by RBL as OPD procedure using minimal resources and manpower, freeing hospital bed for more serious patients.

Table 2 .
Pain at different interval after RBL for 3 rd degree hemorrhoids (n=62)

Table 3 .
Outcome of RBL in 3 rd degree hemorrhoids at 6 week