Banding hemorrhoids

Elastic band ligation is an excellent option for the management of symptomatic Grade II and some Grade III internal hemorrhoids. The technique is based on the principle that internal hemorrhoids become symptomatic when they are allowed to prolapse into the anus by a failure of their attachment to the wall of the low rectum. The low rectal mucosa also becomes unattached and looks floppy when seen on anoscopy. The prolapsed hemorrhoids are traumatized by the straining process during defecation and by the physical effects of stool passing over them, and bleed. If prolapsed internal hemorrhoids remain in the anal canal after defecation, they can secrete mucus which can leak from the anus. Elastic band ligation aims to pull the internal hemorrhoids up out of the anus and to fix them in their original position by removing the redundant rectal mucosa above them. Thus, the bands are placed above the dentate line, on the apex of redundancy of the rectal mucosa. The bands cause the entrapped and strangulated mucosa to die. The necrotic mucosa falls off along with the bands, leaving an ulcer that heals with scar. The scar fixes the hemorrhoids to the underlying rectal wall. In some patients a prolapsing internal hemorrhoid exists with a prominent external component as well. Elastic band ligation can pull the entire complex up within the anus and can decrease the size of the external component.

This is a very simple technique and very effective if done properly. Here are the important parts.

1. Tell the patient what is going to happen. Then describe the feeling of “needing to poop” that will be caused by the presence of the mucosal balls formed by the banding. This can be rather intense but will pass within 24 hours. Tell the patient that they won’t be able to work that day but should just go home and relax and ignore the feeling that they need to poop. They can sit on the toilet and see if there is something to come out, but they must not strain or else the bands may prolapse.

2. Hopefully the patient’s situation allows for a restful rest of the day of the procedure. Knee chest position is better than left lateral, but both are OK. In a left lateral position, the buttocks should be hanging over the edge of the table with the hips flexed and the knees straight.

3. Assess the internal hemorrhoids by anoscopy. There are three internal hemorrhoids. Assess each one separately. Gauge the “floppiness” of the mucosa above them by poking them with a Q tip. There has to be enough floppiness to allow enough mucosa to be pulled into the band applicator for the band to hold. Sort the three hemorrhoids by size. My practice is to band the largest first. This sometimes shrinks the other two. If hemorrhoid number 2 is still large enough to band, do it. Then I stop. Two bands at once in an office setting is well tolerated, but three at once can be quite uncomfortable. If the patient is still symptomatic a month later, they can have the remaining hemorrhoid banded at that time.

4. Expose the target hemorrhoid and tentatively grab the apex of the redundant mucosa with the forceps. It has to be the apex of the redundancy and be high enough above the dentate line that no anoderm will be included in the band. A band placed too low, including the sensate anoderm, will be extremely painful for the patient.

5. Get the band applicator. I prefer the manual variety, not the suction bander. The suction bander does not allow the flexibility of pulling more or less mucosa into the applicator according to the size of the redundancy. The only advantage of the suction bander is that you can do the procedure without an assistant: one hand for the anoscope and one for the bander. Using the manual applicator, you need an assistant to hold the anoscope. Pass the forceps through the applicator, grasp the apex of the mucosa, pull it gently into the applicator. While pulling with the forceps, gently push with the applicator. Then fire. Then let go of the mucosa.

6. Make sure that you grab a decent amount of mucosa with the forceps so that the mucosa doesn’t tear and bleed. Make sure that the mucosa comes well up into the applicator.

The complications of elastic band ligation include:

• Pain, if the band is placed below the dentate line. You will have to remove the misplaced band, using an anoscope and an 11-scalpel blade.

• Vasovagal reaction, in nervous patients. Such patients are better treated under a general anesthetic.

• Bleeding, usually 7 to 10 days later, from an artery in the base of the ulcer created by the band. Sometimes this needs to sutured.

• Infection is extremely rare but necrotizing infection can occur. If patients call within a few days unable to urinate, they need to be examined, usually under anesthetic.

Follow up is only necessary if symptoms are still present a month after the banding. Patients are encouraged to do whatever is necessary to have a stable bowel habit, and not to strain. Recurrence of prolapse can occur but straining at stool makes this more likely.