Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids

Endoscopic hemorrhoidal ligation of symptomatic
internal hemorrhoids
Ming-Yao Su, MD, Cheng-Tang Chiu, MD, Cheng-Shyong Wu, MD, Yu-Pin Ho, MD,
Jau-Min Lien, MD, PhD, Shui-Yi Tung, MD, Pang-Chi Chen, MD
Taoyuan, Taiwan
Background: This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of
patients with symptoms caused by internal hemorrhoids.
Methods: A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were
enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients).
The severity of the hemorrhoids was classified by using the grading system of Goligher.
Results: All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8
to 24 months). The mean number of band ligations per session was 2.86. The mean number of
treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was
achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients
(95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients
experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and
one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered
Conclusions: Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for
patients with symptoms caused by internal hemorrhoids. (Gastrointest Endosc 2003;58:871-4.)
A wide variety of methods have been used over
many decades for treatment of hemorrhoids. Injection sclerotherapy, infrared and laser photocoagulation, cryosurgery, direct application of electrical
current, and rubber band ligation all lead to ablation of hemorrhoids unresponsive to conservative
Internal hemorrhoids can be graded into 4 stages
by using the system of Goligher: grade 1, hemorrhoids with bleeding; grade 2, hemorrhoids with
bleeding and protrusion, with spontaneous reduction; grade 3, hemorrhoids with bleeding and protrusion that require manual reduction; grade 4,
hemorrhoids with prolapse that cannot be replaced.2
First introduced in the United States in 1951,
rubber band ligation has become the mainstay of
treatment for bleeding and prolapsing internal
hemorrhoids.3,4 Rubber band ligation is now a wellestablished, safe, and effective technique.5 It has
Received January 8, 2003. For revision April 5, 2003. Accepted
September 9, 2003.
Current affiliations: Digestive Therapeutic Endoscopy Center, Department of Gastroenterology, Lin-Kou Medical Center, Chang-Gung
Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan.
Partially presented at United European Gastroenterology Week,
October 19-23, Geneva, Switzerland (Gut 2002;51(suppl III):A271).
Reprint requests: Pang-Chi Chen, MD, Department of Gastroenterology, Linkou Medical Center, Chang-Gung Memorial Hospital, 5 Fu-Shin Street, Kweishan, Taoyuan, Taiwan, R.O.C.
Copyright Ó 2003 by the American Society for Gastrointestinal
0016-5107/2003/$30.00 + 0
PII: S0016-5107(03)02308-3
VOLUME 58, NO. 6, 2003
been shown to be substantially better than medication alone in terms of outcome and is not associated
with significant morbidity.6 Conventional band ligation is performed with rigid anoscopic devices with
limited maneuverability and a narrow field of view,
and no ability to document treatment photographically.7 These deficiencies can be overcome by using
a videoendoscopic system that provides a detailed
image of the operative field as well as photographic
capability.8 This study assessed the safety and
efficacy of rubber band ligation by using a videoendoscopy system for treatment of patients with
symptoms caused by internal hemorrhoids.
A total of 576 consecutive patients with grade 2 to 4
internal hemorrhoids, presenting with rectal bleeding and/
or prolapse unresponsive to medication, were treated with
one or more sessions of endoscopic hemorrhoidal ligation
from November 2000 to March 2002. Rectal bleeding was
the chief complaint of 239 patients: 197 had bleeding
combined with rectal prolapse; 41, anemia cause by chronic
hemorrhoidal bleeding; 173, intermittent dripping of blood
from the anal area; and 25 had noted blood intermittently
on toilet tissue. Rectal prolapse requiring manual reduction was the major complaint of 337 patients, 311 of
whom also had intermittent mild rectal bleeding. All
patients underwent flexible sigmoidoscopy or colonoscopy
to exclude other causes of bleeding per rectum. Patients
were excluded if a polyp(s) or cancer was found at
colonoscopy. All patients gave informed consent for the
ligation procedure. The study protocol was approved by the
Ming-Yao Su, Cheng-Tang Chiu, Cheng-Shyong Wu, et al.
Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids
Figure 1. Endoscopic view of internal hemorrhoid 2 to 5 mm
above dentate line ligated with rubber band.
Figure 3. Retroverted endoscopic view of internal hemorrhoid
after ligation with two elastic bands.
Table 1. Ligation bands per session and treatment
sessions per patient*
Ligation bands
per session
*Data expressed as no. (%); Total number of treatment sessions
is 647.
Figure 2. Retroverted endoscopic view of internal hemorrhoid
before ligation.
institutional review board of medical ethics and the human
clinical trial committee of our hospital.
Patients were not asked to discontinue the use of aspirin
or other non-steroid anti-inflammatory medication before
the procedures. After the endoscopic examination, patients
were treated if grade 2 or larger internal hemorrhoids were
present. As with esophageal variceal ligation, a transparent
plastic endoscopic ligation cap (Sumitomo Co., Tokyo,
Japan) was attached to the top of a diagnostic upper
endoscope (GIF-XQ230; Olympus Optical Co., Ltd., Tokyo,
Japan). The dentate line then was identified, and ligation
was performed 2 to 5 mm above the dentate line (Fig. 1).
The hemorrhoid was suctioned into the cap with the tip of
the endoscope in the anal canal, and a single elastic band
was released. If further ligation was required, another
rubber band was placed on the cap. Recto-anal retroverted
endoscopic views before and after ligation of internal
hemorrhoids are shown in Figures 2 and 3. All ligations
were performed in the outpatient setting.
Safety data were recorded; all adverse events were
documented. Patients were seen 1 week later and then
monthly, with sigmoidoscopy. If residual hemorrhoids were
noted or symptoms persisted, further treatments were
conducted monthly. The end point of treatment was to
achieve grade 1 hemorrhoids. In all cases, hemorrhoid
severity was assessed 6 months after the first ligation
The ligation procedure was completed in less than
10 minutes in all cases. A mean of 2.86 bands were
placed per session. The mean number of sessions was
1.24 (range 1-5) (Table 1). Mean follow-up was 17.5
months (range 8-24 months).
The clinical grades of the internal hemorrhoids
before and at 6 months after therapy are shown in
Table 2. A reduction of at least one grade was
achieved in most patients (93.58%)
Eighty-five patients had mild anal pain after
treatment; pain was relieved by orally administered
mefenamic acid. Mild bleeding occurred in 37
patients and was treated by injection of a dilute
solution of epinephrine (1:100,000). From 1 to 3 mL in
divided doses was injected directly into the wound;
this resulted in only mild anal pain. After ligation,
external hemorrhoidal thrombosis developed in 4
VOLUME 58, NO. 6, 2003
Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids
patients, and one patient developed a peri-anal
abscess. These 5 patients were treated surgically
and recovered uneventfully.
Six months after ligation, 11 patients continued to
experience anal bleeding during defecation. Thus,
bleeding was controlled in 95.4% of patients. Twentyseven patients continued to have anal prolapse that
required reduction. The success rate for control of
prolapse was, therefore, 91.99%. All of these 38
patients with persistent symptoms were referred for
further surgical therapy. The proportion of the
patients who reported satisfaction with the results
of treatment was 96.2%. The 1-year recurrence rate
was 3.3% (18 patients). Recurrent symptoms included bleeding (12 patients) and rectal prolapse (6
Hemorrhoids are the most prevalent anorectal
disorder among adults. Over 90% of patients undergoing sigmoidoscopy or colonoscopy have hemorrhoids of varying degrees. Hemorrhoids are defined
as internal and external according to whether they
are located above or below the dentate line. Many
non-surgical options are available for treatment.
Nonoperative management is considered for patients with symptoms (anal bleeding or rectal prolapse) and grade 1, 2, and 3 internal hemorrhoids.
These include local injection therapy, anal divulsion,
elastic band ligation, cryotherapy, infrared coagulation, laser photocoagulation, direct application of
electrical current, and bipolar coagulation.9 Based on
the results of a meta-analysis, MacRae and McLeod7
concluded that rubber band ligation should be
recommended for grade 1 to 3 internal hemorrhoids
and that patients treated by this method were less
likely to require additional therapy than those
treated with local injection therapy or infrared
coagulation. Ligation is preferred to local injections
or cryotherapy in the absence of concomitant anal
disease, such as anal fissure, fistula, or papillomas.10,11
Rubber band ligation has been used to treat
internal hemorrhoids since Blaisdale introduced
a ligation device in 1951. This device is used via an
anoscope. Hemorrhoidal tissue is grasped with small
prongs and an elastic band is applied. The hemorrhoid and its redundant mucosal tissues become
thrombosed and slough, usually within 5 to 7 days.
One notable advantage of band ligation is the
production of submucosal scarring that prevents
subsequent development of new hemorrhoidal tissue.
Rubber band ligation technically is simple and can be
used in the outpatient setting without local anesthesia. The success rate varies between 69% and 97%,
VOLUME 58, NO. 6, 2003
Ming-Yao Su, Cheng-Tang Chiu, Cheng-Shyong Wu, et al.
Table 2. Severity of hemorrhoids before and at 6
months after treatment
(n = 576)
73 (13)
302 (52)
201 (35)
0 (0)
(n = 576)
p Value
(paired t test)
depending on the degree of internal hemorrhoids, the
ligation technique, and the duration of follow-up.6
Serious complications, such as life-threatening massive bleeding12,13 and sepsis, are extremely rare, but
should not be discounted.14,15 Dickey and Garrett16
found that hemorrhoidal banding by using videoendoscopic anoscopy and a single-handed ligator
compared favorably with traditional hemorrhoid
banding by anoscopy. This video endoscopic technique may be preferred in the office setting.
Stiegmann and Goff17 first proposed elastic band
ligation for the treatment of esophageal and gastric
varices by using a device attached to the tip of
a videoendoscope to deploy the bands. Endoscopic
band ligation of esophageal varices now is preferred
to sclerotherapy because of equivalent efficacy, ease
of use, and relatively fewer complications.18,19 The
application of the same device and technique to
eradicate internal hemorrhoids is a logical extension
of this established procedure. Trowers et al.8 reported preliminary experience with endoscopic hemorrhoidal ligation in 1997 in which 95% of internal
hemorrhoids were reduced by more than one grade
after therapy. Berkelhammer and Moosvi20 used
retroflexed endoscopic band ligation to treat bleeding
internal hemorrhoids. Excellent results were
achieved in 80% of patients with grade 2 hemorrhoids. In addition, the result with treatment of
patients with grade 2 hemorrhoids was more likely to
be excellent compared with that for patients with
grade 3 hemorrhoids.20
The present study used an esophageal variceal
ligation device and an upper endoscope for ligation of
internal hemorrhoids. This approach is simple, the
outcome of treatment was good, and complications
were few. A reduction in hemorrhoid grade by at least
one was achieved in over 90% of patients. Furthermore, rectal bleeding was controlled for most
patients or an improvement in rectal prolapse was
noted after therapy. Although external hemorrhoidal
thrombosis occurred in 4 patients and a peri-anal
abscess developed in another, all of these patients
recovered after surgical treatments. Studies have
demonstrated that deployment of up to 3 bands per
Ming-Yao Su, Cheng-Tang Chiu, Cheng-Shyong Wu, et al.
Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids
session is safe.21,22 The patients in the present study
had from one to 5 bands placed without adverse
consequences. The 1-year recurrence rate was only
3.3%, significantly better than that achieved in other
published studies (9%-22%).11,23
In conclusion, endoscopic hemorrhoid ligation is
an important advance in the treatment of patients
with symptoms caused by internal hemorrhoids.
Endoscopic hemorrhoidal ligation is simple, safe,
and effective. Multiple bands can be applied in one
session, and further bands can be applied at subsequent sessions if a single session fails to completely
eradicate the internal hemorrhoids. The treatment
success rate is high, and the long-term recurrence
rate is low.
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