Development of a low-cost simulator for training in hemorrhoidal ligation

Introduction: Rubber band ligation is a minimally invasive outpatient hemorrhoid treatment with low cost, low complication rates, and rapid realization. It is performed with the aid of an anoscope and uses a rubber ring that surrounds the hemorrhoidal nipple, causing compression of the vascular structures of the tissue, leading to necrosis and remission of the hemorrhoid. No device for training this essential procedure for treating this pathology has been identified in the literature. Therefore, we aim to develop a low-cost simulator for training hemorrhoidal rubber ligation. Methods: The model was constructed using PVC pipe wrapped in neoprene fabric. Hemorrhoidal nipples and the pectineal line were also simulated using fabric and sewing threads. The procedure is performed with conventional anoscope and ligature forceps. Conclusion: The device in question is a low-cost simulation model designed to train the skills required to perform a rubber band ligation and review the basic anatomy of the anal canal during anoscopy. Given these qualities, the model can be used for academic training due to its low cost and simplicity of application. (AU)

A prospective clinical study of endoscopic foam sclerotherapy combined with rubber band ligation in the treatment of grade Ⅱ-Ⅲ internal hemorrhoids (with video) / 中华消化内镜杂志

Objective:To evaluate the safety and long-term effectiveness of endoscopic foam sclerotherapy (FS) combined with endoscopic rubber band ligation (ERBL)in the treatment of grade Ⅱ-Ⅲ internal hemorrhoids.Methods:Consecutive patients diagnosed as having grade Ⅱ-Ⅲ internal hemorrhoids in Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January to December 2020 were prospectively enrolled in the study, and randomly divided into ERBL group and FS combined with ERBL group. The 24 h visual analogue scale (VAS) for pain and 1-week degree of bleeding were evaluated after the treatment. After follow-up of 6 months, the effectiveness of treatment was evaluated.Results:A total of 84 patients with age of 54.4±7.9 years were enrolled, 57.1% (48/84) males, and 73.8% (62/84)grade Ⅱ internal hemorrhoids. Forty-three patients were assigned to the ERBL group and 41 to the FS combined with ERBL group. There was no significant difference between the two groups in baseline data ( P>0.05). In the FS combined with ERBL group, the mean amount of polidocanol foam was 13.8±2.5 mL, the mean number of injection site was 4.7±1.2, and the median scores of VAS was 0 (0, 3), which was significantly lower than that of ERBL group [2 (0, 4), Z=-2.116, P=0.034]. The bleeding rate 1 week after treatment in the ERBL and FS combined with ERBL group were 20.9% (9/43) and 29.3% (12/41), respectively, and mild bleeding was the main symptom. There was no significant difference between the two groups in the bleeding degree ( U=807.0, P=0.378). After 6 months of follow-up, the total effective rates in the ERBL group and the FS combined with ERBL group were 81.4% (35/43) and 90.2% (37/41), respectively ( U=684.5, P=0.044). Conclusion:FS combined with ERBL can effectively relieve post-treatment perianal pain, and improve the long-term effectiveness.

Sangrado tardío luego de tratamiento con macroligadura elástica de hemorroides / Late bleeding after hemorrhoid treatment with rubber macroband ligation

Objetivo: Presentar el caso infrecuente de sangrado tardío posterior al tratamiento con macroligadura elástica de hemorroides, tratamiento propuesto por A. Reis Neto. Caso Clínico: Mujer de 26 años con tratamiento de hemorroides con macroligadura elástica. A los 28 días es admitida en urgencia por proctorragia abundante sin signos de shock hipovolémico. Laboratorio: Hematocrito 27%, Hemoglobina 8,9 mg/dl. Se realiza colonoscopia evidenciando la cicatriz de macroligadura con signos de coágulo desprendido sin sangrado activo. Se decide conducta expectante con tratamiento de la hipovolemia incial y anemia. Evoluciona sin resangrado con control endoscópico a los 60 y 180 (sin sangrado y excelentes resultados). Discusión: La macroligadura es una técnica alternativa para el tratamiento de hemorroides con excelentes resultados anatómicos y funcionales. Presenta menor dolor postoperatorio, bajo índice de complicaciones (ninguna severa o propia del método). No existen comunicaciones sobre sangrado tardío grave tanto en ligaduras convencionales como macroligadura. Conclusiones: Se presenta el primer caso comunicado a la fecha de un sangrado tardío en macroligaduras que fue resuelto en forma conservadora.

Objetive: To present an infrequent clinical report of a case of late bleeding after rubber macroband ligation. Case report: A 28-year-old female with severe rectal bleeding but no associated shock was presented 28 days after rubber macroband ligation at emergency room. Blood samples showed acute anemia. An urgent colonoscopy was performed which showed a scar without acute bleeding. Medical treatment was settled. There was no secondary bleeding in follow up. Endoscopic control was done at 60 and 180 days. Discusion: Hemorrhoidal rubber macroband ligation is a modification of conventional rubber band ligation. It was proposed and developed by J.A. Reis Neto (Campinas, SP, Brazil). Morbidity is low and results are excellent. There is no previous report of delayed bleeding considering both rubber band and macroband ligation. Conclusion: The First case of late bleeding after rubber band ligation treated with conservative measures.

Comparison of single versus double versus triple site band ligation for haemorrhoids in a single visit: a case-controlled double blind randomized study

Background: Rubber band ligation is considered one of the most popular non-surgical procedures available, representing the most reasonable balance between efficacy, pain and potential of complication. The present study was a controlled double blinded randomized study to compare Single versus double versus triple site band ligation for haemorrhoids in single treatment visit with special regards to its safety and efficacy in our patient population.Methods: There were 78 patients equally randomized in three groups by closed enveloped method. The number of patients in each group was 26, In Group A, a single, in Group B, two, and in Group C three major haemorrhoidal groups were rubber band ligated, in a single treatment visit on outpatient basis under topical anaesthesia with lignocaine 2% jelly.Results: Rubber band ligation was effective with significant symptom improvement seen in all patients with 88% patient satisfaction at end of 30 days period. Post ligation pain score and number of analgesic requirement in immediate post band ligation period, at 12 hours, at 1,7,14, 21 and 30 days post band ligation were similar in all three groups with p value >0.05. Multiple site haemorrhoidal bandings was done safely at single session without severe discomfort, pain or bleeding or severe complications requiring hospitalization.Conclusions: The study finding shows that triple site band ligation in a single session is a safe way of treating symptomatic haemorrhoids with similar post-procedure pain and patient satisfaction as conventional single or double site band ligation.

Macroligaduras hemorroidales. Tratamiento ideal del prolapso hemorroidario. Seguimiento a 5 años / Hemorrhoidal macro rubber band ligations. Ideal treatment of hemorrhoidal prolapse. Follow-up at 5 years

Introducción: Entre los tratamientos alternativos de las hemorroides se destaca por ser costo-eficientes las ligaduras elásticas convencionales. Las macroligaduras elásticas se hayan en difusión por similares resultados que las bandas elasticas convencionales. La literatura es aun escasa. El objetivo fue analizar los resultados, morbilidad y recidiva a corto y mediano plazo de hemorroides tratadas con macroligaduras. Diseño: Estudio observacional analítico prospectivo. Pacientes: 188 pacientes (110 varones y 78 mujeres). Periodo: 2011-2014. Lugar: Institución privada universitaria. Métodos: Inclusión: pacientes tratados con hemorroides internas sintomáticas. Exclusión: enfermedad anoperineal asociada, tratamiento previo, inmunocompromiso o anticoagulación. Se registraron resultados, complicaciones y recidiva. La técnica empleada fue la descripta por Reis Neto. El Seguimiento fue a 10, 30 días y 6 y 12 meses y 5 años. Resultados: Todos fueron tratados con internación de corta estadía. La edad fue 49,5 años (23-76). Los síntomas fueron prolapso 96, sangrado 44 y ambos 48. Se realizó sólo una sesión en 178 casos (94,6%). Se trataron 2 paquetes en 122 y 3 en 66. El dolor moderado fue en 5 casos y prolongado en 2. El sangrado leve y tenesmo se presentó en la mayoría de los pacientes, pero desapareció en la primera semana. Se registró sangrado inmediato moderado en 5% sin sangrado severo inmediato. Otras complicaciones inmediatas: 2 trombosis y 3 congestión/edema local. En 1 paciente ocurrió un sangrado que requirió de internación sin necesidad de cirugía en forma alejada. Sólo en 3 casos se realizó resección local de plicomas previos. En 139 casos se realizó como único procedimiento. La recidiva fue 6 casos. (2 al primer año y 4 a los 5 años), 5 se trataron con nueva macroligadura y 1 con cirugía. No se registró ninguna complicacion severa, infecciosa o única relacionada al procedimiento. El seguimiento a 1 año fue del 100% y a 5 años del 96%. Discusión y conclusiones: El tratamiento con macroligaduras para el prolapso hemorroidario presentó con baja morbilidad sin complicaciones severas. Los resultados son reproducibles entre diferentes autores. Son el tratamiento ideal para las hemorroides grado III con poco componente externo. (AU)

Introduction: Alternative therapies for internal hemorrhoid plexus are several procedures with specific indications for each grade of hemorrhoid. Due to some major advantages, rubber band ligation has become probably in the most popular between colorectal surgeons. The high-macro rubber band ligation appears to be as the first choice but literature is few. Objective: To analyze results, morbidity and recurrence of internal hemorrhoid disease treated with high-macro rubber band ligation. Design: Observational non-randomized prospective analysis. Patients: 188 patients (110 male). Period: 2011-2014. Setting: Private Institution. Methods: Patients with symptomatic internal hemorrhoid disease (grade II-III-IV). Results, Immediate and late complications and 5 years recurrence were registered. Technique used was the original description by Reis Neto. Patients with immunosuppression, additional perianal disease, previous treatment and anticoagulation were excluded. Results: There was only one session in 178 cases. Two banding were placed in 122 and 3 in 66. Symptoms were prolapse in 96, bleeding in 44 and both in 48. 139 patients were treated as only procedure. Tenesmus and light hemorrhage occurred in most cases. Moderate or late pain was registered in 7 cases, and immediate moderate bleeding in 5%. There was no severe immediate bleeding. Immediate morbidity was 2 thrombosis and 3 anal congestion. There was one moderate late bleeding at day 28 and required admission. Recurrence occurred in six cases, 5 were ligated again and 1 was treated by conventional surgery. There was none severed or unique complication or infection associated. Discussion and conclusion: Macrorubber band presented low morbidity and there are no severe complications at 5 years follow-up. Recurrence of prolapse is low and could be treated by a new session with equal morbidity. Results are equivalent and reproducible by different authors. This procedure might be the ideal treatment for hemorrhoid prolapse. (AU)

Rubber band ligation of hemorrhoids: a hospital based study

Background: Hemorrhoids are symptomatic anal cushions containing arteriovenous anastomosis. Patient with haemorrhoids can present as bleeding per rectum, something (mass) coming out per rectum, perianal itching, Anaemia due to occult blood loss. Various modalities of treatment have been developed to treat symptomatic haemorrhoids. This study was undertaken to determine the efficacy of rubber band ligation in the management of haemorrhoids.Methods: This study was a prospective study conducted in the Department of Surgery, Government Medical College, Srinagar from June 2015 to June 2018. Patients at any age with first, second- or third-degree internal haemorrhoids were included in the study. Patients with fourth degree, complicated haemorrhoids, previous anorectal surgery or anorectal pathology, and chronic liver disease were excluded. A total of 212 patients were included in the study. Rubber band ligation was done as an OPD procedure. The patients were followed at 2 weeks, 4 weeks, 3-month, 6 month and 1 year after the procedure.Results: In this study, out of 212 patients, 154(72.6%) were males and 58(27.4%) females. The mean age of this study was 38.7 yr. (Range 17-73 yr.). Patients presented with the complaints of bleeding (184, 86.8%), prolapse (114, 53.7%), constipation (116, 54.7%), priuritis ani (36, 17.0%), pain (12, 5.6%). Band ligation was successful in 188(88.8%) patients, 169(79.7%) patients were cured and in 19(8.9%) improvement was obtained. Various complications occurred after band ligation including vasovagal syncope (2, 0.9%), bleeding per anum (6, 2.8%), pain (12, 5.6%), fissure in ano (1, 0.5%). Recurrence after one year was seen in 9(4.2%) patients.Conclusions: Author concluded in this study that RBL is an effective outpatient treatment for grade II and III internal haemorrhoids without much complications.

Prospective Study of Benign Breast Disease in a Rural Tertiary Care Hospital

Objective of the present study was to evaluate different patterns of benign breast diseases and theirmode of presentation and also to correlate between clinical and pathological findings in cases ofpalpable lesion of breast. A total of 130 patients who attended the Surgery Department in MMIMSRMedical College, Mullana, Ambala with various forms of BBDs, during the period from January 2014to April 2016, were studied. Early diagnoses by doing a triple assessment such as a clinical examination,fine-needle aspiration cytology or a core needle biopsy, and imaging methods such as ultrasonographyor mammography. The clinical diagnoses were compared with the cytological or histological findingswherever possible, and their accuracies were evaluated. Out of the 130 patients who were studied,majority of patients who presented with breast lumps, were in the reproductive age group. Fibroadenoma(41.5%) and fibrocystic (14.6) diseases were the most common BBD's. Most patients presented aspainless lump which is need to be differentiated from carcinoma. BBD's most commonly affectedupper and outer quadrant. Most of the patient (61%) presented within 6 months of development ofbreast lesion showing increasing awareness in females of rural India. BBDs are common in femalepatients. The triple assessment provided a quick diagnosis, and it alleviated unnecessary anxiety fromthe patients about breast cancer. The clinical diagnosis of a breast lump, as confirmed by cytologyand histology, was accurate in most of the cases.

Hemorrhoidectomy versus rubber band ligation in treatment of second and third degree hemorrhoids: a comparative study

Background: Optimum surgical intervention for low-grade haemorrhoids is unknown. Haemorrhoidal artery ligation (HAL) has been proposed as an efficacious, safe therapy while rubber band ligation (RBL) is a commonly used Out patient treatment.Methods: We compared recurrence after HAL versus RBL in patients with grade II-III haemorrhoids. The diagnosis of hemorrhoids is primarily based on the proctoscopic  examination. The study evaluates comparative results of rubber band ligation (RBL) and hemorrhoidectomy. This study was conducted over a period of 1 year from January 2017 to December 2017. It includes 50 patients having second- or third-degree primary hemorrhoids who attended surgical OPD of Tertiary Care Hospital in Gujarat. These 50 patients were selected randomly and divided into two groups of 25 patients each (hemorrhoidectomy group and RBL group). Patients of fissure, fistulae, and malignancy were excluded. All parameters were recorded and finally analysed.Results: Hemorrhoidectomy and RBL are equally effective especially in second-degree hemorrhoids. However, RBL should be considered the first-line treatment in second-degree hemorrhoids because being an outpatient procedure, it is cost effective for the patients, saves many hospital beds for more sick patients, and takes the pressure off the surgical waiting list. Although RBL is not as effective as hemorrhoidectomy in third-degree hemorrhoid, it does improve bleeding and prolapse and is highly recommended for patients who are unfit for surgery.Conclusions: RBL should be considered as the first-line treatment for second-degree hemorrhoid. However, in the third-degree hemorrhoids, hemorrhoidectomy achieves better results, and RBL is recommend as the first-line treatment for those patients in whom there is contraindication for surgery or anesthesia.

Macroligadura como tratamiento para hemorroides / Macro-ligation as a hemorrhoid treatment

Introducción: Las hemorroides constituyen una dilatación varicosa de los plexos hemorroidales que involucran la mucosa del recto y ano. Estas constituyen la enfermedad anorrectal más frecuente en el mundo occidental, con una alta prevalencia que suele representar el 50 % de las consultas con el proctólogo. Se pueden describir dos grandes grupos de hemorroides, los internos que son aquellos situados por encima de la línea pectínea y los externos que son los que se encuentran por debajo de esta línea, se tendrán en cuenta los internos. A estos últimos se los clasifica por Goligher en relación con el grado de prolapso de la mucosa rectal y la posibilidad de reducción del prolapso. Para las hemorroides grado II y III se han diseñados diferentes métodos quirúrgicos de tratamiento desde la electrocoagulación, la crioterapia, la terapia fotodinámica y RBL El presente trabajo plantea como objetivo describir nuestros resultados iniciales en el tratamiento de patología hemorroidal por medio de la técnica de macroligadura alta por aspiración RBL. Materiales y Métodos: Se incluyeron 40 pacientes a los que se le realizo RBL, comprendidos desde el mes de octubre de 2016 a marzo de 2018, que presenten patología hemorroidal grado II III y IV, técnica de macroligadura alta por succión. Resultados: Del 63% de femenino y un 37% de masculino, la distribución por grados fue de la siguiente manera, grado 2: 75%, grado 3: 17.5% y grado 4: 7.5%, el dolor posterior al procedimiento en forma inmediata fue de 3.78±2.63, a las 48 hs 2.10±2.31 y a los 7 postquirúrgicos 1.10±1.86. Tuvimos un total de 7 (18%) pacientes con recidivas dentro de los 18 meses de seguimiento, tenesmo se presentó 27.59% en los grados 2, un 57,14% en los grados 3 y un 66,67% en los grados 4. Solo reportamos un 23% de sangrado posquirúrgico. Conclusión: Podemos afirmar que la técnica de macro ligadura alta como variante de la RBL, es una técnica segura, aplicable en forma ambulatoria, con un beneficio importante por sobre el resto de las técnicas resectivas que solo requiere una sedación para el procedimiento, con bajos umbrales de dolor postquirúrgicos, pronta recuperación y reinserción laboral; presenta bajos índices de complicaciones. Además, representa una excelente opción para el tratamiento de las hemorroides grado 2 y 3. (AU)

Introduction: Hemorrhoids are a varicose dilatation of the hemorrhoidal plexuses that involve the mucosa of the rectum and anus. These constitute the most frequent anorectal disease in the western world, with a high prevalence that usually represents 50% of consultations with the proctologist. Two large groups of hemorrhoids can be described; the internal ones that are those located above the pectineal line and the external ones that are those below this line, the internal ones will be taken into account. The latter are classified by Goligher in relation to the degree of prolapse of the rectal mucosa and the possibility of prolapse reduction. For the grade II and III hemorrhoids, different surgical methods of treatment have been designed from electrocoagulation, cryotherapy, photodynamic therapy and RBL. The present work aims to describe our initial results in the treatment of hemorrhoidal pathology by means of the macro-adherence technique. High by RBL aspiration. Materials and Methods: Forty patients were included, who underwent RBL, from October 2016 to March 2018, who presented grade II III and IV hemorrhoidal pathology, high suction macroligation technique. Results: Of 63% of female and 37% of male, the distribution by grades was as follows, grade 2: 75%, grade 3: 17.5% and grade 4: 7.5%, pain after the procedure immediately it was 3.78 ± 2.63, at 48 hours 2.10 ± 2.31 and at 7 postsurgical 1.10 ± 1.86. We had 7 (18%) patients with recurrences within 18 months of follow-up; tenesmo presented 27.59% in grades 2, 57.14% in grades 3 and 66.67% in grades 4. We only reported 23% of postoperative bleeding. Conclusion: We can affirm that the high macro ligature technique as a variant of the RBL is a safe technique, applicable in ambulatory form, with an important benefit over the rest of the resection techniques that only requires a sedation for the procedure, with low postoperative pain thresholds, early recovery and re-employment; It presents low rates of complications. In addition, it represents an excellent option for the treatment of grade 2 and 3 hemorrhoids. (AU)

Complicaciones infecciosas graves luego de la ligadura con banda elástica para hemorroides: reporte de un caso y revisión de la literatura / Acute infectious complications after ligation with elastic band for hemorrhoids: a case report and literature review

Introducción: La ligadura con banda elástica es un procedimiento efectivo y de bajo costo, para el manejo de hemorroides grado I-III, que no requiere internación. Sus complicaciones, cuando presentes, son habitualmente leves. Aunque poco comunes, existen complicaciones graves asociadas a este procedimiento. El objetivo de este estudio es realizar una revisión de las complicaciones infecciosas pelvi-perineales de la ligadura con banda elástica, características comunes de presentación y alternativas de tratamiento en aquellos que sufren estas complicaciones. Descripción del caso: Se expone el caso de un hombre de 71 años de edad que presentó una sepsis pelviana severa posterior a la realización de una ligadura con banda elástica. A las 48 horas del procedimiento consulta por dolor perianal, dificultad miccional y fiebre. Se realiza el drenaje quirúrgico de ambas fosas isquiorrectales, luego de lo cual intercurre con shock séptico, realizándose una laparotomía, drenaje de retroperitoneo, colostomía sigmoidea. Posteriormente, debido al desarrollo de un síndrome compartimental abdominal, el abdomen se dejó abierto y contenido con una malla. Discusión: Se han descripto complicaciones sépticas posteriores a escleroterapia y crioterapia hemorroidal, ligadura con banda elástica, hemorroidectomia convencional y con sutura mecánica. Se exponen 20 casos de sepsis pelviana post-ligadura con banda elástica. La relación hombre:mujer fue de 3:1, con un amplio rango de edad (27-82 años). Sólo 2 tenían antecedentes de inmunosupresión. La progresión o la persistencia del dolor asociado a fiebre, dificultad miccional, edema perineal y/o genital fueron signos y síntomas comunes que se manifestaron dentro de los 14 días posteriores a la ligadura. Tal como en el caso aquí referido como en otros ya publicados, la realización de imágenes ayudó al diagnóstico y a la planificación quirúrgica. Todos recibieron antibioticoterapia de amplio espectro y 13 requirieron además cirugía. El espectro de tratamientos quirúrgicos fue desde el drenaje incisional hasta la amputación rectal. Ante la progresión del cuadro séptico, la realización de una ostomía fue la conducta más usual. Cinco pacientes requirieron más de una cirugía, y 8 fallecieron. Conclusión: Es importante conocer las complicaciones infecciosas mayores y su presentación clínica, para realizar un diagnóstico y tratamiento precoz de las mismas, con el fin de disminuir su elevada morbilidad o mortalidad. (AU)

Background: Rubber band ligation is an effective, low-cost procedure for grade I-III hemorrhoids, and does not require hospitalization. Its complications, when present, are usually mild. Although rare, there are serious complications associated with this procedure. The purpose of this review was to identify common presenting features and treatment alternatives in those who suffer pelviperineal infectious complications after rubber band ligation. Case Report: The present case is that of a 71-year-old man who presented severe pelvic sepsis after rubber band ligation. He complained of perianal pain, voiding difficulties and fever 48 hours after the procedure. Surgical drainage of both ischiorectal fossae was carried out. He developed septic shock. Laparotomy, retroperitoneal drainage and sigmoid loop colostomy were performed. In a subsequent operation due to abdominal compartment syndrome, the abdomen was left open and contained with a mesh. Discussion: Septic complications have been described after sclerotherapy, cryotherapy, rubber band ligation, conventional hemorrhoidectomy and stapled haemorrhoidopexy. We describe 20 cases of pelvic sepsis after rubber band ligation. The male: female ratio was 3: 1, with a wide age range (27- 82 years). Only 2 had a history of immunosuppression. The progression or persistence of pain associated with fever, voiding difficulties, perineal and / or genital edema were common signs and symptoms that appeared within 14 days after rubber band ligation. In the case here referred to as in others already published, imaging studies helped the diagnosis and surgical planning. All received broad spectrum antibiotic therapy and 13 required surgery. The spectrum of surgical treatments ranged from incisional drainage to rectal amputation. In view of the progression of the septic condition, performing an ostomy was the most usual conduct. Five patients required more than one surgery, and 8 died. Conclusion: It is important to acknowledge the major infectious complications and their clinical presentation, to help with an early diagnosis and treatment, in order to reduce their high morbidity and mortality. (AU)

A prospective study of efficacy and safety of rubber band ligation in the treatment of Grade II and III hemorrhoids - a western Indian experience / Estudo prospectivo da eficácia e segurança da ligadura elástica no tratamento de hemorroidas de Grau II e III - uma experiência na Índia ocidental

ABSTRACT Background: Hemorrhoids are one of the most frequent diseases of the anal region with high prevalence involving all age groups. Multiple treatment options exist with none being perfect. Rubber band ligation of hemorrhoids is a non-operative treatment which can be performed on outpatient basis. Objective: The study was undertaken to determine efficacy of banding in treatment of Grade II and III hemorrhoids and to follow-up patients treated by banding to evaluate for symptomatic relief, recurrence and complications. Study design: A prospective, interventional study with clearance from the institutional ethics committee was undertaken over the period of 2 years in a tertiary referral center with a sample size of 60. Result: Out of 60 patients, 41 patients (68.30%) had Grade II and 19 patients (31.7%) had Grade III hemorrhoids. At first follow up, success rate for Grade II hemorrhoids was 85% (35/41) as compared to 21% (4/19) in Grade III. The unsuccessful 20 patients were re-banded, however only 2 of them responded to procedure. At the end of 6 weeks, 36 patients with Grade II hemorrhoids (88%) were cured. Failure rate was higher for Grade III hemorrhoids (68.42%, n = 13). Success rate was 86.6% for single hemorrhoid. There were no major complications. Anemia reverted significantly with successful band ligation. Conclusion: Rubber band ligation is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an outpatient procedure. It gives better results for Grade II and single hemorrhoids. Recurrence rate after successful band ligation is low.

RESUMO Background: As hemorroidas são uma das doenças mais frequentes da região anal, com alta prevalência envolvendo todas as faixas etárias. Existem várias opções de tratamento, sendo que nenhuma é perfeita. A ligadura elástica de hemorroidas é um tratamento conservador que pode ser realizado em ambulatório. Objetivo: O estudo foi realizado para determinar a eficácia da ligadura no tratamento de hemorroidas de Grau II e III e para acompanhamento dos pacientes tratados por ligaduras para avaliar o alívio sintomático, a recorrência e as complicações. Design do estudo: Estudo prospectivo e intervencionista com liberação do comitê de ética institucional foi realizado durante o período de 2 anos em um centro de referência terciário com um tamanho de amostra de 60. Resultado: Dos 60 pacientes, 41 (68,30%) apresentaram hemorroidas de Grau II e 19 (31,7%) de Grau III. No primeiro seguimento, a taxa de sucesso para hemorroidas de grau II foi de 85% (35/41), em comparação com 21% (4/19) no Grau III. Os 20 pacientes sem sucesso foram novamente submetidos a ligadura, mas apenas 2 deles responderam ao procedimento. Ao final de 6 semanas, 36 pacientes com hemorroidas de Grau II (88%) foram curados. A taxa de falha foi maior para as hemorroidas de grau III (68,42%, n = 13). A taxa de sucesso foi de 86,6% para hemorroida única. Não houve grandes complicações. A anemia reverteu significativamente com ligadura elástica bem-sucedida. Conclusão: A ligadura elástica é um método simples, seguro e eficaz para o tratamento de hemorroidas sintomáticas de segundo e terceiro graus, como procedimento ambulatorial. Ela promove melhores resultados para hemorroidas de Grau II e únicas. A taxa de recorrência após ligadura elástica bem-sucedida é baixa.

Endoscopic Band Ligation to Treat a Massive Hemorrhoidal Hemorrhage Following a Transrectal Ultrasound-Guided Prostate Biopsy

Prostate cancer is commonly diagnosed by using a transrectal ultrasound (TRUS)-guided biopsy. Although this procedure is usually well tolerated, rarely it may be complicated by massive rectal bleeding. We report a case of a 77-year-old male who underwent a TRUS biopsy and subsequently developed recurrent episodes of rectal bleeding with syncope and anemia requiring the transfusion of multiple units of blood. A sigmoidoscopy revealed the source of the bleeding: a large hemorrhoid on the anterior wall of the rectum with an overlying ulceration. We successfully applied a band to ligate the hemorrhoid, and the patient's condition improved. To our knowledge, this case represents the first report of a successful band ligation to treat massive bleeding from a hemorrhoid that had been punctured in the course of the TRUS biopsy procedure.

Removal of Esophageal Variceal Bands to Salvage Complete Esophageal Obstruction

Esophageal varices develop in almost half of the patients with cirrhosis, and variceal hemorrhage constitutes an ominous sign with an increased risk of mortality. Variceal banding is considered an effective and mostly safe measure for primary and secondary prophylaxis. Although adverse events related to banding including dysphagia, stricture formation, bleeding, and ligation-induced ulcers have been described, complete esophageal obstruction is rare, with only 10 reported cases in the literature. Among those cases, 6 were managed conservatively; 1 patient had esophageal intraluminal dissection from an attempt to remove the bands using biopsy forceps but ultimately recovered with conservative management. Three patients developed strictures following removal of the bands, requiring repeated sessions of dilation therapy. We report on a patient who developed absolute dysphagia and complete esophageal obstruction after variceal banding. We successfully used the endoloop cutter hook to release the bands intact and restore luminal integrity.

Hemorragia Digestiva Alta por Dieulafoy intradiverticular: Tratamiento Endoscópico / Digestive Bleeding by Dieulafoy in Duodenal Diverticulum: Endoscopic Treatment

La Lesión de Dieulafoy es una malformación vascular caracterizada por la presencia de un vaso arterial de gran calibre en la submucosa, ocasionalmente en la mucosa que puede erosionarse, provocar una hemorragia grave, recurrente y, en ocasiones mortal. Es una causa rara de hemorragia gastrointestinal y corresponde a menos del 2% de los episodios de sangrado digestivo agudo. La Lesión de Dieulafoy duodenal ha sido comunicada en un número reducido de casos y, la intradiverticular es excepcional. La endoscopía constituye el método diagnóstico de elección y, en las últimas décadas la terapéutica endoscópica es la técnica preferida por su elevada efectividad y escasa incidencia de complicaciones. Presentamos el caso de un paciente de 82 años con hemorragia digestiva alta grave por lesión de Dieulafoy duodenal intradiverticular diagnosticado en la endoscopía de urgencia y, tratado eficazmente mediante ligadura con banda elástica.

The lesion of Dieulafoy is a vascular malformation characterized by the presence of a large arterial vessel in the submucosa and occasionally in the mucosa, which can erode and cause severe, recurrent and sometimes fatal hemorrhage. It is a rare cause of gastrointestinal bleeding and responds to less than 2% of episodes of acute gastrointestinal bleeding. The duodenal Dieulafoy lesion has been reported in a small number of cases and the intradiverticular is exceptional. Endoscopy is the diagnostic method of choice and in the last decade endoscopic therapy is the preferred technique due to its high effectiveness and low incidence of complications. We present the case of an 82-year-old patient with severe upper gastrointestinal bleeding due to an intradiverticular duodenal injury diagnosed in emergency endoscopy and treated effectively by rubber band ligation.

Repair of an Endoscopic Retrograde Cholangiopancreatography-Related Large Duodenal Perforation Using Double Endoscopic Band Ligation and Endoclipping

Endoscopic closure techniques have been introduced for the repair of duodenal wall perforations that occur during endoscopic retrograde cholangiopancreatography (ERCP). We report a case of successful repair of a large duodenal wall perforation by using double endoscopic band ligation (EBL) and an endoclip. Lateral duodenal wall perforation occurred during ERCP in a 93-year-old woman with acute calculous cholangitis. We switched to a forward endoscope that had a transparent band apparatus. A 2.0-cm oval-shaped perforation was found at the lateral duodenal wall. We repaired the perforation by sequentially performing double EBL and endoclipping. The first EBL was performed at the proximal edge of the perforation orifice, and two-thirds of the perforation were repaired. The second EBL, which also included the contents covered under the first EBL, repaired the defect almost completely. Finally, to account for the possible presence of a residual perforation, an endoclip was applied at the distal end of the perforation. The detection and closure of the perforation were completed within 10 minutes. We suggest that double EBL is an effective method for closure.

Cyanoacrylate injection versus band ligation for bleeding from cardiac varices along the lesser curvature of the stomach

BACKGROUND/AIMS: Practice guidelines recommend endoscopic band ligation (EBL) and endoscopic variceal obturation (EVO) for bleeding from esophageal varices and fundal varices, respectively. However, the optimal treatment for bleeding from cardiac varices along the lesser curvature of the stomach (GOV1) remains undefined. This retrospective study compared the efficacy between EBL and EVO for bleeding from GOV1. METHODS: Patients treated by EBL or EVO via cyanoacrylate injection for bleeding from GOV1 were enrolled. Patients diagnosed with hepatocellular carcinoma or treated with endoscopic injection sclerotherapy were excluded. RESULTS: The study included 91 patients treated for bleeding from GOV1. The mean age was 56.3±10.9 years (mean±SD), and 78 of them (85.7%) were men. Overall, 51 and 40 patients were treated with EBL and EVO, respectively. A trend for a higher hemostasis rate was noted in the EVO group (100%) than in the EBL group (82.6%, P=0.078). Varices rebled in 15 patients during follow-up. The rebleeding rate was significantly higher in the EBL group than in the EVO group (P=0.004). During follow-up, 13 patients died (11 in the EBL group and 2 in the EVO group); the survival rate was marginally significant between two groups (P=0.050). The rebleeding-free survival rate was significantly higher in the EVO group than in the EBL group (P=0.001). CONCLUSIONS: Compared to EBL, EVO offered significantly lower rebleeding rates, significantly higher rebleeding-free survival rates, and a trend for higher hemostasis and survival rates. EVO appears to be the better therapeutic option for bleeding from GOV1.

Analysis of the curative effect of endoscopic band ligation combined with drug injection in the treatment ;of hepatic cirrhosis complicated with upper gastrointestinal haemorrhage / 实用医学杂志

Objective To explore the curative effects of endoscopic band ligation combined with drug injection in the treatment of hepatic cirrhosis complicated with upper gastrointestinal hemorrhage. Methods 76 patients with hepatic cirrhosis complicated with upper gastrointestinal hemorrhage were divided into 2 groups by random double blind method, with 38 cases in each group. The control group were treated by conservative regimen alone while the experimental group were treated by endoscopic band ligation combined with drug injection, based on the control group. The clinical curative effects, adverse reactions, hemostasis time, hospitalization time , rebleeding , haemodynamics and other indexes before and after the treatment in the 2 groups were compared. Results The total effective rate, rebleeding rate and the incidence of fever in the experimental group were 2.6% and 10.5%, respectively. Compared with those in the control group (71.1%, 21.1%, 28.9%), the differences were statistically significant (P < 0.05). The differences in volume of blood transfusion, hemostasis time , time of improvement of symptoms and hospitalization time between the experimental group and the control group were significant (P < 0.01). The blood flow of portal vein(550.2 ± 143.4)mL and splenic vein (284.3 ± 96.4)mLin the experimental group was significantly less than that in the control group [(628.1 ± 156.0)mL, (332.6 ± 100.3)mL] (P < 0.05). Condusions Endoscopic band ligation combined with drug injection in the treatment of hepatic cirrhosis complicated with upper gastrointestinal hemorrhage is effective and can significantly improve the varicose hemodynamics in patients. The rate of rebleeding is low.

Endoluminal Closure of Colon Perforation with Endoscopic Band Ligation: Technical Feasibility and Safety in an In Vivo Canine Model

BACKGROUND/AIMS: Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model. METHODS: We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination. RESULTS: The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis. CONCLUSIONS: EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

A comparative study of rubber band ligation and flavonoids (Daflon) in the treatment of haemorrhoids.

Background: Haemorrhoids is a common disease affecting people of all ages and both sexes. Though there is no confusion on the treatment of 3rd and 4th degree haemorrhoids, there is still confusion regarding the ideal treatment for 1st and 2nd degree haemorrhoids. Aims & Objective: To compare the safety, efficacy, advantages and disadvantages of Rubber Band Ligation and Micronized Flavonoids in the treatment of internal haemorrhoids. Material and Methods: Two hundred patients of haemorrhoids were treated, One hundred cases with Rubber Band Ligation and rest hundred with Daflon 500 mg. The outcome measured in term of relief from bleeding and duration of treatment. Results: 82% of patients on Daflon and 60% of patients undergoing Rubber Band Ligation were completely cured (P<0.01) on the 7th day but on follow up there is no statistical significance. Conclusion: Daflon gives rapid relief from symptoms of haemorrhoids as compared to Rubber Band Ligation but the long duration and higher cost of treatment patient acceptability and compliance is less.

Várices gástricas: un reto para el manejo endoscópico / Gastric varices: a challenge for endoscopic management

La hemorragia de vías digestivas altas por várices gástricas, aunque menos frecuente que la secundaria a lasesofágicas, es una causa de alta mortalidad en los pacientes cirróticos. La ligadura es el tratamiento óptimoen las várices esofágicas, pero este tratamiento para las gástricas es todavía muy discutido.Presentamos el caso de una anciana, con antecedente de cirrosis hepática secundaria a esteatosis hepáticano alcohólica (NASH), que ingresa, con hemorragia de vías digestivas altas, evidenciándose en laesofagogastroduodenoscopia una várice fúndica subcardial con sangrado activo, para la cual se decide manejocon ligadura con banda de caucho con resultado exitoso y desaparición de la várice en control posterior

Upper digestive tract bleeding due to gastric varices, although less common than bleeding secondary toesophageal varices, is one of the causes of high mortality in cirrhotic patients. Although band ligation is theoptimal treatment for esophageal varices, its use for gastric varices is still hotly debated.We report the case of an elderly woman with a history of hepatic cirrhosis secondary to nonalcoholicsteatohepatitis (NASH) and obesity who was admitted to the hospital with upper digestive tract bleeding.An esophagogastroduodenoscopy showed an actively bleeding subcardial varice in the gastric fundus. Thedecision was made to manage the bleeding with rubber band ligation. The outcome was successful outcome,and the varice had disappeared in subsequent check-ups