Top Tips for Endoscopic Banding of Hemorrhoids

TECHNIQUE ARTICLE

Rami Musallam, MD, Gastroenterology Fellow, and Klaus Mönkemüller, MD, PhD, Professor of Medicine, Department of Gastroenterology, Virginia Tech Carilion School of Medicine

Final Diagnosis

Endoscopic rubber band ligation for symptomatic internal hemorrhoids.

Patient Demographics

75-Year-old female patient with intermittent, painless rectal bleeding. During colonoscopy internal hemorrhoids were found.

Clinical History

This patient was referred for colonoscopy and therapy of internal hemorrhoids using rubber band ligation. Endoscopic rubber band ligation is a safe, effective, non-operative, and well-tolerated endoscopic procedure for treating symptomatic internal hemorrhoids.

Endoscopic Findings

1. Visualization of targeted hemorrhoids in retroflex position (Figure 1A, B).
2. Inflation is useful to confirm hemorrhoids to be treated, as those the remain bulging, whereas the small hemorrhoids flatten out (Figure 1B).
3. Water instillation through the endoscope's water channel, with the patient in the left lateral decubitus position, indicates the location of hemorrhoids based on water accumulation (Figures 1C, D). The yellow arrow shows the water accumulation on left side of the rectum. Thus, the bulgy hemorrhoid is located on the right side.

Endoscopic Technique

1. The endoscope is advanced to the rectal canal and positioned in retroflex. The targeted hemorrhoids are visualized (Figure 1A, B).
2. Inflation is performed to identify bulging hemorrhoids; those that disappear with inflation may not require treatment (Figure 1C, D).
3. To precisely localize hemorrhoids, water is instilled through the endoscope's water channel. With the patient in the left lateral decubitus position, water accumulation identifies the corresponding hemorrhoid on the right side. The yellow arrow highlights the area of water accumulation (Figure 1E).
4. Before banding, the location of the hemorrhoid in relation to the dentate line is determined. The dentate line is avoided during ligation to prevent pain.
5. The endoscope, loaded with the banding device, is advanced to the rectal canal. Hemorrhoids are banded in either an antegrade or retroflex position. The retroflex position is preferred for internal targeting and reduced risk of engaging the dentate line, providing excellent visualization of the anorectal area (Fig. 1F, G, H).
6. During suctioning of the hemorrhoid into the cap, excessive suctioning or filling more than two-thirds of the cap is avoided to prevent subsequent large ulcer formation. Also, if too much tissue is suctioned into the cap, the chances of including dentate line are increased. Therefore, controlled and careful suctioning should be applied.
7. After deployment of the rubber band, the area is inspected to confirm appropriate distance from the dentate line (Figure 1H).

Discussion

Endoscopic rubber band ligation remains a cornerstone in the management of symptomatic internal hemorrhoids (1-3). This technique, when performed with careful attention to procedural details, offers a safe and effective treatment option (1-3). Key considerations include precise localization of hemorrhoids, particularly in relation to the dentate line, to minimize patient discomfort and complications. The use of water instillation and retroflex viewing enhances accurate identification and targeting. Optimal suctioning during band placement is critical to prevent over-ligation and potential ulceration. The described preference for retroflex banding highlights an approach aimed at maximizing precision and safety by allowing for direct visualization and internal targeting of the hemorrhoidal tissue, thereby reducing the risk of complications associated with inadvertent banding of the dentate line.

Key Learning Points

1. Visualize and inflate to confirm the presence of treatable hemorrhoids.
2. Utilize water instillation for accurate hemorrhoid localization regarding anatomical position.
3. Avoid the dentate line during banding to prevent pain and complications.
4. Prefer retroflex banding for better visualization and internal targeting, minimizing dentate line involvement.
5. Control suctioning to two-thirds capacity to prevent large ulcer formation during band placement.

References

1. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum. 1995 Aug;38(8):687-94.
2. Lohsiriwat V. Hemorrhoids: from a single symptom to a medical condition. World J Gastroenterol. 2012 May 7;18(17):2021-3 hemorrhoid classification and treatment.
3. Gaj FF, Brattoli S, Di Leo M, et al. Rubber band ligation for hemorrhoids: New insights into a traditional technique. World J Gastrointest Endosc. 2021 May 16;13(5):170-179.