Rubber Band Ligation for haemorrhoids (RBL) (VIDEO)

Background:
•Developed by James Barron (Detroit, Michigan, USA) in 1963 (based on Paul C Blaisdell idea, presented at the Scientific Exhibit of the American Medical Association of 1954).
1. Barron J. “Office ligation treatment of hemorrhoids”. Dis Colon Rectum 1963; 6: 109-13.
2. Barron J. ”Office ligation of internal hemorrhoids”. Am J Surg 1963; 105: 563-70.

Facts:
•Surgery for haemorrhoids should only be recommended to90% of such patients, therefore, are suitable for conservative measures and for interventional non-surgical office procedures, such as RBL

Pros of RBL
•Effective for bleeding internal haemorrhoids, up to 3rd degree, including small prolapse [Rivadeneira DE et al, Standards Practice Task Force of The American Society of Colon & Rectal Surgeons. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 2011; 54: 1059-64].
•Cumulative Success Rate >80% (Iyer VS, Shrier I, Gordon PH. Long-Term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47: 1364-70).
•Safe
•Inexpensive
•Easy to organise / simple
•Outpatient / office procedure
•Immediate recovery
•Performed (through an anoscope) employing either a Vacuum Suction or a Traditional Forcep Ligator
•Two bands (rings) are used on each drum and applied >1 cm above dentate line

Cons of RBL
•Rare complications (bleeding, sepsis, thrombosed haemorrhoids, pain, urinary retention, etc.)
•Recurrence ~20%
•Operator dependent
•Only one or two pair(s) of bands (rings) can be applied at one session
•Sessions can be repeated only after 20-30 days
•Full treatment may, therefore, require up to 3 or 4 months
•Contraindicated in patients on anticoagulants
•Contraindicated to treat external (skin covered) haemorrhoids

What to do, what to expect?
Procedure
•Thorough pre-procedure diagnosis to rule out coexisting causes of PR bleeding
•Outpatient / office procedure
•No enema / bowel prep required (usually)
•No fasting needed
•No sedation indicated
•Patient positioned in left lateral or Sims’ position
•Average procedure time: ~5 minutes (or less)

Post-procedure
•Work can typically be resumed same day or next day
•Recommended medications: stool softeners, antibiotic (prophylaxis), and pain relief (rarely needed)
•Usually, only one or two 11 mm pair(s) of bands (rings) can be applied at one session
•Sense of “foreign body” and urge to move bowel for 24-48 hrs (tenesmus)
•After a few days (typical range: 5 to 10 days) the necrotized haemorrhoidal tissue and the bands (rings) slough away, with minimal bleeding