Hemorrhoidal disease requires different means of treatment: medical, surgical and instrumental. Among these, the elastic ligature seems to be an effective and widespread technique in the world. The aim of our study is to report our experience in methodology and short and medium term results of ligation in a population that strongly fears surgery. Patients and Methods: It’s about a retrospective and descriptive study of 208 outpatients treated with elastic ligations for symptomatic internal hemorrhoids. These patients were collected over a period of 15 years (October 2003-April 2018) at the gastroenterology department of Hassan II CHU in Fez. Results: The average age of our patients was 50.3 years [20 - 82 years] with a sex-ratio M/F of 2.85. The clinical signs were dominated by rectorrhagia (99%) complicated by anemia in 116 cases requiring blood transfusion in 72 cases, followed by proctalgia (27.4%). Transit disorders were noted in 65 patients (31.2%). Indications for elastic ligation were symptomatic internal hemorrhoids Grade 3 (65.4%) and Grade 2 (34.6%). The average number of ligation sessions that achieved the therapeutic goal was 2.30 sessions [1 - 4]. The average number of rings per session was 3.1 rings [1 - 6]. Moderate to severe pain was reported by 20 patients (9.6%) mostly within 6 hours of ligation. Minimal rectorrhagia was reported in 33 cases (15.8%). There were no major complications who required a hospitalization. The success rate was 80.7% (n = 168). Surgery was performed in 31 patients (14.9%) and sclerosis in 7 patients (3.3%). Conclusion: The elastic ligation of internal hemorrhoids remains an effective and inexpensive technique when it comes to the treatment of symptomatic internal hemorrhoids of Grade 2 to 3. The results obtained in our study were very reassuring and motivating.
Hemorrhoidal pathology is one of the most common causes of gastroenterology consultation. It is a benign condition that is expressed by intermittent functional manifestations. Internal hemorrhoids manifest themselves by rectorrhagia and/or prolapse, more rarely by thrombosis. The treatment of internal hemorrhoids involves many medical, instrumental and surgical methods, the choice of which must be adapted to each patient according to the stage and symptoms expressed. Instrumental treatment, of which there are several methods, currently occupies an important place in the management of hemorrhoidal disease. The aim of the instrumental treatment is not to restore a normal anatomy, but simply to permanently omit the symptoms by creating a cicatricial fibrosis which fixes the mucosa in the deep plane and reduces the vascularization, thus allowing the symptomatic relief (rectorragies) and the correction of a possible anatomical defect (prolapse). Among the instrumental treatments, elastic ligation is considered an efficient technique widely used in the world.
Our objective is to present a moroccan series of patients with symptomatic internal hemorrhoids treated by elastic ligation in the hepatogastroenterology department of Hassan II university hospital in Fez. Through this series, we seek to get a general idea of the epidemiological characteristics of internal hemorrhoids, and to report the service experience regarding elastic ligation, while emphasizing short-term and long-term efficiency as well as complications of the technique and compare our results with those present in national and international literature.
This is a retrospective and descriptive study involving 208 patients treated by elastic ligatures for symptomatic internal hemorrhoids, Grade 2 or 3. These patients were collected over a period of 15 years [October 2003-April 2018] at Hassan II University Hospital in Fez, Morocco. Dietary and defecatory hygiene measures were prescribed to all patients. A transit regulator has been prescribed for patients suffering from constipation. Elastic ligation was performed in patients who did not improve after well-conducted medical treatment, or with anemia related to hemorrhoidal disease. Coagulation tests were performed in all patients before the procedure.
All our patients were informed about the indication of the ligature, the progress of the technique, the incidents and also the potential complications. All our patients received post-ligation antibiotic therapy (metronidazole 1.5 g daily) combined with analgesics for 72 h.
The therapeutic goal was defined by the disappearance of clinical symptoms after 1 to 4 sessions of ligations spaced 3 to 4 weeks.
The variables were retrospectively collected in a computer database then their statistical analysis was performed using SPSS 20.0.
There were no limitations of this study.
Short term success: the disappearance of the symptoms after one to four ligation sessions.
Long term succes: non reappearance of symptoms more than one year after the end of ligation protocol.
Failure: the lack of clinical response after a maximum of 4 ligation sessions.
Recurrence rate: the reappearance of symptoms after the end of the ligation protocol.Evidently, it has been clarified exclusively amongst patients who have responded to the ligation protocol successfully.
The purpose of the ligature elastic is to achieve a “sclerosis nail” fixing mucous membrane with free fibers. The method consists of set up an elastic ring in the insensitive cylindrical area suprapectine. The suction apparatus is preferred to the claw device as it does not cause mucosal breakthrough and allows for better control at view. The apparatus comprises two cylinders whose outer is mobile. An elastic band (or vinyl ring in case of allergy latex) is placed using an introducer cone on the inner cylinder. The device is connected to a suction. The mucosa is sucked into the inner cylinder. The outer cylinder is mobilized forward sliding on the inner and pushes the elastic at the base of the pedicle aspirated. The ligated tissues become necrotic by forming a eschar which heals in three weeks (
The average age of our patients was 50.3 years [20 - 82 years] with a large male predominance (sex ratio = 2.85). A personal history of portal hypertension was found in two patients, one hemorrhoidectomy in one patient, an ulcerative colitis in two patients, one patient underwent surgery for a sigmoid adenocarcinoma, and one patient underwent an anal fistula surgery. Clinical
symptomatology was dominated by rectorragies (n = 206 or 99% of cases) and prolapse (n = 176, 84.6% of cases). Anemia was noted in 55.7% of cases (n = 116), with recourse to transfusion in 35.1% of patients (n = 72). The proctological examination found internal hemorrhoids Grade II in 34.6% (n = 72) and Grade III in 65.4% (n = 136). Endoscopic exploration by total colonoscopy was performed in all patients aged over 45 years, and in patients with profound anemia to eliminate another underlying cause. Endoscopic exploration revealed the presence of polyps in 3 patients, two of whom had high grade dysplasia in the histological analysis. The assessment of blood tests based on prothrombin rate and platelet count, was considered good in all patients (
The success rate was 80.7% (n = 168). After an average follow-up of 42 months [4 months - 6 years], the recurrence rate was 25% (n = 52), requiring the use of instrumental treatment in 15 patients (7.2% of cases), with surgical aid in 31 patients (15% of cases), while the remaining 6 patients were medically treated successfully (
The instrumental treatment of hemorrhoids includes methods applying a chemical or a physical process that can treat internal hemorrhoidal disease responsible for rectorragies or Grade 2 or 3 prolapse [
Patients (n = 148) | |
---|---|
Mean age | 50.3 years [20 - 82 years] |
Sex Male Female | 154 (74%) 54 (26%) |
Symptoms Rectorrhagies Prolapse Constipation Proctalgia | 206 (99%) 176 (84.6%) 61 (29.3%) 26 (12.5%) |
internal hemorrhoids grade Grade II Grade III | 72 (34.6%) 136 (65.4%) |
addition, elastic ligation achieves a partial reduction of the internal hemorrhoidal volume, with a more pronounced effect on prolapse [
The elastic ligation is introduced in France by Soullard in 1966, it requires a ligator and a suction system. It must be made at least one centimeter above the pectinate line. The ligated tissues lead to the formation of an eschar of which the cicatrization is done in 2 to 3 weeks. The rhythm between two successive ligatures is one session every 4 weeks, limiting itself to a total of 3 or 4 sessions. The results after a triple ligation in one session [
In our series, the average number of sessions that reached the therapeutic goal was 2.3 sessions (1 - 4 sessions) while the average number of rings per session was 3.1 (1 - 6 rings). In a series of IbnSina university hospital of Rabat covering 191 patients, 4.76% of whom were treated by elastic ligature, the average number of sessions was 2.6 [
Elastic ligations are recommended in case of bleeding (Grade A) [
In case of rectorrhagies without prolapse, elastic ligation should only be proposed as second-line after failure of a treatment normalizing intestinal transit which has a similar efficiency at 3 months [
In the short term, symptoms disappear or improve in 70% to 90% of cases [
In our series, the success rate was 80.7% (n = 168) which is consistent with the literature data. In the series of J. C. Bernal and Al the success rate is at 74% while it is at 99.7% in William W. H. Rudd’s series [
In the Rabat series, the long-term evolution was good in 62% of cases, with a less good evolution and appearance of external hemorrhoidal pathologies and fissures requiring only medical treatment in 19% of cases. Recurrence was noted in 19% of cases within an average of 13 months, this recurrence was controlled by another instrumental treatment technique in 65% of cases and surgery in 35% of cases (immediate in 9 patients and after failure of the 2nd attempt of the instrumental treatment at 2 patients) [
Complications are possible (1% to 5% of cases) with internal or external haemorrhoidal thrombosis, dysuria or, more rarely, acute urinary retention, major pain, or perianal abscess [
In our series, we found minimal rectorrhagies in 15.3% of patients (n = 33), and moderate pain in 9.6% of patients (n = 20); despite the frequency of these complications, they were generally benign, having responded to ambulatory symptomatic treatment.
In the Rabat University Hospital series, immediate complications were represented by pain and bleeding in 31.4% of cases [
The elastic ligation is a safe, economical and effective technique for the treatment of symptomatic internal hemorrhoids especially Grade 3, allowing good results in the short and long term. It allows a high rate of success compared to other instrumental techniques with a recurrence rate and low risk of complications.
In our series, ligation resulted in an initial success of 80.7%, with relatively low rates of minor complications (20.2%) and an acceptable recurrence rate (25%).
The authors declare no conflicts of interest regarding the publication of this paper.
Abid, H., Ousseur, G., Benjira, R., Lahlali, M., Lamine, A., Lahmidani, N., El Yousfi, M., Aqodad, N., Benajah, D., Ibrahimi, A. and El Abkari, M. (2019) The Elastic Ligation of Internal Hemorrhoids: Where Are We Now? Open Journal of Gastroenterology, 9, 28-35. https://doi.org/10.4236/ojgas.2019.91005