Elastic band ligation (banding) for hemorrhoids

Hemorrhoids are normal structures.  Everyone has them, they are just lips at
the other end.  As such, they usually do not cause problems.  It is important
to understand this because many patients who think they are suffering from
hemorrhoids are actually suffering from one of the other types of anal conditions
such as a fissure, perianal hematoma, anal canal dermatitis, skin tags, abscess, etc.  It
is important that an accurate diagnosis is made.  At least 50% of patients referred to
the Pezim Clinic with ‘hemorrhoids’ are misdiagnosed.

The problems that hemorrhoids do cause are either bleeding or prolapsing (sticking
out).  Hemorrhoids rarely cause pain, except in the unusual case in which they clot
off. Pain of a clotted (thrombosed) hemorrhoid is severe, constant for several days,
and accompanied by a noticeable mass at the anus.  Patients who have ‘hemorrhoid
attacks’ of pain lasting for a day or so, or pain with bowel movements or after bowel
movements are not suffering from hemorrhoids at all, and should not be treated for
hemorrhoids.
 And so patients who have severe anal pain should almost never be
banded.  At the Pezim Clinic we consider anal pain a contraindication to banding,
and never band a patient who ‘may also be having pain from a fissure’.  We deal
with one thing at a time.  If the patient is having pain from a fissure, we deal with
that first.  Almost always, if the patient’s fissure is dealt with successfully, the
hemorrhoids prove to be no real problem after all.

Elastic band ligation is a worthwhile procedure for hemorrhoids that are prolapsing.
It involves placing a tiny rubber band over redundant tissue at the upper anal canal,
incorporating some or all of the prolapsing hemorrhoidal tissue.  One has to be
careful to get the band just in the right spot, high enough into the low sensation
tissue to minimize pain, but low enough onto the hemorrhoids to deal with the
problem.  The band is tight enough to occlude the blood supply to that small amount
of tissue that it has encircled and so that tissue sloughs off with the band in 2 to
3 days.  It is like an operation in slow motion.  By taking a few say to cut through,
the underlying vessels have time to clot and so when the band cuts through, there
should be minimal bleeding.

Not everyone with prolapsing hemorrhoids is suitable for banding.  Sometimes
there is so much prolapsing tissue that you just know you will be banding them
forever and their will never be any good.  Such patients should have a formal
operative hemorrhoidectomy under general anesthetic.  Alternatively, sometimes
there is not enough suitable tissue to band and so the procedure should not be
done as it likely will not make any difference but will only expose the patient to
complications.  In patients with a suitable amount of hemorrhoidal tissue, that fits
with their symptoms of prolapse, rubber banding has a good chance of making a
difference.

Unlike at other clinics, at the Pezim Clinic, the rubber band is placed under careful
direct vision so the accuracy of banding is maximized.  Only one band is placed
at any time, and a 6-week period is given in order for the area to heal before
considering any further banding.  Each and every band must make sense for that
individual, and be meticulously placed.  In our experience, if a total of two or three
bands had not made a significant difference to the problem, then banding is not
going to be the solution.  We have seen patients who have had over 50 bands
placed and are still no better!  Patients should be very wary of any physician who
recommends more than 3 or 4 bands in total within a couple of years.

Banding takes only a few minutes to do in those in whom the Pezim Clinic surgeon
feels it will help.  The most common troubles after the procedure are pain and
bleeding.  Most patients will experience some pain for 2 to 5 days after having a
banding.  It is difficult to predict how significant the pain will be.  Some patients
don’t have much trouble with it and carry on with their regular activities, while
others have to take a few days off work.  We advise patients that if they are to have
a banding, they should make sure that their schedule for the ensuing 3 to 5 days
is flexible so that they can take time off if they need to, are not planning to travel,
hosting their daughter’s wedding, etc.  We recommend patients take extra strength
Tylenol regularly for a couple of days after a banding to keep ahead of discomfort.
We advise that they do not take Aspirin or Advil (or any ibuprofen) as that will
increase their risk of bleeding when the band cuts through.  Exercise should be kept
to a minimum for 5 days or so to further minimize possible bleeding.

Bleeding is a known compilation of elastic banding for hemorrhoids.  It is usually
mild, occurring on the 3 or 4th day.  But, in about 1 in 500 cases, it can be severe
enough to warrant a trip to the hospital emergency room.  Very rarely (1 in 1500
cases), a patient may need to be dealt with in the operating room if bleeding is
excessive.

Even if a patient has prolapsing hemorrhoids that look like they would benefit from
banding, the procedure is not for everyone.  Patients who are on blood thinners
or who are elderly and frail are not suitable for this procedure.  Suitability is
determined on a case-by-case basis by the Pezim Clinic surgeon.

A special note on banding for rectal bleeding:
Elastic banding can be very useful for hemorrhoids that are bleeding.  Basically, it
cuts them off and that can be effective in stopping bleeding.  But not all hemorrhoids
that bleed are large enough to be banded easily, and not all bleeding from the anal
canal is due to hemorrhoids.  In such cases, infrared photocoagulation may be a
preferable treatment (see ‘Infrared photocoagulation treatment for hemorrhoids’).

It is also very important to note that many patients who present with rectal bleeding
need to be assessed for other possible causes of bleeding.  As we have noted
above, all patients have hemorrhoids, so the presence of hemorrhoids (even if they
look like they could be responsible for bleeding) is not a good enough reason to
ignore the possibility that the blood may have come from a higher-up much more
significant source such as a polyp or a cancer.  The history of medicine is replete
with stories of patients who were treated for ‘bleeding hemorrhoids’ for months
or years and only later to be found to have been bleeding from an undiagnosed
cancer.  Many patients with rectal bleeding should have a flexible sigmoidoscopy or
colonoscopy before accepting that their problem is due to hemorrhoids.  Patients
should be wary about receiving rubber band ligation treatment for hemorrhoids
without at least a good discussion about whether higher evaluation of the bowel
should be performed and if not, why not.

© Pezim Clinic, Vancouver, British Columbia, Canada