Comparison of Infrared Coagulation and Rubber Band Ligation

Two Simple and Cost Effective Office Procedures for Internal Haemorrhoids

Abstract
Background: Patients with haemorrhoids or piles visit surgical outpatient departments frequently and are offered various methods of treatment, including some day care surgery. Infrared coagulation and rubber band ligation are considered as two common office procedures for haemorroids. Patients, in general, are concerned about the effectiveness, post-procedure pain and the possibility of future recurrence of a particular procedure and insist on a non-ambiguous reply from the treating surgeon. The surgeon has the moral responsibility to explain to the patient regarding the comfort and efficacy of a particular procedure. In the present study, a comparison has been made between infrared coagulation and rubber band ligation, giving greater emphasis on post-procedure discomfort and effectiveness.
Methods: One hundred five patients with second degree bleeding haemorrhoids were treated either by infrared coagulation (N = 51) or rubber band ligation (N = 54). After the procedures, parameters like pain, discomfort, relief in incidence of bleeding, time to return to work and recurrence rate were studied and compared.
Result: The mean duration of disease was 16.5 months (range: 12 to 32 months). There were 68 males and 37 females. The mean age was 42.71 years (range: 20-71 years). Post-procedure pain in the first week was greater in the rubber band ligation group (2-5 vs 0-3 on a visual analogue scale). In the rubber band ligation group, post-defecation pain and rectal tenesmus was more intense (P = 0.0059). Patients in the infrared coagulation group had a higher recurrence rate (P = 0.03) but resumed their duties earlier (2 vs 4 days, P = 0.03). Post procedure, the rubber band ligation group had more pain and discomfort, but the procedure was more effective in controlling symptoms and obliterating hemorrhoids. It was seen that rubber band ligation was more effective but more painful, while infrared coagulation was less painful, but efficacy was also lower. Therefore, it is concluded that infrared coagulation could be considered a suitable alternative office procedure for early stage haemorrhoids as this office procedure can be conveniently repeated in case of recurrence.
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Introduction

Hemorrhoids are the most common cause of ano-rectal discomfort and/or bleeding, and they are common complaints among the general population. The old conventional methods of treatment of haemorrhoids include surgical excision of haemorrhoids under anaesthesia, injection sclerotherapy, cryo-therapy and rubber band ligation. The newer modalities of treatment are laser therapy and infrared coagulation. As per the Thomson’s theory that haemorrhoids are an enlargement and displacement of the normal anal cushions, which are an important part of the continence mechanism, it is logical that we should seek methods which will return these anal cushions to their normal size and position, rather than destroying them by cryo-therapy or excision.

Treatment methods need in some way to reduce the vascularity of haemorrhoidal cushion and to tether the sliding mucosa to the underlying tissues, together with (in the case of large prolaping haemmorrhoids) removing excessively lax mucosa. Injection sclerotherapy, rubber band ligation and infrared coagulation all achieve the first two aims, but only rubber band ligation actually reduces the amount of lax mucosa.

Poen AC et al. has observed that, despite numerous non-surgical therapies being available for out-patient treatment of haemorrhoids, none of them has been proven to be superior.1 Pfenninger JL et al. has mentioned that rubber band ligation has been widely used in treatment of all grades of internal hemorrhoids.2 Pfenninger JL et al. has also observed that in infrared coagulation, high-intensity light is utilized to treat grade I, grade II and some grade III internal hemorrhoids.2 Arullani A et al. in an article has mentioned that other procedures include chemical destruction of a haemorrhoid mass with a direct current probe (Ultroid), or by thermal destruction using bipolar diathermy (Bicap), cryo-ablation and infrared coagulation (IRC).3

Day care surgery procedures like infrared and laser coagulation have notable advantages over other electric and thermal procedures, as coagulation by infrared radiation or laser therapy can be controlled and reproduced. This type of coagulation produces exact depths of necrosis and avoids adjacent tissue damage. Infrared coagulation has a high beam-output divergence, unlike lasers, which allows the use of a focusing mirror assembly to produce high power density only at the focal point. The search for a procedure that is easy to learn, is cost effective, gives satisfactory results and lacks complications has been the prime objective in managing the problems of haemorrhoids. Nath G4 has introduced infrared photo coagulation, a technique which satisfies these requirements. Tajana A et al. has observed that in infrared photo coagulation, the tissue is coagulated by using mechanical pressure with the instrument.5

The aim of this study was to evaluate the post-procedure discomfort, pain, rectal tenesmus, infection, sepsis, time taken to resume routine work and overall effectiveness following out-patient treatment of internal haemorrhoids by IRC, and to compare the results with rubber band ligation (RBL).

Materials and Methods

In this study, 105 patients with early degree bleeding internal haemorrhoids were assigned randomly to IRC or RBL treatment and identified by number. The study was approved by the hospital’s ethics committee and included all patients with early-stage haemorrhoids. Patients with associated infective anal pathologies like cryptitis or proctitis, anal fissures and anal spasm were excluded from the study. Only 5% xylocaine jelly was applied to the anorectal region 10 minutes before the procedure. IRC was performed in the lithotomy position. The left lateral position was used when the lithotomy position was not possible. Haemorrhoid bases were coagulated one by one. The mean treatment duration was 3 minutes, with a range of 2 to 5 minutes.

tungsten-halogen lamp

Fig.1: The source of Infrared Energy is from Tungsten-Halogen Lamp (15 Volts) in the Hand Applicator

IRC was applied to the base of all three principal positions of hemorrhoids using a 220-mm light guide with tip diameter of 6 mm (Fig. 2).

lumatec-infrared coagulator

Fig. 2 : Testing the Lumatec-Infrared Coagulator prior to Infrared coagulation of hemorrhoids (Demonstration)

RBL was performed after drawing in the haemorrhoidal mass into the rubber band ligator and placing the rubber band over the pedicle of the haemorrhoid. (Fig.3 & Fig 4)

internal haemorrhoid

Fig. 3 : Internal haemorrhoid as seen during anoscopy with Heine E-19400 Anal Speculum after Rubber Band Ligation

internal haemorrhoid - rubber band ligation

Fig. 4: Internal haemorrhoids as seen during anoscopy following Rubber Band Ligation

After the procedures, patients were observed for 1 hour and then sent home on the same day. Laxative and 5% xylocaine ointment was advised for local application to relieve the post-defecation discomfort. Analgesics were not prescribed to either group of patients. The patients were cautioned not to strain at stool. Pain was assessed using a visual analogue scale from 0 (no pain at all) to 10 (the worst pain the patient had ever experienced). The level of significance was set at P < 0.05.

Results

There were 51 patients treated with IRC and 54 treated with RBL. We followed up with them for a period of 12 months. Post-procedure analysis found that there were no significant demographic differences between the two groups (Table 1 & Fig. 5).

age profile of patients

Fig. 5: Age profile of patients

Patient demographic data

Table 1: Patient demographic data

The post-procedure results were as described in Table 2.

Comparison between infrared coagulation-rubber band ligation

Table 2: Comparison between infrared coagulation and rubber band ligation of haemorroids

Notes:
# Measured on a visual analogue scale
*P < 0.05 compared to Infrared coagulation unpaired student t-test

In the first week, the postoperative pain intensity and duration were greater in the RBL group than in the IRC group (2-5 vs 0-3 on a visual analogue scale). In the IRC group, the duration of post-defecation pain over the first 7 days was significantly shorter (8 min) than it was in the RBL group (20 min). Post procedure follow-up showed no difference thereafter, with negligible pain in both groups beyond 10 days. After one week, rectal tenesmus was observed in 11 patients from the RBL group and in 3 patients in the IRC group. The total amount of time taken to return to the typical activities of domestic and social life was included in the time off work. IRC group patients were able to return to their routine activities earlier than the RBL group.

No sepsis in the form of local infection or systemic manifestation was observed in either group. Three patients from the RBL group complained of severe pain and returned within one day of the procedure. The bands were removed in these patients. One patient had urine retention from the RBL group. He was catheterized and did not have a similar complaint afterwards. Bleeding per rectum occurred in 7 patients from the IRC group. The bleeding was nearly always associated with defecation. Bleeding was attributed to sloughing of the tissue at the base of the hemorrhoids, due to oozing from the raw area. Four patients from the RBL group reported bleeding between days 7 and 9, most likely due to detachment of the pile mass from the pedicle.

Six patients were lost to the follow-up at one year. In the follow-up examinations of the remaining patients, 7 patients in the IRC group had bleeding recur, and only 1 patient had a recurrence of prolapse of haemorrhoid. Four patients had recurrence of bleeding in the RBL group, and no patient had any prolapse. At the end of one year, the obliteration of the treated hemorrhoids, confirmed by anoscopy, was 84% in the IRC group and 92.5% in the RBL group.

Discussion

Konings M et al. has observed that although there are numerous non-operative treatments for the management of first and second degree hemorrhoids, no single therapy has proven to be superior.6 Infrared coagulation works at the speed of light, penetrating into tissues at a specific depth, and being converted into heat instantaneously. There is very little tissue damage with IRC, and what little there is, it is very superficial and can be compared to the damage caused by lasers. Blood flow is reduced by the mechanical pressure applied by the instrument, so the blood vessels are brought closer to the surface, where a minimal amount of energy achieves coagulation. The depth of coagulation can be precisely determined according to the duration of exposure. The timer in the power unit of the instrument (Fig 1) can be preset from 0.5 to 3 seconds and regulates the duration of the radiation delivered. Exposure for 1 second causes a necrosis of about 6 mm in diameter and 1 mm in depth at the base of the haemorrhoid mass. For each hemorrhoid, usually 3 to 4 applications are enough to achieve coagulation.

The mucosa proximal to the hemorrhoid, and not the hemorrhoid proper, is exposed to radiation. Application of infrared coagulation causes an immediate decrease of blood flow to the hemorrhoids, which is followed by tethering of the mucosa to the underlying tissue, and subsequently healing occurs by cicatrisation. The tip of the IRC instrument does not adhere to treated tissue as the electro coagulation tips do.

Templeton JL et al. has observed that RBL is considered an effective treatment for symptomatic internal hemorrhoids,7 and there have been many useful modifications since its introduction, including suction ligation,8 synchronous ligation9 of all the hemorrhoids with a modified anoscope10 and using a videoscopic anoscope.11

Post-ligation pain and discomfort associated with RBL continues to be a concern for the patient. Poen AC et al. has suggested that with IRC, the concern can be eliminated with results that are nearly as good as with RBL.12 Vrzgula A, et al. and Johanson JF et al. have observed that RBL has a much higher incidence of post-treatment pain reported.13,14 Although RBL demonstrated a greater long-term efficacy, IRC has been reported to be a painless procedure.15 Bat L et al. has opined that application of a rubber band needs expertise in order to place the band correctly, to avoid pile strangulation, necrosis, or sepsis.16 Hooker GD, et al. has suggested that local anesthetics injected into the post-banded haemorrhoid mass may relieve the post-procedure pain,17 which suggests that the high pain intensity described in literature is accurate. Post-ligation pain usually includes mild anal discomfort,11 rectal tenesmus,18 painful priapism,16 urinary hesitancy,19 and anal urgency.6 The pain can be bad enough to cause fainting and vasovagal attacks.20 While rubber band ligation may have a significant number of inflammatory complications, the same has not been reported with IRC. RBL has also had reports of life-threatening complications such as tetanus, band-related abscess21,22 pelvic cellulitis,23 recto-vaginal fistula, and bacteremia16 (Table 3).

Complications following Rubber Band Ligation

Table 3: Complications following Rubber Band Ligation (RBL)

Quevedo-Bonilla G et al. has observed that a combination of pain, fever and urine retention occurs in septic complications.23 IRC is virtually safe and does not have such complications.24 Komborozos VA et al. has suggested that IRC is well-tolerated by younger patients with a hyperactive anal sphincter, who would often endure considerable pain after RBL therapy.25 RBL has also had reports of thrombosis of external hemorrhoids, chronic longitudinal ulcer,26 severe hemorrhage and anal stenosis,8 and pain following an RBL procedure happens more often than previously recognized.

The difference in the depth of tissue destruction between RBL and IRC is the most likely cause for the differences in long-term effectiveness and the post-treatment pain. The rubber bands cause necrosis in hemorrhoidal tissue, and the sloughing that happens about a week later can cause tissue destruction with scarring, followed by fixation of the sub mucosa. But in IRC, the small burn will only damage tissue about 2-3 mm deep. Post-treatment pain is similarly less in IRC, possibly due to the depth of tissue injury.

The results of the present study show that RBL is more effective in the management of early hemorrhoids, since few patients need additional therapy for recurrence of symptoms. Serventi A et al. has observed that, conservative office techniques, especially RBL, can be important in second degree haemorrhoidal disease, in first degree haemorrhoids that are non-responsive to medical treatment and in third degree haemorrhoids in elderly patients with comorbidity or with sectorial or moderate prolapse.27

As per Vrzgula A, et al., if the risks of complications overshadow the benefits, the “most effective” therapy might not be the best option.13 The apparent therapeutic advantage of RBL should be reviewed against the rate and severity of its complications.28

Marques CF et al. has observed that both RBL and IRC were highly efficacious methods for treatment of internal haemorrhoids, and both procedures usually had fairly minor complications. There was more pain associated with RBL after the procedure than with IRC, especially within the first 24 hours.29

Ricci MP et al. has observed that RBL was associated with more pain than IRC in the first week, and the rates of success were not different four weeks after treatment.30 It has been observed that IRC can be nearly as effective as RBL, except since there is less pain, it is preferred by patients. Being that all therapies intend to give the best relief and satisfaction to patients, IRC is likely to overtake traditional procedures such as RBL.

Conclusion

The present study shows IRC to be a safe and effective choice, compared to RBL, since it is fast, hassle-free and safe. There is no special training necessary, and patients are better able to tolerate the procedure, as compared to RBL. After the fixed cost of the instrument, there are no recurring costs. Considering the benefits, IRC can be considered a good alternative for early internal hemorrhoid treatment in an office setting.

Surath Chandra Patra Dr. Surath C. Patra MBBS, MS, FMAS, Dip. STRT (DIMO, USA), (Former Surgeon Captain, Indian Navy) currently is the Professor & Head of the Department of Surgery at ESI PGIMSR MGM Hospital,Parel, Mumbai.

References (click to show/hide)

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