**5.2 Rubber band ligation**

Rubber band ligation (RBL) is the most commonly performed office-based treatment, having the widest therapeutic range and the highest success rate. This procedure is recommended to treat almost all patients affected by symptomatic internal haemorrhoids refractory to conservative treatment, being contraindicated only in few cases:


During the procedure, patients lay on left lateral position or semi-inverted jackknife position, being the former more comfortable for the patient. The anoscope is essential to perform the procedure, consisting on the positioning of a rubber band on the base of the haemorrhoid, at least 5 mm above the dentate line. The application of the elastic band causes immediate ischemic damage and 3 to 5 days delayed necrosis, leading to a localised sub-mucosal scarring that secures the mucosal layers to the underlying tissues. Rubber band application may be performed using both

#### *Ambulatory Surgery for Perianal Disease DOI: http://dx.doi.org/10.5772/intechopen.97119*

forceps or suction devices [27, 28]. The former represents the traditional technique but requires two people to be performed: the operator and the assistance, whose role is to hold the anoscope. The latter includes both endoscopic suction devices and vacuum suction devices, which allow the operator to hold both the ligator and the anoscope, performing the procedure without any assistant.

Usually just one pile per session is treated, in order to reduce procedure-related risks. Multiple sessions should be performed in 4-week intervals, to allow a complete recovery from the previous treatment [29].

If the procedure is correctly performed, with the rubber band placed at least 5 mm above the dentate line, the patient has no pain, thus the procedure can safely be performed without any anaesthesia. Whenever the patient experiences pain, the band is wrongly placed below the dentate line, onto somatically innervated tissue, and should promptly be removed. Beside pain, that occurs in almost 8% of the procedures and is most frequently due to band misplacement [30], other extremely rare complications include [31–34]:


RBL is the most effective office-based procedures, improving symptoms in 93–100% of patients having grade II haemorrhoids and 78–84% of those having grade III haemorrhoids and reducing bleeding in up to 90% of patients [30, 35]. When compared to haemorrhoid artery ligation (HAL), it shows lower rates of bleeding, intra- and post-procedural pain, but higher risk of recurrences. The same has to be said comparing RBL to surgery: the former has a reduced complication risk compared to surgery, while the latter has lower recurrence rates [36].

#### **5.3 Sclerotherapy**

Sclerotherapy is the second most frequently performed outpatient procedure for haemorrhoidal disease. Since bleeding and infection risk is lower than after rubber band ligation, this procedure finds application whenever RBL cannot be performed, thus it is recommended for patients on anticoagulant therapy or coagulation disorders and in case of immunodeficiency or other pathological conditions increasing infective risks [35].

As for RBL, the procedure is performed through an anoscope, with the patient laying on left lateral position. Sclerosing solutions are injected into the submucosa plane above the dentate line, so that the treatment does not require any anaesthesia, and determine an intense inflammatory reaction that leads to scarring and adhesion of haemorrhoids to the underlying tissue just like after ligation with elastic bands.

The most frequently used solutions are aluminium potassium sulphate and tannic acid (ALTA, which seems to be the most effective) [37–39], 5% phenol in vegetable oil and 50% dextrose water.

Complications following sclerotherapy are even rarer than after RBL, considering patients major complain is painful intra-procedural injection, reported in almost 90% of cases, while post-procedural pain is experienced only by 25–50% of patients. Bleeding is uncommon and in the majority of cases is a self-limited condition following injection. The most frequent post-operative complication is mucosal necrosis, which is reported in less than 4% of patients and is usually caused by too superficial injections (not reaching the submucosal layer). Rare but major complications include impotence, fatal necrotising fasciitis, rectourethral fistulas, and rectal perforations, that are mostly ascribed to misplaced injections –both in non haemorrhoidal tissue or in the vascular system [40].

Sclerotherapy successfully manage haemorrhoidal bleeding, leading to an improvement in 100% of patients with second and third degree haemorrhoids [35, 39]. Moreover it leads to a complete resolution of symptoms in 88% of I degree haemorrhoids and 52% III degree haemorrhoids. However, even if much safer than RBL and despite its high success rate, recurrences are more frequent in patients undergoing sclerotherapy than ligation with elastic bands, thus the latter resulting as the preferred choice for both surgeons and patients whenever not contraindicated [41].

### **5.4 Infrared coagulation**

Infrared coagulation (IC) is an outpatient procedure indicated for the treatment of refractory to conservative treatment grade I, II and III haemorrhoidal disease [12, 14]. In literature, data regarding IC treatment are extremely variable, ranging from studies showing similar results as for sclerotherapy, to papers underlying higher recurrence rates with fewer post-procedural complications and less intraprocedural discomfort. Thus, whether to use infrared coagulation or sclerotherapy depends on availability of procedures and surgeon preferences.

Infrared coagulation is also performed through an anoscope, with the patient laying in the same position as for the previous procedures. It consists of infrared light waves application on the haemorrhoidal tissue above the dentate line, which are converted into heat determining an immediate protein coagulation and necrosis, visible as 3 mm wide and 3 mm deep white spot on the mucosa. The treatment of each haemorrhoid cushion may require from three to five applications. As for the other office-based procedures, IC causes a scar fixating the redundant haemorrhoidal mucosa to the underlying tissues.

Complications following infrared coagulation include pain, which is the most frequent occurring in 16–100% of patients and bleeding, which ranges from 15 to 45% of cases [42, 43]. Moreover, many studies report high frequency of persistency and recurrence after the treatment: recurrence rate is estimated to be about 15% at three months.

Success rates reported by a recent meta-analysis widely range from 22 to 51 and 78%, when considering respectively grade III, II and I haemorrhoidal disease [35, 43].

#### **5.5 Excision and incision of thrombosed external haemorrhoids**

Haemorrhoidal excision is a procedure that can be performed both in an officebased setting and in the operating theatre. It is the only office-based procedure

#### *Ambulatory Surgery for Perianal Disease DOI: http://dx.doi.org/10.5772/intechopen.97119*

suitable for the treatment of external haemorrhoids, which are localised below the dentate line, have somatic innervation and thus are more sensitive to pain, making surgery performed in the operating theatre the best therapeutic option.

Thrombosed external haemorrhoids belong to the so called anorectal emergencies. They occur with an acutely painful purplish or blue mass in the perianal area that gradually reduces after the first couple of days; bleeding may present in case the high pressure within the thrombus causes overlying skin erosion. It is important to differentiate this pathologic condition from complicated internal haemorrhoids and anal pigmented melanoma, whose onset in similar being characterised by perianal pain. External haemorrhoids are covered with anoderm and usually suddenly appear, while internal haemorrhoids are covered with mucosa and anal pigmented melanoma has a long story of pigmented skin lesion [44].

Excision of the thrombosed external haemorrhoids is indicated for patients experiencing persistent pain from 72 hours or less, providing immediate relief [45]. After 48 to 72 hours, the thrombus organises and contracts, diminishing symptoms so that a conservative management can be proposed, obviating the need for surgical management. Surgical treatment for thrombosed external haemorrhoids may be required also in case of residual skin tags resulting from the healing process of a small ulcer following a spontaneous evacuation of a thrombosed haemorrhoid. However, residual skin tags rarely cause enough symptoms to warrant its removal; only in case of large skin tags determining skin irritation, itching, pain, or inability to keep proper hygiene, excision can be beneficial.

The office-based procedure to treat thrombosed external haemorrhoids include excision and incision. The former can be performed in the operating room as well as in an appropriately equipped office. After the administration of both local anaesthesia and anal block, the excision of a thrombosed haemorrhoid is performed by making an elliptical incision in the overlying skin. A careful dissection of the haemorrhoid from the superficial fibres of the anal sphincter is carried out, trying to avoid injury. Thereafter skin edges can be left open allowing drainage or reapproximated with absorbable sutures [46]. Topical antibiotic ointments are not routinely applied as infections are rare in this wellvascularized sites.

Inexperienced physicians, unable to perform haemorrhoids excision, can manage this anorectal emergency with a simple incision of the overlying skin, allowing evacuation of thrombus, thus producing immediate relief of pain.

However, incision and evacuation of the clot is associated with a 30% risk of reaccumulation and thrombosis, which may disseminate to adjacent hemorrhoidal columns [47], thus this technique is not recommended and whenever performed requires a follow-up within the next 24 to 48 hours for surgical evaluation. On the contrary, recurrence rate for a completely excised thrombosed hemorrhoid is lower (5–19%) [48, 49].

If surgery is not feasible, conservative management would be offered including anti-inflammatory analgesics, warm sitz bath, reducing activity and avoiding constipation. Education and reassurance about this condition and its benign nature would be beneficial to the patient.
