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Abstract
Background:
Patients' with haemorrhoids or piles visit surgical out-patient 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 offuture 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.
Materials & Methods: One hundredfive patients with second degree bleeding haemorrhoids
were treated either by infrared coagulation (N = 51) or rubber band ligation (N = 54). Post
procedure, parameters like pain, discomfort, relief in incidence of bleeding, time to return to
work and recurrence rate were studied and compared following each procedure.
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. 71years (range 20-71 years). Post procedure
pain in first week was more in Rubber Band Ligation group (2-5 vs 0-3 on a visual analogue
scale). In Band ligation group post-defecation pain and rectal tenesmus was more intense (P
= 0.0059). Patients in 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, Rubber Band Ligation
group had more pain and discomfort but the procedure was more effective in controlling
symptoms and obliterating hemorrhoids.
Conclusion: Rubber Band Ligation was more effective but more painful, while Infrared
coagulation was less painful but their efficacy was also lower. Therefore, It is concluded
thatlit.i;ared 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.
Key Words:
ligation
aProfessor & Head, Department of Surgery, ESI Post Graduate Institute of Medical Science and Research &
Mahatma Gandhi Memorial Hospital, Parel, Mumbai -400012 Maharashtra, India. aCorresponding author:
Email-drscpatra@gmail.com.
Mob: (+91) 9869859992
Jour, Marine Medical Society, 2014, Vol. 16, No.1
23
Introduction
Rmorrhoids
are the most common cause of
ano-rectal discomfort and / or bleeding and are
common complaints among the general population.
The old conventional methods of treatment of
haemorrhoids, includes surgical excision of
haemorrhoids
under anaesthesia,
Inj ection
sclerotherapy,cryo-therapyand 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 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 ofhaemorrhoidal 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. Despite the presence of
numerous non-surgical therapies for out-patient
treatment of haemorrhoids, none of these therapies
has clearly been proven to be superior 1. Many
outpatient methods are available to treat internal
hemorrhoids. Rubber band ligation is widely used in
the treatment of all grades of internal hemorrhoids.
Infrared coagulation uses high-intensity light to treat
grade I, grade II and some grade III internal
hemorrhoids.C) Other procedures include chemical
destructionofhaemorrhoid mass with a direct current
probe (Ultroid), or by thermal destruction with
bipolar diathermy (Bicap), cryo-ablation and infrared
coagulation (IRC)(3). Infrared.and laser coagulation
have decided advantages over the procedures, which
use high frequency electric current and other thermal
techniques. Coagulation by laser or infrared radiation
can be controlled and reproduced. This type of
coagulation is therefore advantageous whenever it is
important to produce exact depths of necrosis whilst
avoiding damage to the adjacent tissue. A distinctive
feature of Infrared Coagulation compared to the laser
is its high beam output divergence. This allows high
power density to be generated only at the focal point
24
Germany
characteristics
Infrared
Coagulation
Rubber
band ligation
No. of patients
51
54
33 (21-61)
51 (26-71)
32 :19
36:18
Duration of disease
16
15
Number of haemorrhoids
under treatment
155
136
-~
-;
The post-procedure
Table 2
Table -2
Comparison of infrared coagulation and rubber
band ligation of haemorroids
Events observed
Rubber
band
ligation,
2-5
0-3 *
8min
20 min *
Rectal tenesmus
11*
Time offwork
6*
84%
92.5 %
Recurrence of bleeding
4*
Recurrence of prolapse
Intensity of post
operative pain
Fig. 4: Internal haemorrhoids as seen during anoscopy
following Rubber Band Ligation
Infrared
coagulation,
N=51
Obliteration ofhaemorrhoids
54
25
26
Discussion
Numerous non-operative treatments have been
proposed and are being extensively used for the
management of first and second degree hemorrhoids,
but no single therapy has been shown to be
consistently better( 6). The developing trend is to
prefer an improved technique for the ablation of
hemorrhoids rather than opting for their excision.
Infrared coagulation works by penetrating the tissues
to a predetermined depth at the speed of light, being
instantly converted into heat. This coagulation method
has a number of significant advantages. The tissue
damage that does occur with IRe is very superficial
and is comparable to that which occurs with lasers.
The mechanical pressure applied by the instrument
reduces blood flow and brings the blood vessels
closer to the surface where a minimal energy dose
achieves the coagulation
effect. The depth of
coagulation can be precisely determined according
to the duration of exposure. The duration of the
radiation delivered is regulated bya timer built in the
power unit of the instrument (F ig 1) and can be preset
from 0.5 to 3 seconds. Exposure for 1 second causes
a necrosis of approximately 6 mm in diameter and 1
mm in depth at the base of haemorrhoid mass. Usually
3 to 4 applications are enough to achieve coagulation
of each hemorrhoid. It is important to point out here
that the mucosa proximal to the hemorrhoid, and not
the hemorrhoid proper, is exposed to radiation. IRe
causes immediate reduction of blood flow to the
hemorrhoids followed by tethering of the mucosa to
the underlying tissue as healing occurs in the process
by cicatrisation( 5). A significant .advantage of IRe
was that the tissues treated with the instrument did
not adhere to its tip as they do with electro
coagulation.
RBL has been considered to be an effective
treatment for symptomatic internal hemorrhoids?
Since its introduction by Barron, many new useful
modifications have been introduced in the procedure.
Suction ligation(8), synchronous ligation(9) of all the
hemorrhoids with a modified anoscope(l 0) and using
a videoscopic anoscope(ll)
has. been few of such
innovations that have helped achieve still better results.
However,
one problem that persists and
continues to bother the surgeon has been the postligation pain and discomfort associated with RBL.
With the introduction of IRe, it had been possible to
Jour. Marine Medical Society, 2014, Vol. 16, No.1
Tetanus,
Band-related abscess
Pelvic celluliti s
Rectovaginal fistula
Bacteremia
'fhrombosi:; of external
hemorrhoids
Severe hemorrhage
Anal stenosis
;.l",usea
+
+
Shaking
Rectal tenesrnus
27
Conclusion
The study shows that IRe is a safe and effective
alternative to RBL since it is quick, hassle-free and
safe. Except for the initial cost of the instrument, there
are no expenses of a recurring nature. The application
is easy and requires no special training and the
procedure-is better tolerated than band ligation. Thus,
it can be considered as a suitable alternative office
procedure for early internal hemorrhoids.
Source of support
Nil
Conflicts of interest
All authors have none to Declare.
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