Treatment of Symptomatic Occult Prolapse by Rubber Band Ligation (RBL) in a Single Outpatient Centre: A Suggestion for an Alternative to Surgery

Abstract

Introduction

This study explores the efficacy of Rubber Band Ligation (RBL) as a treatment for symptomatic occult prolapse in a single outpatient center, proposing it as a viable alternative to traditional surgical methods. The research aims to assess patient outcomes, complication rates, and overall satisfaction with RBL, providing insights into its potential as a less invasive treatment option. Occult prolapse, often underdiagnosed, can significantly impact a patient's quality of life. Traditional surgical treatments, while effective, come with higher risks and longer recovery periods. This study investigates the use of RBL, a minimally invasive procedure commonly used for hemorrhoid treatment, as an alternative for addressing symptomatic occult prolapse.

Methods

A retrospective analysis was conducted on patients diagnosed with symptomatic occult prolapse at a single outpatient center. These patients underwent RBL treatment over a defined period. Data on patient demographics, symptoms, procedure details, and follow-up outcomes were collected and analyzed. The primary endpoints included symptom relief, complication rates, and patient satisfaction.

Results

The study included 186 patients with a mean age of 48.3 years. Symptom relief was achieved in about 80% of patients post-RBL, with a minor complication rate of 9%. Common complications included minor bleeding and discomfort, which were manageable with conservative measures. Results confirmed it is effective until 1 year with a low rate of complications and could be offered conservative treatment for mucosal prolapse.

Keywords

prolapse - rubber band ligation - complications - hospital stays

Introduction

Obstructed defecation is a broad term used to describe the condition of patients with defecatory dysfunction and constipation. These disorders are frequently encountered in clinical practice and affect at least 18% of the population.[1] Although patients frequently complain of constipation, symptoms such as fruitless straining and incomplete evacuation are rather subjective and unreliable. Nevertheless, an international team of experts included these symptoms in the definition of constipation. This “Rome” definition requires two or more of the following criteria: 1) straining on more than 25% of bowel movements, 2) feeling of incomplete evacuation after more than 25% of bowel movements, 3) hard stool on more than 25% of bowel movements, and 4) infrequent defecation with three or fewer bowel actions weekly.[2] Obstructed defecation syndrome (ODS) is a distressing condition which, despite its benign prognosis, can severely affect patients' quality of life (QoL)[3] Multiple functional, anatomical, and psychological factors contribute to the syndrome, and surgical treatment remain controversial because unsatisfactory outcomes are frequently reported.[2] Rectal prolapse is rare and is estimated to occur in ≈0.5% of the general population overall, although the frequency is higher in females and the elderly, and women aged ≥50 years are 6 times more likely than men to prolapse.[4]

Although it is commonly thought that rectal prolapse is a consequence of multiparity, approximately one-third of female patients with rectal prolapse are nulliparous. The peak age of incidence is the seventh decade in women. Interestingly, although fewer men have the condition, the age of incidence for these men is generally ≤40 years. A striking characteristic of younger patients, both male and female, is an increased tendency to have autism, syndromes associated with developmental delay, or psychiatric comorbidities requiring multiple medications.[5]

The diagnosis can be made either under visualization on straining, simply detecting a small piece of pink mucosa protruding through the anal verge, in case of third-degree prolapse, or using transanal ultrasound or defecography.

At transanal ultrasound with a rotating probe (either 7 or 12 MHz), the prolapse is more evident if anterior and appears as an area of mixed echogenicity inside the hypoechogenic circle of the internal sphincter and of the lower anterior rectal muscle.[6] [Fig. 1]

Fig. 1 Classification of rectal prolapse.

Mucosal prolapse and rectal prolapse are related conditions characterized by the protrusion of rectal tissues into the anal canal, yet they differ significantly in the extent and layers of tissue involved. Understanding these differences is crucial for effective diagnosis and treatment. In mucosal prolapse, only the inner lining of the rectum (rectal mucosa) protrudes into the anal canal. This condition affects only the inner layer of the rectal wall and can lead to symptoms such as discomfort, bleeding, and a feeling of incomplete evacuation. Treatment options for mucosal prolapse include conservative management strategies, such as dietary changes and fiber supplements, ambulatory treatments, and, in some cases, surgical interventions. Rectal prolapse is a more severe condition where the entire rectal wall extends through the anus, involving all layers of the rectal wall (mucosa, submucosa, and muscular layers). Patients with rectal prolapse may experience visible protrusion, fecal incontinence, and significant discomfort. A colorectal surgeon faced with a symptomatic internal prolapse must make two critical decisions: whether to operate and if surgery is needed, which procedure to perform. The choice of treatment often depends on the severity of the prolapse. For 1st and 2nd-degree prolapse rubber band ligation (RBL) can be an effective treatment option for mild to moderate cases. This minimally invasive procedure involves placing a rubber band around the base of the prolapsed tissue, causing it to necrotize and eventually fall off.

• 2nd to 3rd Degree Prolapse: More severe cases typically require surgical excision, which involves removing the prolapsed tissue and repairing the rectal wall to prevent recurrence.

Conclusion

Understanding the distinctions between mucosal prolapse and rectal prolapse is essential for selecting the appropriate treatment strategy. While conservative measures and RBL can effectively manage less severe cases, surgical intervention may be necessary for more advanced prolapse. Each treatment decision should be tailored to the individual patient's condition and symptoms, ensuring the best possible outcome.

Banding is a simple, ambulatory procedure that can be carried out when the size of the prolapse is small and of the first or second degree (i.e., if it descends below the anorectal ring at proctoscopy on straining or if it reaches the dentate line)

In the 1950s, Blaisdell[8] described a new technique for the ligation of bleeding internal hemorrhoids which can be performed in the office without the need for hospitalization. The technique of office ligation of internal hemorrhoids was later modified and simplified using rubber bands by Barron[9] in the 1960s. Since then, rubber band ligation (RBL) has been established as one of the most important, cost-effective, and commonly used treatments for first- to third-degree internal hemorrhoids. Rubber band ligation of hemorrhoids is a very effective non-surgical treatment for internal hemorrhoids. causing fibrosis, retraction, and fixation of the hemorrhoidal cushions. RBL may be complicated by pain, rectal bleeding, vasovagal symptoms (dizziness or fainting), and severe perianal sepsis on some occasions.

Degree I and II symptomatic mucosal prolapse should be treated initially with a rich-fiber diet[10] but Barron's technique is reported as effective also to treat symptomatic ods occult prolapse (I-II grade). In some cases, RBL can also be useful in reducing the size of the prolapse as a quick solution before surgical treatment.[11]

Surgical repair is the choice for III-grade rectal prolapse In this context, it would be wise to reconsider the opportunity of treatment to offer patients an effective and safe solution The frequency of unsatisfactory results following surgical intervention is reflected in the multitude of surgical options that have been proposed, including different transabdominal, transanal, transperineal, and transvaginal procedures.[3] [12] Transanal prolapse excision, either manual or stapled is indicated when the bulk of the prolapsing mucosa is likely to be a real cause of obstructed defecation. It may be followed by dehiscence and bleeding in case of circumferential excision of the prolapse. Transabdominal pexy is indicated when the prolapse is more a recto-rectal than a recto-anal intussusception. In this case, the best operation is likely to be the ventral colporectopexy, either laparoscopic or open, via a cosmetic sovrapubic Pfannestiel incision.[13] A transanal mini-invasive operation is described and consists of a combination of anterior excision and posterior pexy and ligation of the rectal internal prolapse or recto-anal intussuscepton when it is circumferential and is aimed at decreasing the risk of both dehiscence and bleeding.[14] It also may be performed when dealing with small external prolapse, 2-3 cm in size. In our retrospective study, we analyze the effectiveness, safety, quality of life, and results of RBL as an outpatient procedure in the management of symptomatic ODS I-II grade prolapse.

Rationale

The core idea was to reconsider the treatment of ODS by rectal prolapse (incomplete or complete I-II) since patients regret hospitalization for a benign disease. The aim was to verify if a conservative and effective method of treatment could be proposed. So, this is a retrospective study of 186 outpatients with rectal prolapse according graded according to Pescatori[6] and compared to the Oxford radiological rectal prolapse grading: High rectal (Grade I - level above the rectocele), low rectal (Grade II - level of the rectocele but above the anal canal), high anal (Grade III - descending to the top of the anal canal), low anal (Grade IV - descending into the anal canal), and external (Grade V - protrusion from the anal canal).[15]

These patients were diagnosed and treated with RBL from January 2020 to January 2023 (minimum follow-up 12 months). The data of all patients with mucosal occult prolapse from I and II grade and some selected III grade (I-III Oxford radiological grade) treated by rubber band ligation. Excluding from the study were III grade (IV-V Oxford radiological grades)

The study included symptoms, short-term and long-term outcomes, and complications after treatment such as pain, bleeding, and any other adverse effects. The bias of the study is the sample size, but the results were compared with the largest experience in the literature.

Statistical Analysis

Statistical analysis was performed using the SPSS 23 system (SPSS Inc., Chicago, IL, USA). Continuous data were expressed as the means ± standard deviation (SD), and categorical variables were expressed as the % changes. The Kruskal-Wallis's test was used to analyze categorical data. All results are presented as two-tailed values with statistical significance defined as p values <0.05.

Methods

This was a retrospective study that was conducted in a single outpatient center at Federico II University Hospital of Naples Italy. Due to its retrospective nature, it was exempted from ethics approval. Only patients diagnosed by proctography and proctoscopy as I to III Oxford grade were considered. All patients included were symptomatic. All underwent the same procedure. Each patient had no more than two procedures repeated. Before treatment, all patients underwent a rectosigmoidoscopy to exclude the presence of rectal lesions. Additionally, a small enema was prescribed for the evening before the procedure. Sedation was not required, although in some cases, 5-10 drops of diazepam were administered beforehand.

All treatments were performed using the LEM, a disposable hemorrhoid ligation suction and banding instrument by Sapimed-Italy. The suction instrument used was the Aspeed 3.0 by GIMA-Italy, and the latex-free bands were supplied by CS Surgical, Louisiana, USA. Patients taking ASA, clopidogrel, or non-steroidal anti-inflammatory drugs (NSAIDs) were instructed to discontinue these medications one week before and two weeks after the treatment.

During the procedure, the suction ligature device, which had a pre-mounted double row of rubber bands, was used to suction the protrusion into the device and deploy the rubber bands at the base of the tissue, 1-2 cm proximal to the dentate line. If the patient experienced pain, the band was released and repositioned more proximally. A maximum of three sites were banded per session.

Post-procedure care included advising patients to follow a fiber-rich diet, avoid straining, and take daily sitz baths. Patients were also informed about potential early and late complications. Non-opioid analgesics were administered if necessary. Complications such as anal pain, chronic ulcer, difficulty in urination, perianal sepsis, incontinence, and anal stricture were documented during follow-up visits.

A follow-up proctoscopy was performed to confirm resolution or to repeat the band application at the same or new sites if necessary. Follow-up visits were scheduled one month after the procedure, with additional outpatient controls or phone calls at six-month and one-year intervals post-banding. Patients with poor results or only slight improvement were invited to repeat the procedure.

Results

A total of 455 rubber band ligations was performed as primary treatment in 186 patients. The age ranged from 21 to 82 years old (mean 48.3 +/− SD). They were 112 (60,21%) male and 74 (39,78%) female. Based on the grade of the prolapse there were 37 (19,898%) patients with I grade symptomatic prolapse 124 II grade (66,66%) and 25 III grades (13,44%), ([Tables 1] and [2])

Table 1 Sex, distribution and grade of rectal prolapse

SEX DISTRIBUTION AND GRADE	NUMBER	%
TOTAL PATIENTS	186
MALE	112	60,21
FEMALE	74	39,78
I GRADE	37	19,89
II GRADE	124	66,66
III GRADE	25	13,44

Table 2 Rubber band ligation as first treatment: number of sites in one session

3 sites: 106 pts	318
2 sites 57 pts	114
1 site 23 pts	23
Total banding 186 pts	455

In 106 patients, three ligations were performed in one session, two ligations in 54 patients, and only one site was ligated in 23 patients, resulting in a total of 455 bandings during the first session. The major symptoms reported were bleeding in 57 patients (30.46%), anal protrusion in 41 patients (22.04%), pain in 35 patients (18.1%), and obstructed defecation/constipation in 22 patients (11.82%). Most patients had one or more of these symptoms in addition to their main complaint. Secondary symptoms included tenesmus in 73 patients (39.24%) and discharge with pruritus ani in 44 patients (23.65%) ([Table 3]).

Table 3 Major complaints in 186 patients

Major complaints and associated symptoms
Prolapse
Bleeding	57 (30,64%)
Pain	35 (18,81%)
Prolapse/Constipation
	41 (22.04%)
Associated Tenesmus	73 (39,24%)
Associated Pruritus Ani	44 (23,65%)

A note of complication was taken after one hour and ten days from treatment: these are usually classified as minor complications and are reported in the table on a total of 231 procedures including a second treatment in 45 patients.

No patients required hospitalization after the procedure. The primary complication was pain, which had a high incidence rate immediately following the procedure but showed significant improvement in the subsequent days. Patients who underwent repeated banding experienced more discomfort and pain, with 27 out of 45 reporting increased pain levels. In cases of prolapsed thrombosed hemorrhoids, the pain was severe and persistent in 22 instances. Vaso-vagal symptoms occurred immediately after the procedure, frequently among young women. Approximately 25% of cases had trouble in urination, necessitating catheterization, with a higher incidence observed in patients with prostatic hypertrophy. In our series, two episodes of priapism were recorded, both resolving in a short time. Major complications were rare, recorded in only three cases: one patient developed a perianal abscess following severe pain and fever, another had persistent severe pain requiring opioid analgesia and a third required surgical hemostasis under local anesthesia. ([Table 4])

Table 4 Complications after RBL in 231procedures

MINOR	Within 4 hrs	Within 10 days
Pain (oral analgesia)	215 (93,07%)	22 (9,52%)
Bleeding (mild)	25 (10,82%)	11 (4,76%)
Vaso-vagal symptoms	41 (17,74%)	-
Slippage	2 (0,86%)	-
Urinary difficult	34 (14,71%)	-
Need catheter	8 (3,46%)	-
Trombosed Hemorroid	-	22 (9,52%)
MAJOR
Perianal abscess, severe pain, late bleeding	-	3 ( 1,29%)

Outcomes

Six months after the procedure 145 patients were examined out of 184 (78,1%). In this second group, 105 (72,41%) had resolution with an improved condition in 28 (20,74%). 12 (8,88%) patients showed the persistence of original complaints

One year after the first treatment 121 of 135 patients were scheduled (76,56%) and 93 of them (76,85%) showed a persistent resolution, 15 a further improvement (14,85%), and 13 (12,87%) a complete failure. ([Table 5])

Table 5 Outcome after 1,6,12 months

FOLLOW-UP	1 MONTH	6 MONTHS	12 MONTHS
RESOLUTION	148 (80,4%)	105 (72,41%)	93 (76,85%)
IMPROVED	27 (14,5 %)	28 (20,74%)	15 (14,85%)
FAILURE	9 (4,89%)	12 (8,88%)	13 (12,87%)
TOTAL	184	145	121
LOST F.U.	2 (1,07%)	39 (21,9%)	34 (23,44%)

Regarding the grade of prolapse, most patients who experienced resolution had Grade II disease ([Table 6]). At the 1- and 6-month follow-ups, patients with Grade II prolapse showed a higher incidence of resolution compared to those with other grades. However, this trend was not evident after 12 months, possibly due to the number of patients lost to follow-up. Based on these results, there is no statistically significant difference in terms of resolution across the three follow-up periods, as reported in [Table 7].

Table 6 Grade of prolapse in patients with resolution

RESOLUTION	PATIENTS	%	I GRADE	II GRADE	III GRADE	P
1 MONTH	148/186		37	90	21	0.003
6 MONTHS	105/145		27	60	18	0.007
12 MONTHS	93/121	76,8	24	58	13	0.15

Table 7 Significativity of resolution at different stages of follow-up

RESOLUTION	p. value
1 month vs 6 months	0.18	n.s
1 month vs.12 months	0.96	n.s
6 months vs 12 months	0.40	n.s

The procedure was repeated in 19 patients within one month after the initial treatment, resulting in improvement in 14 cases and no change or failure in 5 cases. A second session was performed six months after the initial treatment in 16 patients, with 11 showing improvement and 5 experiencing poor results. Finally, at twelve months, 10 patients underwent retreatment, with 7 improvements and 3 failures. Ultimately, 21 out of 186 patients required surgical hemorrhoidectomy due to persistent bleeding and discomfort.

Discussion

Perineal procedures (rubber band ligation, mucosal excision) can be used for patients with full thickness prolapse who are not candidates for surgery and for those with first and second-degree mucosal prolapse.[16] In most cases the prolapse was mainly of the anterior wall. There is controversy over which treatment for prolapse of the anterior rectal wall provides the longest complete remission from symptoms. Kleinübing et al. have carried out a preliminary, single-center study into the use of multiple, longitudinally sited, rubber-band ligation. Their results indicate that this treatment could be a valuable alternative to standard care.[17] Complete and persistent remission of symptoms was reported by 14 patients (median 12 months, range 9–15 months). Of the two symptomatic patients, one was successfully treated by repeat ligation. The Authors graded pretreatment prolapse severity according to the Pescatori and Quondamcarlo scheme[5], but this failed to identify the patient with complete rectal prolapse. They recommend, therefore, that defecography should be performed before rubber-band ligation to identify patients who might benefit. Further studies with larger patient groups and longer follow-ups are now needed.

Rubber-band ligation is a safe, simple procedure, that leads to the resolution of symptoms and may prevent progression to total rectal prolapse. In Niv experience internal rectal prolapse was diagnosed in 21 patients with signs and symptoms consistent with this syndrome. They all underwent rubber-band ligation of the excess mucosa-(2.2 procedures per patient on average). Eight patients became asymptomatic and 13 significantly improved clinically. Six patients, despite the clinical improvement, had rectoscopic evidence of recurrence. No side effects or complications were noted in this case,[18]

Japanese authors introduced endoscopic band ligation as a less-invasive therapeutic option for the treatment of mucosal prolapse. The endoscopic band ligation led to scarring, which resolved the symptoms of mucosal prolapse without recurrence in 24 months of follow-up care. This may represent an exciting minimally invasive option for patients with persistent symptoms that do not yield to medical management before more-invasive surgical intervention is attempted.[19] [20]

Concerning complications, we reported 41 patients with vaso-vagal symptoms (dizziness or fainting) after RBL mainly occurring in young ladies In an Aram[21] study on 890 patients post-banding vasovagal symptoms occurred in five cases (0.6 %) that is very low incidence, but the Author doesn't report if any sedation was administered before the procedure.

Difficulty in urination was observed in 14% of cases with 8 (3,46%) patients needing a catheter just to void the bladder: in Aram[21] there were no cases of urine retention that necessitated catheterization, this result is lower than Ayman et al.[22] who found this complication in ten cases (1.33%) in their study. Dekker[23] reported a urinary retention more often after haemorrhoidectomy (2-34%) than after RBL (0-0.4%) Pain is a common complication after RBL and is present up to 50% as mild pain for the first 48 hours.[24] In a prospective study pain was the most common symptom occurring in almost 90% with the pain scores higher 4 hours following the procedure and after 1 week 75% of patients did not experience any pain at all.[25] [26] From the HubBle trial pain was lower after RBL than the HAL surgical procedure compared to after 1 day and after 1 week.[27] [28] As reported in the literature no patient with incontinence was observed.[29] In 3 studies anal incontinence was reported from 0 to 7.7% after surgical haemorrhoidectomy but this was not reported after RBL Anal stenosis is reported in one patient by Bakhtawar in 2017 out of 471 patients while reported in 26 cases after haemorrhoidectomy[30] Septic complication have been reported including pelvic sepsis, Fournier's gangrene, liver abscess, and bacterial endocarditis. The hypotheses are related to transmural necrosis that facilitates the spread of sepsis to adjacent tissues.[31] We reported only one case of a little perianal abscess drained in the outpatient room. Finally, data regarding healthcare costs from other studies is sparse. Cost analysis has been carried out in one trial comparing stapled haemorrhoidopexy with RBL, with the cost of stapled haemorrhoidopexy being substantially higher and unlikely to be considered cost-effective at 1 year. Moreover, it offers the possibility of resolution without the need for hospitalization or anesthesia and enables the patient to immediately return to his normal working activity with a limited recovery time. Awad et al.[20] reported a hospital stay of 2.5 days after prolassectomy versus 1 day after RBL. Loss of working days was reported by Murie et al.[32] favoring RBL (32 vs. 3): this difference was statistically significant. Overall postoperative complications were more frequent after surgery: pain and bleeding were evaluated in all studies with a higher incidence after surgical treatment

Thus, RBL is regarded as the most effective and safe outpatient procedure for I-III grades of symptomatic mucosal prolapse in terms of short- and long-term results and fewer complications. In our experience, RBL was applied to patients from first to third grade without affecting the possibility of surgery.

In our series 186 patients were evaluated with a minimum follow-up of 12 months. A resolution is reported in 76,8% after 12 months even if only 121 out 186 patients were re-examined: these results could be even better if the total of patients could be re-examined. The procedure was repeated in about 24% of the patients at different stages of the follow-up. There is some uncertainty if repeated banding must be considered a recurrence or part of treatment. For rebanding two or three sessions are common and patients may find this more agreeable than one operation if the results are comparable in the long period. In our experience, repeated banding was limited to two sessions: in literature, except for 2 trials that performed 1 session RBL, none out of the 8 trials reported by Dekker describes the exact number of sessions. Finally, surgical hemorrhoidectomy was offered in, 21 patients out of 186. (11%) RBL is considered the most effective conservative method such as prolassectomy for surgical procedures. Reliable outcome measurements relate to the definition of rectal prolapse. The choice of treatment is based on the Pescatori classification of prolapse, but symptoms are not reliably related to it should be more a solid definition of failure or recurrence by a validated score of symptoms.[33] The success rates of the method in the literature range between 79% and 91.8.[34] Bleeding is a significant complication of RBL, and it cannot be prevented. It is the result of the fall of the hemorrhoidal nodule and local inflammation; in our series, it is about 10% but always mild and does not require hospitalization or transfusion. One patient went to the emergency room 8 days after the procedure for three repeated episodes of bleeding and was observed for one night without any transfusion. Ayman et al.[22] in their study of 750 cases found that 31 patients (4.13 %) had bleeding which is lower than our results.

Conclusion

Surgical treatments seem to provide better symptom control but at the cost of more pain and complications. Due to the fear of surgery, many patients regret hospitalization for surgery and choose to delay treatment. Rubber band ligation (RBL) can be proposed as a successful procedure for patients with Grade I-II prolapse, requiring only a short hospital stay. It is an efficacious, cost-effective, and simple treatment and is also more effective than sclerotherapy and infrared coagulation, though it is more painful. Overall, complications occur in less than 10% of cases. The cure rate is high with low recurrence rates. Most patients with Grade I and II, as well as select patients with Grade III who fear surgery or have comorbidities and fail medical treatment, can be effectively treated with office-based procedures such as banding, sclerotherapy, and infrared coagulation but banding is typically the most effective option.[35] [36]

Conflict of Interest

None declared.

Author's Contribution

All authors contributed equally to the conception, design, execution, and interpretation of the research. They participated in writing and reviewing the manuscript, ensuring its accuracy and completeness. Each author has approved the final version of the manuscript for submission.

• References

• 1 Ellis CN, Essani R. Treatment of obstructed defecation. Clin Colon Rectal Surg 2012; 25 (01) 24-33 10.1055/s-0032-1301756
• 2 Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis 2007; 22 (03) 231-243
• 3 Drossman DA, Thompson WG, Talley NJ. et al. Identification of sub-groups of functional bowel disorders. Gastroenterol Int. 1990; 3: 159-172
• 4 Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94 (03) 207-210
• 5 Marceau C, Parc Y, Debroux E, Tiret E, Parc R. Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome. Colorectal Dis 2005; 7 (04) 360-365
• 6 Pescatori M, Quondamcarlo C. A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis 1999; 14 (4-5): 245-249 10.1007/s003840050218
• 7 Pescatori M. . The Iceberg diagram for the treatment of obstructed defecation Società Italiana di Chirurgia Colo Rettale www.siccr.org 2019 ; 50: 430–439
• 8 Blaisdell PC. Office ligation of internal hemorrhoids. Am J Surg 1958; 96 (03) 401-404
• 9 Barron J. Office ligation of internal hemorrhoids. Am J Surg 1963; 105: 563-570
• 10 Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol 2019; 17 (01) 8-15 10.1016/j.cgh.2018.03.020
• 11 Siddiqui UD, Barth BA, Banerjee S. et al; ASGE Technology Committee. Devices for the endoscopic treatment of hemorrhoids. Gastrointest Endosc 2014; 79 (01) 8-14
• 12 Picciariello A, O'Connell PR, Hahnloser D. et al. Obstructed defaecation syndrome: European consensus guidelines on the surgical management. Br J Surg 2021; 108 (10) 1149-1153
• 13 Tsunoda A. Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature. J Anus Rectum Colon 2020; 4 (03) 89-99 10.23922/jarc.2019-035
• 14 Pescatori M, Favetta U, Dedola S, Orsini S. Transanalstapled excision of rectal mucosal prolapse. Tech Coloproctol 1997; 1: 96-98 10.1093/bjs/znab123
• 15 Lindsey I. Internal rectal prolapse. In: Lindsey I, Nugent K, Dixon T. eds Pelvic Floor Disorders for the Colorectal Surgeon (Oxford, 2010; online edn, Oxford Academic, 1 May 2013). Oxford: Oxford University Press; 2010: 93-102
• 16 Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: rectal prolapse. FP Essent 2014; 419: 28-34
• 17 Kleinübing Jr H, Pinho MS, Ferreira LC. Longitudinal multiple rubber band ligation: an alternative method to treat mucosal prolapse of the anterior rectal wall. Dis Colon Rectum 2006; 49 (06) 876-878
• 18 Niv Y, Abu-Avid S, Oren M. Internal rectal prolapse: rubber-band ligation as treatment for a neglected disease. Mt Sinai J Med 1990; 57 (02) 106-108
• 19 Shiratori Y, Ikeya T, Fukuda K. Endoscopic band ligation for persistent mucosal prolapse syndrome. Gastrointest Endosc 2023; 98 (05) 870-871
• 20 Awad AE, Soliman HH, Saif SA, Darwish AM, Mosaad S, Elfert AA. A prospective randomised comparative study of endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosis. Arab J Gastroenterol 2012; 13 (02) 77-81 10.1016/j.ajg.2012.03.008
• 21 Aram FO. Rubber Band Ligation for Hemorrhoids: an Office Experience. Indian J Surg 2016; 78 (04) 271-274 10.1007/s12262-015-1353-1
• 22 El Nakeeb AM, Fikry AA, Omar WH. et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol 2008; 14 (42) 6525-6530 10.3748/wjg.14.6525
• 23 Dekker L, Han-Geurts IJM, Rørvik HD, van Dieren S, Bemelman WA. Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials. Tech Coloproctol 2021; 25 (06) 663-674 10.1007/s10151-021-02430-x
• 24 Sajid MS, Bhatti MI, Caswell J, Sains P, Baig MK. Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis. Updates Surg 2015; 67 (01) 3-9
• 25 Watson NF, Liptrott S, Maxwell-Armstrong CA. A prospective audit of early pain and patient satisfaction following out-patient band ligation of haemorrhoids. Ann R Coll Surg Engl 2006; 88 (03) 275-279
• 26 Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg 2016; 8 (09) 614-620 10.4240/wjgs.v8.i9.614
• 27 Brown SR, Tiernan JP, Watson AJM. et al; HubBLe Study team. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet 2016; 388 (10042): 356-364 10.1016/S0140-6736(16)30584-0 Erratum in: Lancet. 2016 Jul 23;388(10042):342. PMID: 27236344; PMCID: PMC4956910
• 28 Giordano P. The HubBle trial: a word of caution. Lancet 2016; 388 (10063): 2995-2996 10.1016/S0140-6736(16)32531-4
• 29 Riss S, Weiser FA, Schwameis K. et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis 2012; 27 (02) 215-220
• 30 Cheng FCY, Shum DWP, Ong GB. The treatment of second degree haemorrhoids by injection, rubber band ligation, maximal anal dilatation, and haemorrhoidectomy: a prospective clinical trial. Aust N Z J Surg 1981; 51 (05) 458-462
• 31 Bakhtawar A, Khalid MA, Arshad A. Comparison of Milligan - Morgan haemorrhoidectomy vs rubber band ligation in management of haemorrhoids. Med Forum Mon 2017; 28 (09) 83-86
• 32 Murie JA, Mackenzie I, Sim AJ. Comparison of rubber band ligation and haemorrhoidectomy for second- and third-degree haemorrhoids: a prospective clinical trial. Br J Surg 1980; 67 (11) 786-788 10.1002/bjs.1800671108
• 33 Altomare DF. ODS score and obstructed defecation. Dis Colon Rectum 2010; 53 (03) 363 , author reply 363 10.1007/DCR.0b013e3181cbf35b
• 34 Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47 (08) 1364-1370
• 35 Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL. Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2011; 54 (09) 1059-1064
• 36 Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018; 61 (03) 284-292 10.1097/DCR.0000000000001030

Publication History

Received: 05 December 2024

Accepted: 05 February 2025

Article published online:
26 March 2025