Elastic ligation and sclerosis of hemorrhoids

Elastic ligation of hemorrhoids: why operate if it can be avoided?

The outpatient treatment of internal hemorrhoids includes two distinct techniques that I associate in my operative protocol: the elastic ligation and the sclerosis.

GRADES are a simple (though not the only) conventional system of classifying hemorrhoids:
1st degree: small hemorrhoids, which never prolapse (= protrude);
2nd degree: hemorrhoids that prolapse but shrink spontaneously;
3rd degree: hemorrhoids that prolapse, and that the patient must reduce manually (= that do not fall back on their own)
4th grade: hemorrhoids that cannot be reduced.

Many authors place indication to the elastic ligation only up to grade IIelastic ligation of hemorrhoids hemorrhoidal; in fact, experience has taught us that. Grade III hemorrhoids can also be conveniently treated with elastic ligation, thus avoiding the operating table. This is particularly attractive for elderly patients, often with multiple pathologies, for whom the indication for surgery, taking into account the anesthesiological risk, must be placed with caution.

Elastic binding: my protocol

Our protocol has been standardized for many years: 6 sessions of elastic ligation, spaced 15 days apart, and two final sessions of hemorrhoid sclerosis, also at 15-day intervals.
safety of such a designed protocol is extremely high. The Sacred Books claim that it is possible to ligate up to three hemorrhoid pads at a time; in reality what is achieved with elastic ligation is ISCHEMIA and subsequent detachment of the bound area, with formation of a scar that anchors the mucosa of the rectum to the underlying muscular planes. Increasing the ischemic area increases the risk of perforation of the rectum (a dreaded event that can result in severe perirectal soft tissue infection and, nri extreme cases, lead to death), so NEVER ligate more than one hemorrhoidal pad at a time! In addition, I have seen severe hemorrhoidal prolapses, with urgent surgical indication, caused by incorrect execution of the technique of elastic ligation in patients to whom three or more hemorrhoids had been ligated at once. Prudence first, that is the secret of effective treatment!

Elastic binding: quick, painless, effective!

The elastic ligation, if done well, is VERY QUICK AND PRACTICALLY PAINLESS: what the patient may feel immediately is a kind of discomfort, as of urge to defecate without being able to do so. This discomfort, which can be greatly reduced by simply taking some metamizole, paracetamol, or at any rate an analgesic half an hour before the session, is transient and almost always disappears within a few hours; a few days after the elastic ligation, the strangulated gavage falls off and is eliminated with the feces, usually without the patient noticing anything (occasionally, a few drops of blood may be noted).

The 6 cycles of elastic ligation, as mentioned, are followed by two sessions of sclerosis in our protocol. The hemorrhoidal sclerosis involves injecting the mucosa of the hemorrhoidal area with kinurea, the only drug authorized by the European Pharmacopoeia for this procedure. Similar to the sclerosis of leg capillaries, kinurea causes an inflammatory reaction that has two results: that of further reducing any residual hemorrhoidal mass and, more importantly, that of "gluing" the mucosa of the hemorrhoidal area to the underlying layers of the rectum wall, thus preventing new prolapses.

After the treatment is finished, our protocol is to check the patient once a year.

To learn more, here is our brochure on the treatment of hemorrhoidal pathology by elastic ligation.

Dr. Salvatore Cuccomarino
Cuccomarino, MD
Corso Galileo Ferraris 3
Phone 0110438161