Dott. Nando Gallese

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Legatura elastica delle emorroidi

Informazioni ai pazienti

La legatura elastica è la tecnica chirurgica meno invasiva per il trattamento della malattia emorroidaria.

Da molti anni rappresenta il “gold-standard” negli USA, per l ’ ottimo rapporto tra efficacia (benefici ottenuti) e la bassissima percentuale di rischio (rare e modeste complicanze).

Viene eseguita ambulatorialmente, è indolore e, pertanto, non richiede nessuna anestesia.

Immediatamente dopo l’intervento il paziente è in grado di riprendere le normali attività

Il dolore postoperatorio, nei rari casi in cui si presenta, è facilmente controllabile con comuni farmaci analgesici

Piccole (e rare) complicazioni, facilmente risolvibili, possono essere rappresentate da modeste perdite di sangue (nelle prime settimane) che non richiedono nessun altro intervento, ma si arrestano spontaneamente.

Ancora più raro è il caso della formazione di piccoli, fastidiosi coaguli (trombi) nelle vene del margine anale: la risoluzione è spontanea in pochi giorni

Immediatamente dopo la legatura il “fastidietto” più frequente, ma completamente sopportabile e transitorio, è la cosiddetta “urgency” (= urgenza defecatoria o tenesmo), cioè uno stimolo ad andare di corpo, più o meno intenso, più o meno prolungato (da poche ore a qualche giorno): il paziente ha l’impressione di dover evacuare, ma, in effetti, si tratta solo di un aumento della sensibilità dei recettori nervosi del canale ano-rettale, stimolata dalla presenza degli elastici applicati

La legatura viene effettuata con strumenti disposable (“usa e getta”), generalmente mediante “aspirazione” dei tessuti muco-emorridari, sui quali vengono posti piccolissimi elastici.

Nel giro di 1 o 2 settimane i noduli legati vanno in necrosi ischemica e cadono insieme agli elastici, generalmente senza manifestazioni particolari, tranne, in rari casi, una piccola e temporanea emorragia. Solo in rarissime occasioni, in pazienti particolari (in terapia anticoagulante, dializzati, portatori di alterazioni coagulative, ecc.), è richiesto un controllo chirurgico emostatico.

La legatura elastica è un metodo che non prevede un trattamento “massivo”, ma richiede, opportunamente, sedute ripetute (così come un trattamento dal dentista).

Generalmente si ottengono discreti risultati dopo 2-3 sedute

La legatura elastica non preclude, ne prima, ne dopo, qualsiasi altra tecnica diagnostica (es.: Colonscopia, Defecografia, ecc.) o terapeutica (qualsiasi intervento maggiormente invasivo)

La legatura elastica costituisce un utile complemento degli interventi maggiori (Emorroidectomia, HAL-Mucopessia, prolassectomia di Longo, STARR o Transtar, ecc) con cui si integra, potendo precederli come “tentativo mininvasivo” o seguirli come “rifinitura”

Modern hemorrhoids treatment: Rubber Band Ligation

The use of rubber bands in the therapy of hemorrhoids is currently the most widely accepted form of treatment for this ailment, due to its low cost, practicality and effectiveness. In this form of treatment, which is performed on an outpatient basis here in our office, and which does not require anesthesia.

With this procedure only a minor discomfort is felt by the patient in the form of a mild pinching sensation during the application of the bands, which is well tolerated by just about all patients.

Rubber band ligation is the most widely used technique for treatment of symptomatic internal hemorrhoids that are refractory to conservative treatment. This procedure has been available since the early 1960s and is effective, inexpensive, requires no anesthesia, is easy to perform, and only rarely causes serious complications. The technique may be used for first, second, and selected third-fourth degree hemorrhoids. Successful ligation results in necrosis of the hemorrhoid, and the development of localized submucosal scarring.

History

The principle behind rubber band ligation technique is actually an ancient one – in 460 BC, Hippocrates wrote about a surgical procedure of ligating or tying a thread around the hemorrhoids to cause them to shrivel.

In the nineteenth century, rubber band ligation experienced increased popularity. However, at the time, this technique involved painfully tying off the hemorrhoids with the surrounding sensitive tissue and skin, and soon it fell into disuse.

In 1958, Blaisdell suggested that only the hemorrhoidal tissue be ligated, resulting in a less painful procedure. Today’s modern technique of rubber band ligation was pioneered by Barron in 1963, who used a special instrument to apply the bands with great precision. In his honor, this technique and instrument are called Barron’s Ligature method and the Barron ligator, respectively.

How It Works

Rubber band ligation works by using a constricting band to stop the blood flow into the hemorrhoids, thus causing them to shrivel and fall off along with the band. This usually happens within 7 to 10 days. Recently ligated hemorrhoid in which the strangling effect of the rubber bands which eventually leads to necrosis (drying out) of the hemorrhoid is observed. This effect is similar to the drying out of the ligated umbilical chord in the newborn.

This technique is more effective for treating second-degree hemorrhoids, but all degrees can be treated.

The band is a small rubber O-ring about 1 mm in diameter and 2.5 mm in thickness.

This simple design has been improved over the past years: for example, the McGiveny ligator also has a short cylinder at the end of the shaft. The hemorrhoidal mass can be maneuvered into this cylinder (manually or by use a vacuum), thus improving the accuracy of the application of the band.

Success Rate

Studies have suggested that rubber band ligation is comparable to other methods of treating hemorrhoids of similar grade. Typically, between 60 to 80% of patients who have undergone this procedure are satisfied with the result.

Some possible complications of this procedure are:

Mild pain or a feeling of pressure is normal and should go away within one to two hours.
Some bleeding normally occur at the first bowel movement after the procedure. However, severe bleeding which requires hospitalization and blood transfusion is very rare and occurs at a rate of less than 1%.

When the hemorrhoid shrivels and falls off about a week after the procedure, some bleeding is to be expected. If the bleeding does not stop by itself, however, local pressure, local application of adrenaline or stitching may be necessary.
Slippage of the band can occur if there is not enough pile mass to band in the first place. Use of two bands at each site avoid failure due to slippage or breakage.
In cases of band slippage, re-application is all that is required.
Infection and Pelvic Sepsis are very rare, complications
In about 5% of patients, a very painful blood clot develops in a condition called thrombosed hemorrhoids. Sometimes surgery may be necessary to excise this type of hemorrhoids.
Anal Fissure develops in about 1% of the patients as a result of sloughing of the hemorrhoid. Although most cases of fissure can be treated by prescribing pain killer medications, some may require surgery.

As can be seen the treatment of hemorrhoids with rubber bands is a simple and effective method of curing this ailment. A normal patient is cured after an average of four weekly treatments on an outpatient basis. Patients that are on a tight schedule can receive these treatment sessions at 2 to 3 day intervals.

Beware: "He thought to have hemorrhoids but turned out to have rectal cancer". Its important to point out that a number of patients have treated themselves with self-prescribed anti hemorrhoidal ointments or suppositories, only to have a rectal carcinoma detected on a later rectal digital examination.

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