RUBBER BAND LIGATION:
This is a minor procedure involving tiny rubber bands being placed internally in the rectum, usually at the origin of the haemorrhoid. It is usually performed in the endoscopy suite at Mater Private Hospital, where an anaesthetist will provide sedation for you so that you are asleep when the procedure is being done. We often perform this at the same time as an endoscopic assessment of the colon so that we can ensure that there is no other polyp or lesion in your bowel causing your symptoms. This can be a complete colonoscopy, or a flexible sigmoidoscopy which is an assessment of the lower half of the colon.
The procedure is generally painless and is a day procedure. A percentage of patients develop a dull ache after the procedure but this generally lasts a few hours then resolves. Paracetamol can be effective in alleviating this pain. More severe pain is very uncommon and usually related to the rubber bands being placed too low. Delayed bleeding is also a small risk, occurring with a frequency of about 1 in 200 procedures.
You would normally need to be in the endoscopy unit for about 3 hours from the time you arrive to when you can leave. It is important to have someone available to take you home and to be with you if you have had any anaesthetic. We cannot discharge you from hospital without someone else being available to look after you.
Rubber band ligation works by pulling the haemorrhoids back inside the anus, thereby improving symptoms of prolapse or mucus leakage. The rubber band constricts the lining of the rectum where the haemorrhoid starts, leading to scarring and this stops the haemorrhoid from stretching any more. The rubber bands fall off within a few days and are passed in the faeces, you will not notice this.
The success rate of rubber band ligation is about 50-90% and this effect usually lasts years, however it is only effective for smaller haemorrhoids with less “external component”.
An excisional haemorrhoidectomy involves surgical excision of prolapsing haemorrhoidal tissue from the inside of the rectum, extending to the skin just on the outside of the anus. It is generally reserved for larger haemorrhoids where there is involvement or extension into the perianal skin, or significant ulceration or bleeding. Patients may have suffered from “haemorrhoidal crises” with sudden swelling and pain in the haemorrhoids and are left with skin tags and haemorrhoids extending from inside to outside.
At Brisbane Colorectal, we perform an excisional haemorrhoidectomy under general anaesthetic in the operating theatre, using an energy device called a “Ligasure”. This has been shown to result in a quicker, less painful operation compared to traditional excisional haemorrhoidectomy. Most patients spend one night in hospital, but some patients go home on the same day if the surgery is done in the morning and they are comfortable after the operation. We insert a “pudendal nerve block” which is a nerve block using long-acting local anaesthetic at the beginning of the operation to numb the area and this often can last even for 2-3 days to improve the initial pain after the operation. Not uncommonly, patients will have little to no discomfort until the nerve block wears off.
Excisional haemorrhoidectomy has been shown to be the most effective treatment for haemorrhoids in terms of long-term success. The rate of return of haemorrhoids is the lowest with this operation. The down-side is it can be a painful operation – with discomfort/pain lasting usually 1-2 weeks, the worst discomfort is usually with the first bowel motion. We routinely prescribe painkillers for patients to have at home, along with laxatives and antibiotics (also shown to reduce pain). Most patients find the operation quite tolerable and very rarely do patients need further haemorrhoidal surgery after this operation.
The wounds heal usually by 2-4 weeks and most patients can return to work in one week (often a small pad is required inside the underwear if there is any leakage of fluid from the wounds). Risks of the operation include excessive pain, and delayed bleeding. Urinary retention occasionally happens and infection and faecal leakage are rare.
Stapled haemorrhoidectomy is an alternative surgical procedure designed to address haemorrhoids. It involves excision of tissue – but rather than the actual haemorrhoidal tissue being excised, a stapled haemorrhoidectomy involves excision of some of the inner lining of the rectum above the haemorrhoids. This causes some scarring which helps to “pull the haemorrhoids back inside”. The operation is performed in the operating theatre under general anaesthesia and a circular stapler is used to excise part of the rectal “mucosa”. It is a relatively quick procedure and is tolerated quite well, with generally minimal discomfort or pain. The maximal effect can sometimes take some weeks to be achieved as the haemorrhoids are “pulled” inside.
Your surgeon can explain the specific risks of this procedure with you. Stapled operations carry a very small rate of longer-term problems but are generally tolerated well.
HAEMORRHOIDAL ARTERY LIGATION AND RECTOANAL REPAIR (HAL-RAR):
Another procedure for haemorrhoids is the haemorrhoidal artery ligation and rectoanal repair. This operation is also performed under general anaesthetic and is performed inside the rectum, above the haemorrhoids themselves. It involves a suture used to tie off some of the blood vessels supplying the haemorrhoids, and a running suture used to pull the haemorrhoids and prolapsing anal tissue back inside. This results in shrinkage of the haemorrhoids and a return of the haemorrhoids to their usual position inside the anus. The main advantage of the procedure is that it is very well tolerated, with minimal side effects and can be done as day surgery. Discomfort is usually minimal and the risk of bleeding is also very low. It can be repeated if haemorrhoids recur at a later time. Patients with smaller haemorrhoids or anal ectropion “the anus turning inside out” can benefit most from this procedure. A discussion with your surgeon will determine if this option is suitable for you. For more information see haemorrhoidinfoservice.com.au
HAEMORRHOIDAL ENERGY THERAPY
A novel technique for the management of haemorrhoids is called haemorrhoidal energy therapy (HET). This involves the use of electrical energy (“bipolar current”) to slowly and gently heat the tissue around haemorrhoids, within the rectum.The tissue is heated to 55 degrees – which is a temperature high enough to cause scarring at the haemorrhoid, but not high enough to cause any tissue damage. Haemorrhoidal energy therapy is done to each haemorrhoid, and circumferentially around the rectum to ensure complete treatment of haemorrhoids.
The procedure is performed under sedation, and we will often perform a colonoscopy or a flexible sigmoidoscopy to examine the bowel at the same time. The advantages of the technique are that there is minimal pain or discomfort and the rate of complications, including bleeding, is very small. The procedure can be performed even on patients who need to remain on anticoagulants with a good safety profile.
Haemorrhoidal energy therapy is a useful alternative to rubber band ligation and we can provide this service for all Brisbane Colorectal patients.