Comparison of Infrared Coagulation and Rubber Band

Ligation, two Simple and Cost Effective Office

Procedures in the Treatment of Internal Haemorrhoids
Surg Capt Surath C. Patra (Retd.):

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

Out-patient Treatment; Haemorrhoids;

Infrared coagulation; Rubber band

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

of the focusing mirror assembly. The search is ever

on for a procedure that is easily learned, is cost
effective, gives satisfactory results and lacks
complications. A method that could return the anal
cushions to their normal size and positions would be
naturally preferred to methods that destroy tissue and
may interfere with the mechanism of continence.
Infrared photo coagulation, a technique introduced
by N ath (4), satisfies these requirements. In this
procedure the tissue is coagulated by infrared
photocoagulation using mechanical pressureS. The
aim ofthis study was to evaluate the, post-procedure
discomfort, pain, rectal tenesmus, infection, sepsis,
time taken to resume routine work and overall
effectivenessfollowingout-patienttreatmentof internal
haemorrhoids by IRC and compare the results with
Rubber Band Ligation (RBL).
Materials and Methods:
In this study, 105 patients with early degree
bleeding internal haemorrhoids were assigned
randomly to IRC or RBL and identified by number.
The study was approved by the hospital's ethics
committeeand included all patients with early stage
haemorrhoids. Patients with associated anal fissures,
anal spasm or infective anal pathologies like cryptitis
or proctitis were excluded from the study. No
anesthesia was administered during the procedures.
However, a 5% xylocainejelly was generouslyapplied
to the anorectal region 10 minutes before the
procedure to reduce the sensitivity of the area. IRC
was performed in lithotomy position because it
permitted sufficient ease of maneuver. The left lateral
position was chosen in cases in which the lithotomy
position was not possible. All haemorrhoid bases
were coagulated one after the other. There was
no special preference for the positions of the
hemorrhoids to be dealt with first, although the

Fig 1: Infrared Coagulator-Lumfltec-Munchen,

Germany

Jour. Marine Medical Society, 2014, Vol. 16, No.1

largest haemorrhoid was dealt with first and soon.

The mean treatment duration was 3 min (range: 2 to
5 min). The IRC instrument used for the study was
supplied by Lumatec (Munich, Germany) (Fig.1).
A 220-mm light guide with a tip diameter of 6
mm was used for coagulation. IRC was applied to
all three principal positions of hemorrhoids. (Fig. 2)

analgesics were prescribed to the patients from either

group. The patients were cautioned not to strain at
stool and were warned that they should expect some
bleeding during first week. Pain was assessed using
a visual analogue scale from 0 (no pain at all) to 10
(the worst pain the patient had ever experienced).
The unpaired Student t-test was used to measure
postoperative parameters. Data were entered into a
database and analysed using the Graph Pad
Software. The level of significance was set at P <
0.05.

Fig. 2 : Testing the Lum atec-Infrared Coagula tor prior to

Infrared coagulation of hemorrhoids (Demonstration)

RBL was performed

by drawing in the
haemorrhoid mass into the ligator and placing the band
over the pedicle. Care was taken to place the band
exactly above the dentate line. (Fig.3 & Fig 4)

Fig. 5: Age profile of patients

Table -1
Patient

characteristics

Infrared
Coagulation

Rubber
band ligation

No. of patients

51

54

Mean (range) age in years

33 (21-61)

51 (26-71)

Sex ratio(male: female)

32 :19

36:18

Duration of disease

16

15

Number of haemorrhoids
under treatment

155

136

-~

Fig. 3 : Internal haemorrhoid as seen during anoscopy with

Heine E-19400 Anal Speculum after Rubber Band Ligation
ill

-;

The post-procedure
Table 2

results were as described

Table -2
Comparison of infrared coagulation and rubber
band ligation of haemorroids
Events observed

Patients were sent home 1 hour after the

procedure. A regular dose oflaxative was prescribed.
A 5% xylocaine ointment was prescribed for local
application to relieve the post-defecation discomfort
and the possible burning sensation at the site. No
Jour. Marine Medical Society, 2014, Vol. 16, NO.1

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

Period of post defecation

pain (first week)#

Obliteration ofhaemorrhoids

54

25

#Measured on a visual analogue scale "P < 0.05

compared to Infrared coagulation unpaired student
t- test
The intensity and duration of postoperative pain
in the first week were greater in the RBL than in the
IRe group (2-5 vs 0-3 on a visual analogue scale).
The duration of post-defecation pain during the first
ten days were significantly shorter in the IRe group
(8 min) than in the RBL group (20 min), although no
difference.was observed thereafter, with negligible
pain in both groups. Eleven patients from the RBL
group had rectal tenesmus when assessed after one
week, as opposed to only three patients in the IRe
group. Time off work is defmed as the total period
taken to return to the usual activities of domestic and
social life. Patients from the IRe group were able to
resume their routine activities comparatively earlier
than patients from the RBL group. None of the patients
from the two groups had any sepsis in the form of
local infection or systemic manifestation. Three
patients from the RBL group returned within a day of
the procedure complaining of severe pain. The bands
were removed to provide relief to these patients. One
of the patients from the RBL group reported urine
retention and consequent
discomfort.
He was
catheterized for relief and did not report a similar
complaint thereafter. Seven patients from the IRe
group complained of bleeding. Such complaints were
reported mostly during the period from day 5 to day
10 after the procedure. The bleeding was almost
always associated with defecation. This condition was
attributable to sloughing of the tissue at the base of
the hemorrhoids, resulting oozing from the raw area.
F our patients from the RBL group reported bleeding
between the 7th and 9th day, presumably due to
detachment of the pile mass from the pedicle. Six
patients-Were lost to the follow up at one year. At
follow-up
examination
at one year after the
procedures, 7 patients from the IRe group had
recurrence of symptoms in the form of bleeding and
only one patient complained of recurrence of prolapse
of haemorrhoid . From the RBL group 4 patients
had recurrence of bleeding and no patient complained
of any prolapse in an identical comparison of results.
The obliteration of the treated hemorrhoids, confirmed
by anoscopy at the end of one year, was 84% in the
IRe group and 92.5% in the RBL group.

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

eliminate this potential cause of concern while

achieving results that almost match those obtained
with RBL(12).
Although
the RBL method
demonstrated a greater and long-term efficacy, it was
associated with a sigIiificantly higher incidence of posttreatment pain(13;14). In contrast, IRe has been
reported to be a painless procedure (15). No special
training is required for a surgeon to carry out the
coagulation, except keeping the area of coagulation
above the dentate line, On the other hand, application
of a rubber band needs expertise in placing the band
in the right place and failure to do so possibly lead to
complications like bleeding, pile strangulation, necrosis,
or sepsis(l6). In some studies local anesthetics was
injected into the post-banded haemorrhoid mass to
relieve the pain occurring after the procedure(17).
This indicates that the pain intensity after the procedure
has been truly as severe as generally described in the
literature. The characteristics of post-ligation pain most
often include mild anal discomfort(ll),
rectal
tenesmus(18),
painful priapism(16),
urinary
hesitancy(19), and anal urgency(6). The intensity of
pain may at times lead to fainting and vasovagal
attacks (20). While band ligation is marked by a large
number of complications of an inflammatory character
, no such incidence has been reported with IRe. Lifethreatening complications like tetanus, band-related
abscess(21,22) pelvic cellulitis(23), recto-vaginal
fistula, and bacteremia(l6) have been reported after
RBL (Table 3).
Table - 3 Complications

The septic complications are manifested as a

clinical triad of pain, fever and urine retention(23). In
contrast, IRe is virtually safe and free from such
dreaded complications(24). IRe tolerated well by
younger patients with a hyperactive anal sphincter, in
whom RBL reportedly causes considerable pain after
therapy(25). A few other complications that follow
RBL include thrombosis of external hemorrhoids,
chronic longitudinal ulcer(26), severe hemorrhage and
anal stenosis8. Pain after RBL occurs more often than
previously recognized. The long-term effectiveness
ofRBL compared to IRe is probably related to the
depth of tissue destruction involved in the two. The
strangulating effect of the rubber band leads to
necrosis ofhemorrhoidal tissue. The sloughing, which
occurs after about one week, causes tissue
destruction with scarring and a subsequent fixation
of the sub mucosa. In contrast, IRe causes only a
small burn which results in minimal tissue injury of a
depth of about 2 to 3 mm. The difference in posttreatment pain between IRe and RBL may also be
the result of a difference in the depth of tissue injury.
The greater the tissue destruction, the greater is the
amount of post-procedural pain.
The results of the present study demonstrate RBL
as a more effective therapy in the management of
early hemorrhoids in that only a few patients require
additional therapy for symptom recurrence. One
recent study which states that, conservative office

following Rubber Band Ligation (RBL)

Tetanus,
Band-related abscess
Pelvic celluliti s
Rectovaginal fistula

Bacteremia
'fhrombosi:; of external
hemorrhoids
Severe hemorrhage
Anal stenosis

;.l",usea

+
+

Shaking

Rectal tenesrnus

Minor post-op bleeding

Jour. Marine Medical Society, 2014, Vol. 16, No.1

27

techniques, and rubber band ligation in particular,

have an important
role in second
degree
haemorrhoidal disease in non-responsive medical
treatment first degree haemorrhoid and in third degree
haemorrhoids in elderly patients with comorbidity or
with sectorial or moderate prolapse(27).
The most effective therapy, however, may not
be the optimal one if the risks of potential
complications outweigh the benefits oftreatment(l3).
This apparent therapeutic advantage, however, should
be examined in the light of the rate and severity of
complications associated with RBL(28).
Both RBL and IRe were well-accepted and
highly efficacious methods for the treatment of internal
haemorrhoids; in addition, both procedures in most
cases were associated
with relatively
minor
complications. RBL associated with more pain than
IRe in post procedure period especially in the first
24-hour(29). One more study observed RBL was
associated with more pain than infrared photocoagulation during the first week following the
procedures and their success rate were not different
at four weeks oftreatment(30). It has been observed
that IRe has been as effective as RBL apart from
less painful and consequently more acceptable to the
patient. The ultimate aim of all therapies is to provide
optimum relief and satisfaction to the patient. Weighed
on this scale, IRe certainly is destined to outweigh
traditional procedures like RBL.

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.

How to cite the article

Patra S C. Comparison of Infrared Coagulation and Rubber
Band Ligation, two Simple and Cost Effective Office Procedures
in the Treatment ofInternal Haemorrhoids. J. Marine Medical
Society, 2014, 16 (1) : 23-29

Source of support
Nil

Conflicts of interest
All authors have none to Declare.

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