Advertisement

Endoscopic treatment of internal hemorrhoids by use of a bipolar system

Open AccessPublished:August 11, 2017DOI:https://doi.org/10.1016/j.vgie.2017.07.004
      Hemorrhoids occur in 4% of the population and are identified in 39% to 45% of colonoscopies.
      • Pfenninger J.L.
      • Surrell J.
      Nonsurgical treatment options for internal hemorrhoids.
      Internal hemorrhoids have been categorized further according to the Banov classification, which has grades I to IV. Although grades III and IV have typically been managed surgically, grades I and II can be treated by endoscopic means.
      • Pfenninger J.L.
      • Surrell J.
      Nonsurgical treatment options for internal hemorrhoids.
      • Salvati E.P.
      Nonoperative management of hemorrhoids: evolution of the office management of hemorrhoids.
      • MacRae H.M.
      • McLeod R.S.
      Comparison of hemorrhoidal treatments: a meta-analysis.
      Numerous endoscopic methods have been described to treat internal hemorrhoids, but these techniques are fraught with high rates of postprocedural pain.
      • MacRae H.M.
      • McLeod R.S.
      Comparison of hemorrhoidal treatments: a meta-analysis.
      • Johanson J.F.
      • Rimm A.
      Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation and injection sclerotherapy.
      • Iyer V.S.
      • Shrier I.
      • Gordon P.H.
      Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.
      • Su M.Y.
      • Tung S.Y.
      • Wu C.S.
      • et al.
      Long-term results of endoscopic hemorrhoidal ligation: two different devices with similar results.
      The described technique for hemorrhoidal therapy is a bipolar system that uses a novel anoscope with built-in illumination and a consistent compression apparatus (Figs. 1 and 2). This allows for stable energy delivery, which causes lower rates of collateral damage and, therefore, less postprocedural pain.
      Figure thumbnail gr1
      Figure 1Bipolar system: visible bipolar device platform with active blue light (upper right corner), signifying power-on status and green light (mid-left), with power into electrocautery system.
      Figure thumbnail gr2
      Figure 2Speculum and bipolar system: visible bipolar system (left) and speculum with built-in illumination, bipolar energy delivery system, and handle that controls tissue approximation (right).
      This video (Video 1, available online at www.VideoGIE.org) demonstrates appropriate patient selection, positioning, equipment, setup, and procedural nuances necessary for obtaining success with this bipolar system (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6). Specifically, we emphasize various techniques that can be implemented for proper tissue apposition of the hemorrhoidal cushions with the bipolar probe.
      Figure thumbnail gr3
      Figure 3Equipment: 2-inch tape (left), hemorrhoidal forceps (upper right), through-the-scope grasping forceps (lower right, left-most), surgical lubricant (lower right, right-most).
      Figure thumbnail gr4
      Figure 4Proper installation of bipolar system: cord from bipolar device placed into uppermost bipolar portion of electrocautery system.
      Figure thumbnail gr5
      Figure 5Electrocautery setting for bipolar system. Visible monitor reveals bipolar setting of electrocautery system at effect 1, 8 W.
      Figure thumbnail gr6
      Figure 6Bipolar system high-temperature alarm. Visible bipolar system with red light (lower left) indicating above-target temperature reached, accompanied with audible alarm.
      A 33-year-old woman presented with blood per rectum with straining. The patient underwent a colonoscopic examination, which identified 2 grade I hemorrhoids in the right anterior and posterior cushions and 1 grade II hemorrhoid in the left lateral cushion, with a hypertrophied anal papilla. No additional bleeding lesions were seen throughout the colon.
      She then underwent the bipolar procedure to treat her symptomatic hemorrhoids. Using a through-the-speculum grasper to allow for tissue apposition, we delivered electrocautery energy using a bipolar current to each of the hemorrhoidal cushions (Figure 3, Figure 4, Figure 5, Figure 6). Postprocedural assessment demonstrated appropriate energy delivery. Follow-up evaluation revealed absence of symptoms, and endoscopic inspection at 1 month showed resolution of hemorrhoids.
      Endoscopic treatment of internal hemorrhoids with this bipolar system was safe and effective. There are numerous variations of this endoscopic technique, all of which are useful in achieving clinical success.
      • Piskun G.
      • Tucker R.
      New bipolar tissue ligator combines constant tissue compression and temperature guidance: histologic study and implications for treatment of hemorrhoids.
      • Kantsevoy S.V.
      • Bitner M.
      Nonsurgical treatment of actively bleeding internal hemorrhoids with a novel endoscopic device (with video).

      Disclosure

      Dr Khara is a consultant for Medtronic-Covidien. Dr Johal is a consultant for Boston Scientific. Dr Diehl is a consultant for Boston Scientific and Olympus. All other authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      References

        • Pfenninger J.L.
        • Surrell J.
        Nonsurgical treatment options for internal hemorrhoids.
        Am Fam Physician. 1995; 52 (839-41): 821-834
        • Salvati E.P.
        Nonoperative management of hemorrhoids: evolution of the office management of hemorrhoids.
        Dis Colon Rectum. 1999; 42: 989-993
        • MacRae H.M.
        • McLeod R.S.
        Comparison of hemorrhoidal treatments: a meta-analysis.
        Can J Surg. 1997; 40: 14-17
        • Johanson J.F.
        • Rimm A.
        Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation and injection sclerotherapy.
        Am J Gastroenterol. 1992; 87: 1600-1606
        • Iyer V.S.
        • Shrier I.
        • Gordon P.H.
        Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.
        Dis Colon Rectum. 2004; 47: 1364-1370
        • Su M.Y.
        • Tung S.Y.
        • Wu C.S.
        • et al.
        Long-term results of endoscopic hemorrhoidal ligation: two different devices with similar results.
        Endoscopy. 2003; 35: 416-420
        • Piskun G.
        • Tucker R.
        New bipolar tissue ligator combines constant tissue compression and temperature guidance: histologic study and implications for treatment of hemorrhoids.
        Med Devices (Auckl). 2012; 5: 89-96
        • Kantsevoy S.V.
        • Bitner M.
        Nonsurgical treatment of actively bleeding internal hemorrhoids with a novel endoscopic device (with video).
        Gastrointest Endosc. 2013; 78: 649-653