Counselpatientstomaintainstoolsoftwithhydration,fiberuse,and stoolsoftener.Minordiscomfortshouldbemanagedwith acetaminophen.

Althoughfrequentlyfatalwhenitdoesoccur,postbandingsepsisisrare. Vigilanceandearlytreatmentarevital.Patientsshouldbeadvisedthat increasingpain,urinaryretention,orfevershouldprompturgent evaluationastheycouldbetheharbingerofpostbandingsepsisorpelvic cellulitis.Treatmentofpostbandingsepsisrequiresearlyintravenous antibiotics,bandremoval,debridementofnecrotictissue,andsupportive careinanintensivecareunit.Therearereportsofpostbandingsepsis developingintoFournier’sgangrene.Urinaryretentionismorefrequent whenmultiplequadrantsarebandedatonesetting.

OthercommoncomplicationsofRBL(<5%ofpatients)arerectal bleeding,pain,vasovagalsymptoms,thrombosedexternalhemorrhoids, andrarely,bacteremia.Bleedingoccurswhenthebandedtissuesloughs offtypically4–10daysafterbanding.Thebleedingisoftenself-limited, butmaybesignificantenoughtowarrantanemergencyroomvisit,andin rarercases,examinationunderanesthesiaforsuturesatthebaseofthe pedicle.

Asingle-institutionreviewbyWrobleskiof266patientswhounderwent RBLwithameanfollow-upof60monthsshowed80%hadimproved symptoms,with69%totallyfreeofallsymptoms,andonly7.5%requiring subsequenthemorrhoidectomy.Iyer’sretrospectivereviewof805 patientswhounderwent2,114rubberbandligatures,notedsuccess (permanentrelieformarkedimprovementofsymptoms)in80.3%of patientwithinthefollowingperiodof1year.Thisreviewnoted complicationsofbacteremia(0.09%)andbleeding(2.3%),which unsurprisinglywasincreasedinpatientsonAspirin,nonsteroidalanti­inflammatorydrugs,andwarfarin.Bayerreviewed2,934patientswith gradesIIandIIIhemorrhoidswhoweretreatedbyRBL(usuallyone ligationpersession),79%werecompletelycured,18%neededadditional sessionsoftreatment,and2.1%failedtobecuredbyRBLandwere referredforhemorrhoidectomy.

RBLisawell-toleratedandeffectiveoffice-basedtreatmentfor symptomaticgradesI,II,orIIIhemorrhoidsoncemedicaltherapyfails. Recurrenceafterbandingcanbemanagedwithrepeatbandingor surgicalexcision.PelvicsepsisafterRBLisrare,butearlyrecognitionand treatmentisvital.

Themajorityofperianalsepsisisidiopathicorcryptoglandularin origin,andarisesfromtheobstructionofanalglands,leadingtostasisof glandularsecretionsand,ifsecondarilyinfected,suppurationandabscess formation.Theabscesstypicallyformsintheintersphinctericspace,but canextendintotheischiorectalfossaorsupralevator/suprasphincteric spaces.Followingeitherspontaneousorsurgicaldrainageoftheabscess, apersistentfistulatractdevelopsinabout30–50%ofpatients,extending fromtheanalcanal(usually)totheperinealskin.

Fistulotomyremainsthemainstayoftreatmentforlowfistulatracts, thatis,thosefistulasinvolvinglessthanthedistalthirdoftheinternal

Someauthorshavereportedtreatingthefistulatractbysimplyclosing theinternalopening,withoutusinganadvancementflap.Theargument forthistypeofrepairisthatinthepresenceofadequateperfusionand theabsenceofunduetension,atthecoaptedsurfaces,simple appositionalclosureshouldsufficeandthistypeofrepairmaintainsthe sphincterintegrity.Althoughthisprocedureisnotpracticedatour institution,asithasbeenshowntobeinferiortothemethodsusingflap reinforcement,andisgenerallycombinedwithaflapadvancement procedurenow,and/orafistulotomy,brieflymentionedherefor completeness.

ThomsonandFowlerdescribeusinganarrowtransverseellipseto excisetheinternalopening,closingthedefectwithtwoorthree monofilamentabsorbablesutures.Athanasiadisetal.describeexcising theinternalopeningandintersphinctericpartofthefistulatractuptothe intersphinctericplane,andthenseparatelyexcisingtheexternalpartof thetractandthesurroundingskinandfatuptotheexternalsphincter. Closureisachievedusingathree-layer,nonstaggeredtechnique,closing themucosaandsubmucosa,theinternalandtheexternalsphincter muscles.TheLIFTprocedureisamodificationofthistechniqueandis discussedindetailelsewhere.