Rubber Band Ligation of Hemorrhoids is often a Necessary Complement in the Management of Hemorrhagic Radiation Proctitis

Background: Management of radiation proctitis presents a treatment challenge. Limited data exist on the management of symptomatic hemorrhoids in radiated patients. This study aims to present a practical approach to the management of radiation proctitis, particularly in patients with synchronous hemorrhoids. Methods: A total of 52 consecutive cases of radiation proctitis managed between September 1999 and October 2017 were retrospectively reviewed. The primary treatment was formalin application, plus rubber band ligation in conjunction with formalin when hemorrhoids were a significant component of bleeding, and occasionally argon plasma coagulation. Results: The primary indication for radiotherapy was for the treatment of prostate cancer (71%), anal squamous cell carcinoma (10%), and gynecological malignancies (18%). More than half of the patients (52%) presented with radiation proctitis and concomitant internal hemorrhoids. The hemorrhoids were managed with rubber band ligation (56%) and stapled hemorrhoidectomy (7%), at the same procedure as formalin application. At a median follow-up of 12 months, no recurrent rectal bleeding occurred, and no further treatment was needed for most patients. One patient experienced a short period of perianal pain, which was treated with analgesics. Conclusion: Formalin application has consistently demonstrated an excellent cure rate and safety profile comparable with the published results as a primary treatment for radiation proctitis. The prolapse of irradiated mucosa over the internal hemorrhoids appears to exacerbate bleeding. Local hemorrhoid treatment is often required as an adjunct in the management of these patients.