Complications After Hemorrhoid Banding Surgery

Injury from hemorrhoid ligation in the anal canal?

Dear Dr.
Ke,
I underwent three rubber band ligation procedures for internal hemorrhoids at a clinic in Taipei from January to March 2014.
After the procedures, I experienced occasional bleeding during bowel movements in April.
The clinic physician administered two additional injection treatments.
In early May, I had slight bleeding again, which prompted me to visit another hospital in late May.
The physician there indicated that I still had one internal hemorrhoid that needed to be ligated (located on the left anterior side near the genital area) to resolve the occasional bleeding issue.

I recall that the procedure took a long time and was quite painful, which was different from my previous experiences at the clinic.
After the ligation that day, the pain was intense, unlike the previous three procedures.
I was unable to sleep that night and could not get out of bed the next day, so I took a day off work.
In the afternoon, I went to a nearby large hospital for assistance in removing the rubber bands.
To my surprise, the physician removed two rubber bands manually without any tools, which caused me significant pain and resulted in several wounds.
The physician warned that this could potentially lead to severe bleeding in the future.

That night, I experienced a considerable amount of discharge from the wounds, which developed into ulcerated sores, but fortunately, there was no major bleeding.
By late June to early July, I observed that the external wounds appeared to have healed completely, but I could not assess the internal wounds at the anal opening.

I later noticed that since 2014, the caliber of my stools seems narrower than before (prior to the hemorrhoid treatment), which used to be two to three fingers wide, now it is at most about two fingers or the width of a thumb.
Even slightly harder stools (even if not large) can easily cause tearing or a tearing sensation, along with minor bleeding.
When I insert my finger into the anus to apply medication, I find that the anal canal does not seem as wide as it was before treatment, and both sides feel somewhat firmer, lacking the softness I had prior to treatment.
Although I can still successfully insert my finger into the anus for medication application, I am concerned.
Could the manual removal of the rubber bands by the physician have caused permanent damage to some tissues in the anal canal that will never heal? I came across a website stating that injuries below the dentate line in the anal membrane area do not heal, and that the anal membrane aids in bowel movements.
Has my anal membrane been damaged, causing the anal canal to narrow? Or could it be due to the sclerotherapy injections that have reduced the elasticity of the anal canal? Is it possible that I can no longer pass stools that are the same width as before (two to three fingers)? If I can still insert my middle or index finger, does that indicate anal stenosis?
Thank you for your patience in reading my concerns and for providing clarification.
I appreciate it.

Wen Zhong, 30~39 year old female. Ask Date: 2015/04/30

Dr. Ke Fangxu reply Surgery

1.
In medical terminology, there is no such term as "anal membrane." The website refers to the mucosal tissue above the anal dentate line, which is the lower rectal mucosa.
This mucosal tissue typically heals within about a week unless subjected to high doses of radiation therapy or significant trauma causing a rupture of the anal canal.
There is no possibility of permanent damage, nor will anal stenosis occur due to hemorrhoid ligation.

2.
Sclerosing agents are mineral oil or olive oil combined with a chemical agent such as phenol, injected into the anal tissue to induce vascular sclerosis.
Therefore, this procedure should not lead to decreased anal elasticity unless the injection is too deep and injures the sphincter muscle, but it is not possible to determine such an occurrence based on your description.
3.
Anal stenosis has a specific definition: its diagnosis must be made through a physical anal examination.
Based on your description, it does not seem to qualify as anal stenosis; however, a definitive answer cannot be provided through online consultation.
Since you have undergone multiple anal procedures at three different medical facilities in a short period, this may have caused some damage to the anal tissue.
It is recommended that you maintain normal bowel movements and take warm sitz baths to allow the delicate anal tissue time to rest and recover, and then observe the healing progress afterward.

Reply Date: 2015/04/30

More Info

After undergoing hemorrhoid banding surgery, it is not uncommon for patients to experience complications, including persistent bleeding, pain, and changes in bowel habits. In your case, it appears that you have had multiple procedures, and the ongoing issues you are facing warrant a thorough understanding of potential complications and their implications.

Firstly, it is important to recognize that hemorrhoid banding is a minimally invasive procedure aimed at treating internal hemorrhoids by cutting off their blood supply. While it is generally safe, complications can arise, particularly if the procedure is not performed correctly or if there are underlying conditions that predispose the patient to complications.

The persistent bleeding you experienced after your initial surgeries could indicate that not all hemorrhoids were adequately treated, or it could be a sign of other issues such as anal fissures or even a rectal ulcer. The fact that you underwent additional treatment suggests that your condition was not fully resolved, which is not uncommon in cases of multiple hemorrhoids or complex presentations.

Regarding the pain you experienced during and after the last procedure, it is concerning that the physician removed the rubber bands manually without the use of appropriate tools. This could potentially lead to trauma to the anal canal and surrounding tissues, resulting in pain, inflammation, and possibly scarring. The presence of discharge and ulceration at the site of the procedure is also indicative of tissue trauma and could lead to further complications if not managed properly.

You mentioned that your bowel movements have changed, with a noticeable reduction in the diameter of your stools and an increased tendency for tearing or bleeding. This could be attributed to several factors:
1. Tissue Damage: If the anal canal or surrounding tissues were damaged during the removal of the rubber bands, it could lead to scarring or changes in the elasticity of the anal sphincter. This might explain the narrower caliber of your stools and the discomfort you experience during bowel movements.

2. Injection Sclerotherapy Effects: If you received sclerotherapy (injection of a hardening agent) prior to your surgeries, this could also contribute to changes in the anal tissue. Sclerotherapy can lead to fibrosis and changes in the anal canal, which may affect its ability to stretch and accommodate stool.

3. Anatomical Changes: The healing process after any surgical intervention can lead to changes in the anatomy of the anal canal. If the internal structures have been altered, this could result in a narrower passage.

Regarding your concern about permanent damage, it is difficult to ascertain without a physical examination and possibly imaging studies. However, if you can still insert a finger into the anal canal, it suggests that there is still some degree of patency, although it may not be as wide as before. The definition of anal stenosis (narrowing of the anal canal) typically involves difficulty in passing stool or the presence of significant pain during bowel movements, which you have described.

In terms of management, it is crucial to consult with a colorectal specialist who can perform a thorough examination and possibly recommend further interventions if necessary. This may include dietary modifications to ensure softer stools, the use of stool softeners, or even physical therapy focused on pelvic floor rehabilitation to improve anal sphincter function and elasticity.

In summary, while it is possible that the manual removal of the rubber bands and the previous treatments have contributed to changes in your anal canal, a definitive diagnosis can only be made through a clinical evaluation. It is essential to address these concerns with a healthcare provider who specializes in colorectal issues to explore potential treatments and ensure that any complications are managed effectively.

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