Expert Recommendations on Cap-Assisted Endoscopic Sclerotherapy for Hemorrhoids

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Expert Recommendations on Cap-Assisted Endoscopic Sclerotherapy for Hemorrhoids: Rationale, Techniques, and Clinical Protocols

Cap-assisted endoscopic sclerotherapy (CAES) has emerged as a minimally invasive treatment for internal hemorrhoids and rectal mucosal prolapse. This approach combines endoscopic visualization with targeted injection of sclerosing agents, aiming to reduce iatrogenic risks associated with traditional anoscope-based methods. The LPRA (left, posterior, right, anterior) positioning system, introduced in China, enhances precision during therapy. This article outlines the rationale, technical details, clinical protocols, and outcomes of CAES as established by expert consensus from the China Gut Conference.

Rationale for CAES

CAES addresses limitations of conventional sclerotherapy, particularly misplaced injections leading to complications such as mucosal necrosis or prostatic abscess. The integration of a cap attachment on the colonoscope improves visualization and stabilizes the anal canal, facilitating accurate submucosal injection. Key advantages include:

  1. Enhanced Visualization: Air insufflation through the colonoscope lifts the anal canal, while the cap prevents air leakage, optimizing exposure of hemorrhoidal cushions.
  2. Simultaneous Diagnosis and Therapy: CAES allows differentiation of hemorrhoids from other anorectal pathologies (e.g., malignancies, fistulas) and enables concurrent colon screening.
  3. Minimally Invasive Profile: Compared to surgery, CAES reduces postoperative pain and bleeding, making it suitable for high-risk patients with comorbidities like cerebrovascular disease or immunodeficiencies.

Anus Positioning: The LPRA System

Traditional lithotomy positioning lacks directional specificity for anal lesions. The LPRA method, based on the left lateral decubitus position used in colonoscopy, leverages residual fluid or injected water to identify anatomical landmarks:

  • Left Anus: Fluid accumulation in the anal canal’s left side under endoscopic view serves as the reference point.
  • Clockwise Division: From the left anus, the anal circumference is divided into four quadrants—left, posterior, right, and anterior—further subdivided into eight directions (e.g., left-posterior, right-anterior).
    This systematic approach standardizes lesion localization, improving communication between clinicians and patients. Figure 1A illustrates fluid-guided identification of the left anus, while Figure 1B demonstrates LPRA’s eight-directional mapping.

Indications and Patient Selection

Internal Hemorrhoids

  • Grades I–II: CAES is recommended for bleeding hemorrhoids unresponsive to lifestyle modifications or topical therapies. Studies report symptom resolution in 85–90% of cases, with minimal postprocedural discomfort.
  • Grade III: CAES is an option for patients refusing surgery or deemed unfit for invasive procedures. A 2015 study by Zhang et al. demonstrated technical success in 78% of Grade III cases, with prolapse reduction achieved via submucosal fibrosis.

Rectal Mucosal Prolapse

CAES is effective for small symptomatic prolapses presenting with tenesmus, obstruction, or anal protrusion. Submucosal injection induces fibrosis, stabilizing the mucosal layer. Early evidence suggests symptom improvement in 70% of cases, though long-term outcomes require further validation.

Contraindications

CAES is contraindicated in:

  • Active Infections or Structural Abnormalities: Perianal abscess, fistula, stricture, or anal malignancy.
  • Inflammatory Conditions: Radiation proctitis, immune-mediated ulcers, or unexplained anal ulcers (risk of perforation).
  • Advanced Hemorrhoids: Thrombosed or strangulated hemorrhoids, Grade IV internal hemorrhoids, or external hemorrhoids.
  • Psychiatric Factors: Hypochondriasis or somatization disorders necessitating psychiatric evaluation before intervention.

Technical Protocols

Bowel Preparation

Standard bowel cleansing regimens (e.g., polyethylene glycol) are mandated to ensure clear endoscopic visualization. Sedation or anesthesia improves patient tolerance, particularly during prolonged procedures.

Equipment Setup

  • Endoscopic Cap: A short-straight cap (Figure 1C) optimizes hemorrhoid exposure and stabilizes the injection site.
  • Needle Selection:
    • Long Needles (≥10 mm): Preferred for hemorrhoids with prolapse, enabling deeper submucosal injection.
    • Short Needles: Suitable for isolated bleeding hemorrhoids.

Injection Technique

  • Sclerosants: Lauromacrogol (0.5–2.0 mL per site) is widely used in China due to its rapid fibrotic effect. Alternatives include polidocanol and traditional agents like Xiaozhiling.
  • Site Selection: The 6 o’clock position (posterior anus) is prioritized for initial injection (Figure 1D–F). Submucosal delivery over 5 seconds ensures even dispersion.

Postprocedural Management

  1. Immediate Care:
    • Supine positioning for ≥2 hours minimizes prolapse risk.
    • Avoidance of laxatives or high-fiber diets for 6–12 hours prevents early defecation.
  2. Complication Management:
    • Gas Retention: Enema alleviates symptoms of rectal distention.
    • Bleeding or Ulcers: Conservative management with topical hemostatics; antibiotics reserved for suspected infections.
  3. Long-Term Follow-Up:
    • Address underlying constipation or diarrhea to prevent recurrence.
    • Patient-reported outcomes (pain, prolapse, bleeding) assessed at 4-week intervals.

Core Outcome Measures

The CAES-LPRA Study Group emphasizes patient-centric evaluation:

  • Primary Outcomes: Resolution of pain, prolapse, bleeding, itching, and soiling.
  • Secondary Outcomes: Complication rates, recurrence, and patient satisfaction.
    A 2020 multicenter trial reported 92% patient satisfaction at 6 months, with major complications (e.g., chronic pain, ulcers) occurring in <3% of cases.

Conclusions

CAES represents a paradigm shift in hemorrhoid management, combining endoscopic precision with minimally invasive therapy. The LPRA system standardizes anatomical targeting, reducing procedural variability. Ongoing studies aim to validate long-term efficacy, particularly for Grade III hemorrhoids and mucosal prolapse. Integration of CAES into global practice requires training programs to mitigate learning-curve-associated complications.

doi.org/10.1097/CM9.0000000000001836

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