Hemorrhoid Banding: A Cost-Effectiveness Analysis

Endoscopic polidocanol foam sclerobanding for treatment of internal hemorrhoids: A novel outpatient procedure

In the study, we comment on the article by Qu et al. Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings.

The role of the Rafaelo procedure in the management of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to summarize the current evidence regarding the role of the Rafaelo procedure in the management of hemorrhoidal disease (HD).

METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed (Medline, Scopus, CENTRAL, and Web of Science) from inception to 25/09/2022. Grey literature databases were also reviewed. The primary endpoint was the pooled complications rate of the Rafaelo procedure in patients with HD. Secondary endpoints included short- (bleeding, pain, thrombosis, necrosis, urinary retention, fever, oedema, anal fissure, and readmission) and long-term (stenosis, meteorism, constipation, anal tags, anal hyposensibility, reoperation, and recurrence) postoperative complication rates. Both prospective and retrospective studies were considered. Quality evaluation was performed via the ROBINS-I tool. Certainty of Evidence was based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

Overall, 6 non-randomized studies and 327 patients were included. The overall complication rate was 17.6% (95% CI 8.8-26.3%). Short-term complications were bleeding (7.5%, 95% CI 2.5-12.5%), thrombosis (2.2%, 95% CI 0.4-4.8%), and pain (1.6%, 95% CI 0.2-3.3%). Reoperation and recurrence rates were 1.8% (95% CI 0.3-3.4%) and 4.8% (95% CI 1.2-8.4%), respectively. A significant improvement in the presenting symptoms was noted. Method approval and patient satisfaction rates were 89.1% (95% CI 81.7-96.6%) and 95% (95% CI 89.8-100%), correspondingly. Overall CoE was "Very Low".

CONCLUSIONS

Further randomized controlled trials are required to delineate the exact role of the Rafaelo procedure in HD.

A comparative study of rubber band ligation versus BANANA-Clip in grade 1 to 3 internal hemorrhoids

PURPOSE

Rubber band ligation (RBL) for grade 1 to 3 internal hemorrhoids is a well-established modality of choice. But RBL is also a kind of surgical treatment; it is not free from complications (e.g., delayed bleeding [DB], rectal stenosis). This study aimed to investigate the results of the comparative treatment of RBL and BANANA-Clip (BC; Endovision).

METHODS

Study participants were 632 consecutive patients with grade 1 to 3 internal hemorrhoids attended to Department of Colorectal Surgery at Wellness Hospital between January 2010 and May 2019. We retrospectively reviewed the incidence rate of complications, including DB between RBL and BC.

RESULTS

There were 304 male and 328 female patients, whose ages ranged from 15 to 84 years, with a mean age of 45.7 years. The common symptom and cause of treatment was prolapse (70.1%). The number of ligated sites was 1.49±0.57 in the RBL group and 1.99±0.77 in the BC group. RBL showed a significantly higher incidence of DB (3.5%) compared to BC (0%) (P=0.001). The 1-year success rate was 95.9% in the RBL group and 99.7% in the BC group (P=0.005).

CONCLUSION

In our study, BC was more reliable in treating grade 1 to 3 internal hemorrhoids with higher success rates and less post-ligation complications, especially DB, compared to RBL.

Belgian consensus guideline on the management of hemorrhoidal disease

Introduction

Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking.

Methods

A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020.

Results

Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids.

Conclusions

The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Cap-assisted endoscopic sclerotherapy for internal hemorrhoids: technique protocol and study design for a multi-center randomized controlled trial

BACKGROUND

Cap-assisted endoscopic sclerotherapy is a new interventional therapy for internal hemorrhoids and rectal prolapse under colonoscopy. The proper length of the endoscopic injection needle is the core for performing cap-assisted endoscopic sclerotherapy well with more benefits and less complications. However, no data are currently available to guide endoscopists to consider the length of injection needle before cap-assisted endoscopic sclerotherapy. This study is designed to evaluate the efficacy and safety of cap-assisted endoscopic sclerotherapy with long or short injection needle in the treatment of internal hemorrhoids.

METHODS

This is a nationwide multi-center, prospective, single-blind and randomized controlled trial. Patients with grade I-II internal hemorrhoids who have failed to conservative treatments and grade III internal hemorrhoids who are not suitable for surgery or refuse surgery will be included. Participants will be randomized 1:1 into either long or short injection needle group. The primary outcome is the recurrence rate of internal hemorrhoids 24 weeks after cap-assisted endoscopic sclerotherapy. The secondary outcomes are as follows: (1) symptom severity score, (2) three-level EuroQoL five dimensions health scale scores, (3) occurrence of adverse events and severe adverse events, and (4) patients' attitudes toward cap-assisted endoscopic sclerotherapy. Data collection will be conducted before and during operation, the 1st day, 1st week, 2nd week, and 24th week after cap-assisted endoscopic sclerotherapy.

DISCUSSION

The outcome of this study is expected to provide a practical clinical protocol of cap-assisted endoscopic sclerotherapy for patients with internal hemorrhoids and promote the use of this new endoscopic technique.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03917056. Registered on 12 April 2019.