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

Efficacy of two endoscopic rubber band ligation methods for symptomatic hemorrhoids: a randomized controlled trial

BACKGROUND

Endoscopic rubber band ligation (ERBL) is considered an effective nonsurgical treatment for symptomatic grade I to III hemorrhoids; however, it is unclear whether ligation of hemorrhoids or simultaneous ligation of hemorrhoids and proximal normal mucosa (combined ligation) is safer and more effective. This controlled, open-label, and prospective study aimed to evaluate the efficacy and safety of both methods for symptomatic grade I to III hemorrhoids.

METHODS

Seventy patients with symptomatic grade I to III hemorrhoids were randomly assigned to the hemorrhoid and combined ligation groups (35 in each group). Patients were followed up at 3, 6, and 12 months to assess symptom improvement, complications, and recurrence. The primary outcome was overall therapeutic success rate (complete resolution and partial resolution rates). The secondary outcomes included recurrence rate and efficacy for each symptom. Complications and patient satisfaction were also assessed.

RESULTS

Sixty-two patients (31 in each group) completed the 12-month follow-up; 42 (67.8%) experienced complete resolution, 17 (27.4%) experienced partial resolution, and 3 (4.8%) experienced no change in overall efficacy. The rates of complete resolution, partial resolution, and no change in the hemorrhoid ligation and combined ligation groups were 71.0 and 64.5%, 22.6 and 32.3%, and 6.5 and 3.2%, respectively. No significant differences in overall efficacy, recurrence rate, or efficacy for each symptom (including bleeding, prolapse, pain, anal swelling, itching, soiling, and constipation) were observed between groups. No life-threatening events requiring surgical intervention occurred. The incidence of postoperative pain was higher in the combined ligation group (74.2% vs. 45.2%, P = 0.02). No significant differences between groups in terms of incidences of other complications or patient satisfaction were observed.

CONCLUSION

Both methods achieved satisfactory therapeutic effects. No significant differences in efficacy and safety of the two ligation methods were observed; however, combined ligation resulted in a higher incidence of postprocedural pain.

Minimally Invasive Treatment for Advanced Hemorrhoids

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Long-term efficacy and safety of cap-assisted endoscopic sclerotherapy with long injection needle for internal hemorrhoids

BACKGROUND

Hemorrhoids are a common anal condition and can afflict an individual at any age. Epidemiological survey results in China show that the prevalence of anorectal diseases is as high as 50.1% among which 98.08% of patients have hemorrhoid symptoms.

AIM

To assess long-term efficacy and safety of cap-assisted endoscopic sclerotherapy (CAES) with long injection needle for internal hemorrhoids.

METHODS

This study was retrospective. Data from patients with symptomatic internal hemorrhoids treated with CAES using endoscopic long injection needle from April 2016 to December 2019 were collected. Patients were telephoned and followed at two time points, December 2020 and 2021, to evaluate the improvements in symptoms, complications, recurrence, and satisfaction.

RESULTS

Two hundreds and one patients with internal hemorrhoids underwent CAES with the long needle. The first median follow-up was performed 33 mo post-operatively. Symptoms improved in 87.5% of patients after the first CAES. Efficacy did not decrease with treatment time extension. Fifty-four patients underwent colonoscopy after the first CAES treatment of which 21 underwent CAES again, and 4 underwent hemorrhoidectomy. At the first follow-up, 62.7% of patients had both improved hemorrhoid grades and symptoms, and 27.4% had a significant improvement in both parameters. At the second follow-up, 61.7% of the patients showed satisfactory improvement in their hemorrhoid grade and symptoms when compared with pre-surgery values. 90% of patients reported CAES was painless, and 85% were satisfied/very satisfied with CAES treatment outcomes.

CONCLUSION

The present study based on the largest sample size reported the long-term follow-up of the treatment for internal hemorrhoid with the CAES using endoscopic long injection needle. Our findings demonstrate that CAES should be a micro-invasive endoscopic technology yields satisfactory long-term efficacy and safety.

Sclerotherapy in Hemorrhoids

Injection sclerotherapy for all grades of interhemorrhoids in various situations and co-morbidities has become popular method of treatment. Several types of surgical operations both conventional and stapled hemorrhoidectomy has many and serious described side effects. On the contrary, proctoscopic injection sclerotherapy using some of the modern sclerosants and thin bore needle injections is an office-based ambulatory method of treatment of internal hemorrhoids; it is low in cost, devoid of any major complications besides it is quite successful as reported. Its safety and efficacy has been published in recent years. This manuscript is a result of thorough systemic review using PRISMA guidelines on various sclerosing agents, their merits and demerits, methods of administration, and outcome in internal hemorrhoids.