Aluminum potassium sulfate and tannic acid sclerotherapy for Goligher Grades II and III hemorrhoids: Results from a multicenter study

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review to assess the safety and efficacy of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for the treatment of hemorrhoidal disease.

METHODS

Our study was conducted in accordance with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020. Primary endpoints included overall recurrence and type of recurrence while secondary endpoints included postoperative complications, reintervention, presence of rectal ulcer, rectal stricture, defecation abnormalities and perianal abscess. Α regression analysis, where the percentage of patients with grade II, III and IV hemorrhoidal disease was used as a covariate, was also performed.

RESULTS

Twelve studies with 4249 patients met all the inclusion criteria and were eventually included. The crude and pooled estimates of the overall recurrence and complications by the end of follow-up were 10% (95% CI, 6.52%-14.08%) and 5.20% (95% CI, 2.59%-8.52%), respectively. Regression analysis displayed no correlation between recurrence and the grade of hemorrhoid disease II, β= -0.0012 (95% CI, -0.0074 to 0.0049) (p = .64), grade III β= -0.0006 (95% CI, -0.0056 to 0.0045) (p = .79) and grade IV β = 0.0025 (95% CI, -0.0075 to 0.0124). However, a trend suggestive of increased recurrence was observed in patient populations with a higher proportion of grade IV disease.

CONCLUSION

ALTA sclerotherapy may be a safe and viable alternative for patients with hemorrhoidal disease. Long-term follow-up and high-quality randomized controlled trials will help define the place of ALTA sclerotherapy in the armamentarium of treatment of hemorrhoids.

Sclerotherapy for hemorrhoidal disease: systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the safety and efficacy of sclerotherapy methods for hemorrhoidal disease (HD) over the past 40 years.

METHODS

The review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A comprehensive literature search was conducted, including studies reporting the use of sclerotherapy in patients with HD. Study eligibility criteria were defined, and data were extracted independently by the authors. Random-effects meta-analyses were performed to assess outcomes of interest.

RESULTS

Out of 1965 records identified, 44 studies met the inclusion criteria, involving 9729 patients. The majority of studies were conducted in Japan, followed by the UK, Italy, and Portugal. The median age of participants was 52 years, and the majority were male. The Goligher grade distribution indicated varying degrees of HD severity. Sclerotherapy was predominantly administered through anoscopy, with polidocanol being the most commonly used agent. The procedure was generally performed without pre-injection analgesia. The meta-analysis of 14 randomized controlled trials (RCTs) revealed that sclerotherapy was not inferior to control interventions in terms of success rate (risk ratio [RR] 1.00, 95% CI 0.71-1.41) and recurrence rate (RR 1.11, 95% CI 0.69-1.77), while resulting in fewer complications (RR 0.46, 95% CI 0.23-0.92).

CONCLUSIONS

This systematic review highlights the safety and efficacy of sclerotherapy for HD, which yields similar success rates and fewer complications compared to other conservative or surgical approaches. Further research is warranted to optimize sclerotherapy techniques and evaluate long-term outcomes.

REGISTRATION

PROSPERO 2023 CRD42023396910.

Mid-term outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids

BACKGROUND

Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for the treatment of internal hemorrhoids. ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids.

METHODS

Patients with grade III hemorrhoids who underwent AM surgery were enrolled in this retrospective analysis of prospectively collected data from a single institution. Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed.

RESULTS

The median number of ALTA injection procedures was 3 (range 1-4), and the median total injection dose was 19 mL (range 7-32 mL). The median number of mucopexy procedures was 2 (range 1-4). The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2. The total dose of analgesics administered during the first two weeks after surgery was 1 (range 0-25). Six patients (5.3%) showed postoperative complications: five showed Clavien-Dindo (C-D) grade I and one showed C-D grade IIIa complications. Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively. Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year.

CONCLUSIONS

AM surgery is an effective non-excisional surgery with satisfactory mid-term results for grade III hemorrhoids, and is associated with lower complication rates, postoperative analgesic requirements, and higher patient satisfaction.

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.

Clinical impact of a new method using a clear proctoscope to evaluate the therapeutic effect of sclerotherapy with aluminum potassium sulfate and tannic acid (ALTA) for internal hemorrhoids: a prospective cohort study

Background

Hemorrhoids are a common benign disorder that can require surgery for treatment. Aluminum potassium sulfate and tannic acid (ALTA) have been used as a sclerotherapy agent that induces noninvasive sclerosis and regression of hemorrhoids without surgery. However, there is no objective index for determining its effectiveness. In this study, we prospectively investigated the usefulness of our method as an objective indicator of the effectiveness of ALTA sclerotherapy.

Methods

From April 2015 to April 2019, 241 patients underwent ALTA sclerotherapy. We standardized a simple evaluation method using the lumen of the lower rectum as observed through a clear plastic proctoscope. Patients' hemorrhoids were evaluated preoperatively and their subjective satisfaction with treatment by our new method was evaluated on postoperative day 7.

Results

Our method showed that among patients who lost the rectal lumen before treatment, the lumen was reacquired after ALTA sclerotherapy in 96.1% (224/233). McNemar test showed the effect of ALTA sclerotherapy to be significantly associated with lumen gain [κ value, 0.0027; 95% confidence interval (CI): 0.0001-0.0052], P<0.001]. Patients' subjective satisfaction with the treatment was significantly higher in the group reacquiring the lumen (Fisher's exact test, P=0.0186). Among those patients needing re-treatment, 59.4% (19/32) had lost their lumen during follow-up [mean difference, 0.578; standard deviation (SD): 0.502, P<0.001].

Conclusions

Our simple method using a clear plastic proctoscope could objectively indicate the effect of ALTA sclerotherapy and patients who needed re-treatment on losing their lumen during follow-up. We believe this method is highly advantageous for patients, can advocate the concept of the hemorrhoid shrinking sign, and will contribute to the development of new indication criteria for ALTA sclerotherapy.

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy complicating laparoscopic low anterior resection of rectal cancer: Case report

Introduction

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy is increasingly popular for treating internal hemorrhoids. This injectable compound incites inflammation to dampen hemorrhoidal blood flow and inflict secondary fibrosis. Herein, we detail the implications of ALTA treatment for laparoscopic low anterior resection of rectal cancer.

Patient presentation

A 72-year-old man receiving ALTA sclerotherapy for internal hemorrhoids thereafter required laparoscopic low anterior resection for newly discovered early rectal cancer. Observed changes of anal canal resembled those of radiochemotherapy and proved problematic. There was mural thickening and sclerosis at the planned resection site. To ensure proper removal, the bowel was compressed and stapled slowly. A two-shot resection took place (without straining), anastomosis was performed, and a covering stoma was constructed. Recovery was uneventful, allowing discharge on postoperative Day 10. The ileostomy was closed at a later time.

Discussion

Although little information is available on long-term rectal pathology after ALTA therapy, existing data suggest that sclerosis persists well beyond injection timeframes. Hence, caution is required in dissecting and debriding sclerotic remnants. We have identified only four earlier reports in this setting, the present case providing added perspective.

Conclusion

Colonoscopy is highly advisable prior to ALTA therapy. A thorough work-up before rectal surgery is also essential, documenting any past treatments for anorectal disease, especially ALTA.

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Rectal surgery after ALTA therapy requires caution due to mural thickening.

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ALTA-induced tissue fibrosis is sustained for at least 5 years.

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Careful preoperative histories of prior anorectal treatments are essential.

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Colonoscopy is strongly recommended prior to treatment of anorectal disease.

Long-term Outcomes of Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy for Prolapsed Hemorrhoids: A Single-Center, Observational Study

BACKGROUND

Aluminum potassium sulfate and tannic acid sclerotherapy for hemorrhoids produced almost the same effects as excisional hemorrhoidectomy. However, its long-term effectiveness remains unknown.

OBJECTIVE

The purpose of this study was to investigate the long-term results of sclerotherapy using aluminum potassium sulfate and tannic acid for treating prolapsed hemorrhoids.

DESIGN

This was a retrospective review of a single-institution experience.

SETTINGS

This study was conducted within a coloproctology unit at a community-based hospital.

PATIENTS

In total, 1180 patients with grade II to IV hemorrhoids treated with injection sclerotherapy were enrolled.

MAIN OUTCOME MEASURES

Efficacy measures included cumulative recurrence rates and postoperative complications.

RESULTS

Recurrence rates at 3, 6, and 9 years were 7.4%, 27.2%, and 47.5%. Postoperative complications included fever ≥38°C in 16 (1.4%) patients, rectal ulcer in 10 (0.9%) patients, rectal stricture in 5 (0.4%) patients, and perianal abscess in 4 (0.3%) patients.

LIMITATIONS

This was a retrospective, nonrandomized, single-center study. In addition, office visits after 3 years were optional and the number of follow-ups steadily decreased.

CONCLUSIONS

Sclerotherapy using aluminum potassium sulfate and tannic acid offers reasonable long-term results and is associated with low complication rates. Therefore, it seems to be an attractive alternative for patients with prolapsed hemorrhoids. See Video Abstract at http://links.lww.com/DCR/B733.RESULTADOS A LARGO PLAZO DE LA ESCLEROTERAPIA CON SULFATO DE ALUMINIO Y POTASIO, Y ÁCIDO TÁNICO PARA LAS HEMORROIDES PROLAPSADAS: ESTUDIO OBSERVACIONAL DE UN SOLO CENTRO.

ANTECEDENTES

La escleroterapia con sulfato de aluminio y potasio, y ácido tánico para las hemorroides produjo casi los mismos efectos que la hemorroidectomía por escisión. Sin embargo, se desconoce su eficacia a largo plazo.

OBJETIVO

El propósito de este estudio fue investigar los resultados a largo plazo de la escleroterapia con sulfato de aluminio y potasio, y ácido tánico para tratar las hemorroides prolapsadas.

DISEO

Revisión retrospectiva de la experiencia de una sola institución.

ENTORNO CLINICO

Este estudio se realizó dentro de una unidad de coloproctología en un hospital comunitario.

PACIENTES

En total, 1.180 pacientes fueron inscritos con hemorroides grado II a IV tratados con inyecciones esclerosantes.

PRINCIPALES MEDIDAS DE VALORACION

Las medidas de eficacia incluyeron tasas acumulativas de recurrencia y complicaciones posoperatorias.

RESULTADOS

La tasa de recurrencia a los 3, 6 y 9 años fue del 7,4%, 27,2% y 47,5%, respectivamente. Las complicaciones posoperatorias incluyeron fiebre ≥ 38 grados Celsius en 16 pacientes (1,4%), úlcera rectal en 10 (0,9%), estenosis rectal en 5 (0,4%) y absceso perianal en 4 (0,3%) pacientes.

LIMITACIONES

Este fue un estudio retrospectivo, no aleatorio, de un solo centro. Adicionalmente, las visitas al consultorio después de 3 años eran opcionales y el número de seguimientos disminuyó constantemente.

CONCLUSIONES

La escleroterapia con sulfato de aluminio y potasio, y ácido tánico ofrece resultados razonables a largo plazo y está asociada con bajas tasas de complicaciones. Por tanto, parece ser una alternativa atractiva para pacientes con hemorroides prolapsadas. Consulte Video Resumen en http://links.lww.com/DCR/B733. (Traducción- Dr. Francisco M. Abarca-Rendon).

Early Postoperative Outcomes of a Novel Nonexcisional Technique Using Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy With Mucopexy on Patients With Grade III Hemorrhoids

Purpose

Aluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids.

Methods

AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial.

Results

The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6–5.5] vs. 7.6 tablets [range 3.3–11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery.

Conclusion

AM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

Efficacy and safety of sclerotherapy with polidocanol in children with internal hemorrhoids

BACKGROUND

Hemorrhoids are an extremely rare condition in children, and data on its incidence and treatment in the pediatric population remains scarce. We retrospectively reviewed children who underwent sclerotherapy for internal hemorrhoids, and analyzed patients' characteristics and outcomes.

METHODS

A total of 14 pediatric patients who underwent sclerotherapy were included. Patients' ages and the required amount of polidocanol, depending on the grade of hemorrhoids, and the correlation between age and volume of sclerosant, were statistically analyzed.

RESULTS

Patients had a male predominance with a ratio of 2.5:1 (grade 2:6 patients, grade 3:8 patients). Four children had underlying conditions including portal hypertension and Klippel-Trenaunay syndrome. Of the 14 patients, 43% had constipation requiring medication or enema. Only one minor complication, a perianal ulceration, was found to be associated with sclerotherapy. Patients with grade 3 hemorrhoids required a significantly larger amount of polidocanol than those with grade 2 hemorrhoids. Two patients with grade 3 hemorrhoids required a second session of treatment for recurrence. The success rate of sclerotherapy with polidocanol was 86%.

CONCLUSIONS

Sclerotherapy with polidocanol is a safe, effective, and less invasive treatment option for internal hemorrhoids in children. Further studies are needed to investigate this treatment approach.

Laparoscopic anterior resection for rectal stenosis caused by ALTA injection for internal hemorrhoids: A case report

We herein report the first case of rectal stenosis that developed after internal hemorrhoid treatment with aluminum potassium sulfate and tannic acid (ALTA) therapy that was successfully treated by laparoscopic surgery. A 72-year-old man suffered from a fever and rectal stenosis after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA at a previous clinic. Three months after ALTA therapy, he developed frequent mucous and bloody stools. Lower intestinal tract endoscopy revealed circumferential severe rectal stenosis. He was therefore referred to our hospital. The patient suffered from frequent stool build-up and difficulty defecating. We performed balloon-dilatation intervention. The stenosis was not improved at all. Five months after ALTA therapy, we performed laparoscopic low anterior resection with diverting ileostomy. Three months after the operation, ileostomy takedown was performed. The patient has experienced no rectal stenosis in the 2 years since his radical operation.

Progress in Endoscopic Treatment of Hemorrhoids

Hemorrhoids are one of the most common diseases of the anorectal region. Previously, treatment for hemorrhoids included conservative treatment, outpatient treatment, and surgical treatment. The development of flexible reversible endoscopes has provided precise controllability and imaging, enabling further improvement and development of various endoscopic techniques to treat hemorrhoids. This article discusses several of these endoscopic techniques: rubber band ligation, sclerotherapy, and electrocoagulation. The development, efficacy, and advantages of these treatments are summarized and evaluated. It is expected that going forward, endoscopic technology will be further applied in clinical practice and may become the first-line method for the treatment of hemorrhoids.

Gluteal-fold flap repair of rectovaginal fistula caused by aluminum potassium sulfate hydrate-tannic acid injection for internal hemorrhoids: a case report

BACKGROUND

Rectovaginal fistula (RVF) following aluminum potassium sulfate hydrate-tannic acid (ALTA) injection therapy for hemorrhoids is a rare complication. We report the first case of RVF after ALTA injection therapy successfully treated by gluteal-fold flap.

CASE PRESENTATION

A 49-year-old female suffered from a fever and rectal ulcer after undergoing internal hemorrhoid treatment with a submucosal ALTA injection at a previous clinic. One week after ALTA therapy, she noted obvious passage of flatus and stool through the vagina, and was diagnosed with RVF by anoscope at another clinic. She was referred to our hospital 3 weeks after ALTA therapy. Sigmoid colostomy was performed for fecal diversion as a preliminary step for fistula repair. However, the fistula was scarred and the defect between the rectum and vagina did not improve at all. Ten months after ALTA therapy, we performed fistula repair by gluteal-fold flap. Seven months later, sigmoid-colostomy reversal was performed. The patient has experienced no RVF in the 3 years since sigmoid-colostomy reversal.

CONCLUSIONS

The gluteal-fold flap strategy is a useful option for severe RVF management.

Portuguese Society of Gastroenterology Consensus on the Diagnosis and Management of Hemorrhoidal Disease

Hemorrhoidal disease (HD) is a frequent health problem with considerable repercussions on patients' quality of life. However, much of the clinical practice related to HD is based on knowledge without scientific evidence and supported largely by empirical experience of the physician who deals with this pathology. As in other countries, the goal of this consensus is to establish statements supported by solid scientific evidence and whose purpose will be to standardize and guide the diagnosis and management of HD both in the general population and in some particular groups of patients.

Robot-assisted low anterior resection after aluminum potassium sulfate and tannic acid sclerosing therapy for internal hemorrhoids

Background

Internal hemorrhoids are the most common anal diseases. Aluminum potassium sulfate and tannic acid (ALTA) injection is a new sclerosing therapy for the treatment of internal hemorrhoids. Although ALTA injection has been widely used, there are no previous reports of rectal cancer patients who underwent robot-assisted low anterior resection (Rob-LAR) after ALTA injection to treat internal hemorrhoids.

Case presentation

A 70-year-old man with rectal cancer was presented to our hospital. He had an ALTA injection 2 months before presentation at a clinic due to hematochezia with internal hemorrhoids. The rectal tumor was located 7 cm above the anal verge, and Rob-LAR with the da Vinci Xi system was performed. The patient had sclerosis on the stump of the anal side, which made it difficult to transect the rectum with linear staplers. This required multiple repeats of compression through the SmartClamp feedback. After anastomosis with the double-stapling technique, we constructed a diverting ileostomy.

Conclusion

Although ALTA injection is a promising strategy for internal hemorrhoids, rectal cancer should be excluded before the sclerosing therapy.

Effectiveness of Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid as a Non-Surgical Treatment for Internal Hemorrhoids

BACKGROUND/AIMS

Sclerotherapy with aluminum potassium sulfate and tannic acid (ALTA) has a potent effect on internal hemorrhoids. In this retrospective study, we compared the effects of endoscopic ALTA therapy and standard ALTA therapy.

METHODS

We investigated patients who underwent treatment for internal hemorrhoids at our institution between 2014 and 2016. They were divided into a standard ALTA group (n=33, treated using proctoscopy) and an endoscopic ALTA group (n=48). We compared the clinical findings between the 2 groups.

RESULTS

There were no intergroup differences in background factors. The mean ALTA dose was 21.9±7.2 mL and 17.8±3.4 mL in the standard and endoscopic ALTA groups, respectively (p<0.01). Adverse events occurred in 4 patients (12.1%) from the standard ALTA group and 6 patients (12.5%) from the endoscopic ALTA group. In both groups, the patients reported good satisfaction with the therapeutic effect at 1 month after the procedure. Hemorrhoids recurred in 2 patients (6.3%) from the standard ALTA group and 4 patients (8.3%) from the endoscopic ALTA group.

CONCLUSION

Endoscopic ALTA sclerotherapy is equivalent to standard ALTA therapy in terms of efficacy, adverse events, and recurrence. Therefore, it is a useful non-surgical option for patients with internal hemorrhoids who prefer a less invasive treatment.

Laparoscopic low anterior resection for rectal cancer after Whitehead's hemorrhoidectomy: A case report

A 65-year-old man presented with bloody stool. Colonoscopy revealed a raised tumor in the rectum, above the peritoneal reflection. He underwent endoscopic mucosal resection, but the pathological findings suggested the possibility of residual cancer. We performed laparoscopic low anterior resection using a circular stapling instrument for additional curative surgery. However, we could not insert the shaft of the endoscopic circular stapler from the anus because of anal stenosis due to Whitehead's hemorrhoidectomy the patient had undergone 20 years earlier. Therefore, we planned to use a linear stapler to insert an anvil into the rectum. The cartridge-carrying instrument was inserted from the sigmoidal side, and we performed a side-to-end anastomosis. The patient was discharged without anastomotic leakage or defecation disorder. We present this case because laparoscopic low anterior resection for rectal cancer with anal stenosis has not been previously reported.

Liver injury after aluminum potassium sulfate and tannic acid treatment of hemorrhoids

We are reporting a rare case of acute liver injury that developed after an internal hemorrhoid treatment with the aluminum potassium sulfate and tannic acid (ALTA) regimen. A 41-year-old man developed a fever and liver injury after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA with lidocaine. The acute liver injury was classified clinically as hepatocellular and pathologically as cholestastic. We could not classify the mechanism of injury. High eosinophil and immunoglobulin E levels characterized the injury, and a drug lymphocyte stimulation test was negative on postoperative day 25. Fluid replacement for two weeks after hospitalization improved the liver injury. ALTA therapy involves injecting chemicals into the submucosa, from the rectum to the anus, and this is the first description of a case that developed a severe liver disorder after this treatment; hence, an analysis of future cases as they accumulate is desirable.