Rubber Band Ligation Compared with other Modes of Therapy for Symptomatic Hemorrhoids

A meta-analysis 1 including 18 randomised controlled trials with a total of 1 952 subjects was abstracted in DARE. The studies, published from 1966 to February 1994, compared manual dilation of the anus versus hemorrhoidectomy (6 trials), rubber band ligation versus hemorrhoidectomy (3 trials), sclerotherapy versus infrared photocoagulation (2 trials), sclerotherapy versus rubber band ligation (4 trials), and rubber band ligation versus infrared coagulation (3 trials). Sixteen trials were included in the meta-analysis.

• Haemorrhoidectomypatients had a better response to treatment than did patients treated with rubber band ligation (p=0.001), although complications were greater (p=0.02) as was pain (p<0.0001).
• Rubber band ligation was better than sclerotherapy in response to treatment for all haemorrhoids (p=0.005), as well as for haemorrhoids stratified by grade (grades 1 to 2 ; p=0.007; grade 3 p=0.042), with no difference in the complication rate (p=0.35).
• Patients treated with rubber band ligation were less likely to require further therapy than those treated with sclerotherapy (p=0.031) or infrared coagulation (p=0.0014), although pain was greater after rubber band ligation (p=0.03 for sclerotherapy, p<0.0001 for infrared coagulation).
• Haemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (p=0.0017) with less need for further therapy (p=0.034), no significant difference in complications (p=0.60), but significantly more pain (p<0.0001).

Authors' conclusion: Rubber band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates it is associated with more complications and pain than rubber band ligation, and should thus be reserved for patients who fail to respond to rubber band ligation

The trials comparing rubber band ligation (RBL) and excisional haemorrhoidectomy (EH) were also reviewed in a Cochrane review 2 (abstract , review [Abstract]) including 3 studies of poor methodological quality, with a total of 332 subjects. Complete remission of haemorrhoidal symptom was better with EH (three studies, 202 patients, RR 1.68, 95% CI 1.00 to 2.83). There was significant heterogeneity between the studies (I² = 90.5%; P = 0.0001). Similar analysis based on the grading of haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04 to 1.45; P = 0.01). However, no significant difference was noticed in grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94 to 1.21; P = 0.32) Fewer patients required re-treatment after EH (three trials, RR 0.20 CI 0.09 to 0.40; P < 0.00001). Patients undergoing EH were at significantly higher risk of postoperative pain (three trials, fixed effect; 212 patients, RR 1.94, 95% CI 1.62 to 2.33, P < 0.00001). The overall delayed complication rate showed significant difference (P = 0.03) (three trials, 204 patients, RR 6.32, CI 1.15 to 34.89) between the two interventions.

The following decision support rules contain links to this evidence summary:

• Rubber band ligation for hemorrhoids http://www.ebmeds.org/ebmeds/ebmeds_home.asp?mode=scripts&submode=view&id=scr00518&country=UK

References

• MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis ColonRectum 1995 Jul;38(7):687-94. [PubMed] [DARE]
• Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev 2005 Jul 20;(3):CD005034. [PubMed]