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.
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.
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