Advertisement

Diseases of the Colon & Rectum

, Volume 38, Issue 7, pp 687–694 | Cite as

Comparison of hemorrhoidal treatment modalities

A meta-analysis
  • Helen M. MacRae
  • Robin S. McLeod
Original Contributions

Abstract

PURPOSE: The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials. METHOD: A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain. RESULTS: A total of 18 trials were available for analysis. Hemorrhoidectomy 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). Patients undergoing hemorrhoidectomy 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 hemorrhoids (P=0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2;P=0.007; Grade 3 hemorrhoids,P=0.042), with no difference in the complication rate (P=0.35). Patients treated with sclerotherapy (P=0.031) or infrared coagulation (P=0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P=0.03 for sclerotherapy;P<0.0001 for infrared coagulation).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, thus should be reserved for patients who fail to respond to rubber band ligation.

Key words

Hemorrhoids Meta-analysis Hemorrhoidectomy Rubber band ligation Injection sclerotherapy Infrared coagulation 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Freiman JA, Chalmers TC, Smith H, Kuebler RR. The importance of beta, the type II error and sample size in the design and interpretation of the randomized control trial: survey of 71 “negative” trials. N Engl J Med 1978;299:690–4.PubMedGoogle Scholar
  2. 2.
    Boissel JP, Sacks HS, Leizorrovicz A, Blanchard J, Panak E, Peyrieux JC. Meta-analysis of clinical trials: summary of an international conference. Eur J Clin Pharmacol 1988;34:535–8.PubMedGoogle Scholar
  3. 3.
    Corman ML. Colon and rectal surgery. 3rd ed. Philadelphia: JB Lippincott, 1993:111–5.Google Scholar
  4. 4.
    Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum and anus. St. Louis: Quality Medical Publishing, 1992:196–7.Google Scholar
  5. 5.
    Solomon MJ, McLeod RS. Clinical studies in surgical journals—have we improved? Dis Colon Rectum 1993;36:43–8.PubMedGoogle Scholar
  6. 6.
    Demets DL. Methods for combining randomized clinical trials: strengths and limitations. Stat Med 1987;6:341–8.PubMedGoogle Scholar
  7. 7.
    Rosenthal R. Meta-analytic procedures for social research. Beverly Hills, CA: Sage Publications, 1984.Google Scholar
  8. 8.
    Breslow NE, Day NE. Statistical methods in cancer research. Vol. 1. The analysis of case-control studies. Lyon: IARC, 1980:122–59.Google Scholar
  9. 9.
    Hood TR, Alexander-Williams J. Anal dilatationversus rubber band ligation for internal hemorrhoids, method of treatment in outpatients. Am J Surg 1971;122:545–8.PubMedGoogle Scholar
  10. 10.
    Varma JS, Chung SC, Li AK. Prospective randomised comparison of current coagulation and injection sclerotherapy for the outpatient treatment of haemorrhoids. Int J Colorectal Dis 1991;6:42–5.PubMedGoogle Scholar
  11. 11.
    Wright RA, Kranz KR, Kirby SL. A prospective crossover trial of direct current electrotherapy in symptomatic hemorrhoidal disease. Gastrointest Endosc 1991;37:621–3.PubMedGoogle Scholar
  12. 12.
    Andrews BT, Layer GT, Jackson BT, Nicholls RJ. Randomized trial comparing diathermy hemorrhoidectomy with the scissor dissection Milligan-Morgan operation. Dis Colon Rectum 1993;36:580–3.PubMedGoogle Scholar
  13. 13.
    Griffith CD, Morris DL, Wherry DC, Hardcastle JD. Outpatient treatment of haemorrhoids: a randomised trial comparing contact bipolar diathermy with rubber band ligation. Coloproctology 1988;6:332–4.Google Scholar
  14. 14.
    Senagore A, Mazier WP, Luchtefeld MA, MacKeigan JM, Wengert T. Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpelus. contact Nd:YAG laser. Dis Colon Rectum 1993;36:1042–9.PubMedGoogle Scholar
  15. 15.
    Reid Neto JA, Quilici FA, Cordeiro F, Reis JA. Openversus semi-open hemorrhoidectomy: a random trial. Int Surg 1992;77:84–90.PubMedGoogle Scholar
  16. 16.
    Roe AM, Bartolo DC, Vellacott KD, Locke-Edmunds J, Mortensen NJ. Submucosalversus ligation excision haemorrhoidectomy: a comparison of anal sensation, anal sphincter manometry and postoperative pain and function. Br J Surg 1987;74:948–51.PubMedGoogle Scholar
  17. 17.
    Hinton CP, Morris DL. A randomized trial comparing direct current therapy and bipolar diathermy in the outpatient treatment of third-degree hemorrhoids. Dis Colon Rectum 1990;33:931–2.PubMedGoogle Scholar
  18. 18.
    Smith LE, Goodreau JJ, Fouty WJ. Operative hemorrhoidectomyversus cryodestruction. Dis Colon Rectum 1979;22:10–6.PubMedGoogle Scholar
  19. 19.
    Wang JY, Chang-Chien CR, Chen JS, Lai CR, Tang R. The role of lasers in hemorrhoidectomy. Dis Colon Rectum 1991;34:78–82.PubMedGoogle Scholar
  20. 20.
    Murie JA, Mackenzie I, Sim AJ. Rubber band ligation and hemorrhoidectomy for second and third degree hemorrhoids: a prospective clinical trial. Br J Surg 1980;67:786–8.PubMedGoogle Scholar
  21. 21.
    Murie JA, Mackenzie I, Sim AJ. Rubber band ligationversus hemorrhoidectomy for prolapsing hemorrhoids: a long term prospective clinical trial. Br J Surg 1982;69:536–8.PubMedGoogle Scholar
  22. 22.
    Walker AJ, Leicester RJ, Nicholls RJ, Mann CV. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of hemorrhoids. Int J Colorectal Dis 1990;5:113–6.PubMedGoogle Scholar
  23. 23.
    Leicester RJ, Nicholls RJ, Mann CV. Comparison of infrared coagulation with conventional methods and the treatment of hemorrhoids. Coloproctology 1981;5:313–5.Google Scholar
  24. 24.
    Sim AJ, Murie JA, Mackenzie I. Comparison of rubber band ligation and sclerosant injection for first- and second-degree hemorrhoids: a prospective clinical trial. Acta Chir Scand 1981;147:717–20.PubMedGoogle Scholar
  25. 25.
    Sim AJ, Murie JA, Mackenzie I. Three year follow-up study on the treatment of first- and second-degree hemorrhoids by sclerosant injection or rubber band ligation. Surg Gynecol Obstet 1983;157:534–6.PubMedGoogle Scholar
  26. 26.
    Dennison A, Whiston RJ, Rooney S, Chadderton RD, Wherry DC, Morris DL. A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids. Dis Colon Rectum 1990;33:32–4.PubMedGoogle Scholar
  27. 27.
    Mortensen PE, Olsen J, Pedersen IK, Christiansen J. A randomized study on hemorrhoidectomy combined with anal dilatation. Dis Colon Rectum 1987;30:755–7.PubMedGoogle Scholar
  28. 28.
    Seow-Choen F, Ho Y-H, Ang H-G, Goh H-S. Prospective, randomized trial comparing pain and clinical function after conventional scissors excision/ligationversus diathermy excision without ligation for symptomatic prolapsed hemorrhoids. Dis Colon Rectum 1992;35:1165–9.PubMedGoogle Scholar
  29. 29.
    Anscombe AR, Hancock BD, Humphreys WV. A clinical trial of the treatment of haemorrhoids by operation and the Lord procedure. Lancet 1974;2:250–3.PubMedGoogle Scholar
  30. 30.
    Chant AD, May A, Wilken BJ. Hemorrhoidectomyversus manual dilatation of the anus. Lancet 1972;2:398–9.PubMedGoogle Scholar
  31. 31.
    Lewis AA, Rogers HS, Leighton M. Trial of maximal anal dilatation, cryotherapy and elastic band ligation as alternatives to hemorrhoidectomy in the treatment of large prolapsing hemorrhoids. Br J Surg 1983;70:54–6.PubMedGoogle Scholar
  32. 32.
    Cheng FC, Shum DW, Ong GB. The treatment of second degree hemorrhoids by injection, rubber band ligation, maximal anal dilatation and hemorrhoidectomy, a prospective clinical trial. Aust N Z J Surg 1981;51:458–62.PubMedGoogle Scholar
  33. 33.
    Hiltunen KM, Matikainen M. Anal dilatation, lateral subcutaneous sphincterotomy and haemorrhoidectomy for the treatment of second and third degree haemorrhoids: a prospective randomized study. Int Surg 1992;77:261–3.PubMedGoogle Scholar
  34. 34.
    Hardy KJ, Wheatley IC, Heffernan EB. Anal dilatation and haemorrhoidectomy a prospective study. Med J Aust 1975;2:88–91.PubMedGoogle Scholar
  35. 35.
    Ambrose NS, Morris D, Alexander-Williams J, Keighley MR. A randomized trial of photocoagulation or injection sclerotherapy for the treatment of first- and second-degree hemorrhoids. Dis Colon Rectum 1985;28:238–40.PubMedGoogle Scholar
  36. 36.
    Gartell PC, Sheridan RJ, McGinn FP. Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligation with phenol injection. Br J Surg 1985;72:478–9.PubMedGoogle Scholar
  37. 37.
    Greca F, Hares MM, Nevah E, Alexander-Williams J, Keighley MR. A randomized trial to compare rubber band ligation with phenol injection for treatment of haemorrhoids. Br J Surg 1981;68:250–2.PubMedGoogle Scholar
  38. 38.
    Ambrose NS, Hares MM, Alexander-Williams J, Keighley MR. Prospective randomised comparison of photocoagulation and rubber band ligation in treatment of haemorrhoids. BMJ 1983;286:1389–91.PubMedGoogle Scholar
  39. 39.
    Templeton JL, Spence RA, Kennedy TL, Parks TG, Mackenzie G, Hanna WA. Comparison of infrared coagulation and rubber band ligation for first and second degree haemorrhoids: a randomised prospective clinical trial. BMJ 1983;285:1387–9.Google Scholar
  40. 40.
    Keighley MR, Buchmann P, Minervini S, Arabi Y, Alexander-Williams J. Prospective trials of minor surgical procedures and high-fibre diet for haemorrhoids. BMJ 1979;2:967–9.PubMedGoogle Scholar
  41. 41.
    Arabi Y, Gatehouse D, Alexander-Williams J, Keighley MR. Rubber band ligation or lateral subcutaneous sphincterotomy for treatment of haemorrhoids. Br J Surg 1977;64:737–40.PubMedGoogle Scholar
  42. 42.
    Fleiss JH. Statistical methods for rates and proportions. New York: John Wiley and Sons, 1973:146.Google Scholar
  43. 43.
    Thompson SG, Pocock SJ. Can meta-analyses be trusted? Lancet 1991;338:1127–30.PubMedGoogle Scholar
  44. 44.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–8.PubMedGoogle Scholar
  45. 45.
    Standards Task Force American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of hemorrhoids. Dis Colon Rectum 1990;33:992–3.Google Scholar
  46. 46.
    Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol 1992;87:1601–6.Google Scholar
  47. 47.
    Clay LD III, White JJ Jr, Davidson JT, Chandler JJ. Early recognition and successful management of pelvic cellulitis following hemorrhoidal banding. Dis Colon Rectum 1986;29:579–81.PubMedGoogle Scholar
  48. 48.
    Shemesh EI, Kodner IJ, Fry RD, Neufeld DM. Severe complication of rubber band ligation of internal hemorrhoids. Dis Colon Rectum 1987;30:199–200.PubMedGoogle Scholar
  49. 49.
    Scarpa FJ, Hillis W, Sabetta JR. Pelvic cellulitis: a lifethreatening complication of hemorrhoidal banding. Surgery 1988;103:383–5.PubMedGoogle Scholar
  50. 50.
    Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study. Gastroenterology 1990;98:380–6.PubMedGoogle Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1995

Authors and Affiliations

  • Helen M. MacRae
    • 1
    • 2
  • Robin S. McLeod
    • 1
    • 2
  1. 1.Department of Surgery and Samuel Lunenfeld Research UnitMount Sinai HospitalTorontoCanada
  2. 2.University of TorontoTorontoCanada

Personalised recommendations