Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids

BACKGROUND: Traditional treatment methods for haemorrhoids fall into two broad groups: less invasive techniques including rubber band ligation (RBL), which tend to produce minimal pain, and the more radical techniques like excisional haemorrhoidectomy (EH), which are inherently more painful. For decades, innovations in the field of haemorrhoidal treatment have centred on modifying the traditional methods to achieve a minimally invasive, less painful procedure and yet with a more sustainable result. The availability of newer techniques has reopened debate on the roles of traditional treatment options for haemorrhoids. OBJECTIVES: To review the efficacy and safety of the two most popular conventional methods of haemorrhoidal treatment, rubber band ligation and excisional haemorrhoidectomy. The original study has now been up dated using the same search strategy. SEARCH METHODS: We searched MEDLINE, EMBASE, CENTRAL, and CINAHL October 2010 SELECTION CRITERIA: Randomised controlled trials comparing rubber band ligation with excisional haemorrhoidectomy for symptomatic haemorrhoids in adult human patients were included. DATA COLLECTION AND ANALYSIS: We extracted data on to previously designed data extraction sheet. Dichtomous data were presented as relative risk and 95% confidence intervals, and continuous outcomes as weighted mean difference and 95% confidence intervals. MAIN RESULTS: Three trials (of poor methodological quality) met the inclusion criteria. Complete remission of haemorrhoidal symptom was better with excisional haemorrhoidectomy (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. AUTHORS' CONCLUSIONS: The present systematic review confirms the long-term efficacy of EH, at least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the expense of increased pain, higher complications and more time off work. However, despite these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment modalities seems to be similar following both the techniques implying patient's preference for complete long-term cure of symptoms and possibly less concern for minor complications. So, RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results but with out the side effects of EH while reserving EH for grade III haemorrhoids or recurrence after RBL. More robust study is required to make definitive conclusions. One additional study was identified from the updated search (Ali 2005). However, after careful review and discussion among the authors, it was decided that this study did not meet the necessary criteria for including in the analysis. Hence, the results and conclusion remains the same.