Jutabha R, Jensen DM, Chavalitdhamrong D.
Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids.
Am J Gastroenterol. 2009 Aug;104(8):2057-64. doi: 10.1038/ajg.2009.292. Epub 2009 Jun 9.
Abstract/Text
OBJECTIVES: Our purpose was to compare the efficacy, complications, success rate, recurrence rate at 1 year, and crossovers of rubber band ligation (RBL) with those of bipolar electrocoagulation (BPEC) treatment for chronically bleeding internal hemorrhoids.
METHODS: A total of 45 patients of mean age 51.5 years, who had rectal bleeding from grade II or III hemorrhoids and in whom intensive medical therapy failed, were randomized in a prospective study comparing RBL with BPEC. Treatment failure was predefined as continued bleeding, occurrence of a major complication, or failure to reduce the size of all internal hemorrhoidal segments to grade I in < or =3 treatments. Patients were followed up for 1 year.
RESULTS: With similar patients, rectal bleeding and other symptoms were controlled with significantly fewer treatments of RBL than of BPEC (2.3+/-0.2 vs. 3.8+/-0.4, P<0.05), and RBL had a significantly higher success rate (92% vs. 62%, P<0.05). RBL had more cases of severe pain during treatment (8% vs. 0%, P<0.05), but significantly fewer failures and crossovers (8% vs. 38%). Symptomatic recurrence at 1 year was 10% RBL and 15% BPEC.
CONCLUSIONS: For patients with chronically bleeding grade II or III internal hemorrhoids that are unresponsive to medical therapy, safety and complication rates of banding and BPEC were similar. The success rate was significantly higher with RBL than with BPEC. Symptom recurrence rates at 1 year were similar.
Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP.
Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy.
Arch Surg. 2007 Dec;142(12):1209-18; discussion 1218. doi: 10.1001/archsurg.142.12.1209.
Abstract/Text
OBJECTIVE: To evaluate the short-term outcomes of hemorrhoidectomy performed using the LigaSure vessel sealing device (Valleylab, Boulder, Colorado) or the conventional approach.
DATA SOURCES: MEDLINE, EMBASE, Ovid, and Cochrane databases for studies published between 2002 and 2006.
STUDY SELECTION: Randomized controlled trials published between 2002 and 2006 comparing short-term outcomes for LigaSure vs conventional hemorrhoidectomy.
DATA EXTRACTION: Operative parameters, short-term complications, and postoperative recovery. Trials were assessed using a modified Jadad score. Random-effects meta-analytical techniques were used in the analysis.
DATA SYNTHESIS: Nine randomized controlled trials with matched selection criteria reporting on 525 patients, of whom 266 (50.7%) underwent LigaSure and 259 (49.3%) underwent conventional hemorrhoidectomy. Operative time (weighted mean difference [WMD], - 8.67 minutes; 95% confidence interval [CI], - 15.34 to - 2.00 minutes), blood loss (WMD, - 23.08 mL; 95% CI, - 27.24 to - 18.92 mL), and pain the day after the operation measured by the visual analog scale (WMD, - 2.31; 95% CI, - 3.37 to - 1.26) were significantly reduced following LigaSure hemorrhoidectomy. There was a decrease in time taken to return to work or normal activity (WMD, - 3.49 days; 95% CI, - 7.40 to 0.43), which was of marginal significance (P = .08). Incidence of postoperative hemorrhage was comparable as was incidence of anal stenosis and fecal and flatus incontinence between the 2 groups.
CONCLUSIONS: LigaSure hemorrhoidectomy results in a significant reduction in operative time and blood loss, but it may not confer any advantage over the conventional operation in terms of postoperative pain, length of hospital stay, or time taken to return to work or normal activity. The expediency of the device must be weighed against its additional cost. Long-term evaluation of outcomes and morbidity are still needed.
Chauhan A, Tiwari S, Mishra VK, Bhatia PK.
Comparison of internal sphincterotomy with topical diltiazem for post-hemorrhoidectomy pain relief: a prospective randomized trial.
J Postgrad Med. 2009 Jan-Mar;55(1):22-6. doi: 10.4103/0022-3859.48436.
Abstract/Text
AIM: To assess the efficacy of internal sphincterotomy compared with application of topical 2% Diltiazem ointment after hemorrhoidectomy for pain relief.
SETTINGS AND DESIGN: Prospective randomized study.
MATERIALS AND METHODS: In an 18-month period, 108 subjects with uncomplicated Grade 3/ 4 hemorrhoids were enrolled in the study and were randomized into two equal groups: Subjects in Group A underwent internal sphincterotomy at time of primary surgery while those in Group B received 1 g of 2% Diltiazem ointment locally, thrice daily for seven days. Postoperative pain perception was measured using visual analog score (VAS) and on the basis of number of analgesic tablets (Tab tramadol 50 mg) required in each group. Time to discharge, time to return to work and incidence of complications measured and compared.
STATISTICAL ANALYSIS USED: Statistical techniques applied were Student T test, Chi-square and Fisher's Exact Test.
RESULTS: There were 102 analyzable subjects (Group A: 50 and Group B: 52). The mean VAS score was significantly less in the internal sphincterotomy group from the fourth postoperative day onwards compared to topical Diltiazem (2.23 vs. 3.72; P =0.031). Similarly, the mean requirement of analgesic tablets [10.54 vs. 15.40; P =0.01] was much lower in Group A. There was no significant difference in terms of time to discharge and time to return to work between the two groups. The incidence of complications was more with the internal sphincterotomy group (11.5% vs. 3 %; P =0.488).
CONCLUSIONS: In patients undergoing hemorrhoidectomy, addition of surgical internal sphincterotomy results in lesser pain in the postoperative period as compared to those receiving topical application of Diltiazem.
Nisar PJ, Acheson AG, Neal KR, Scholefield JH.
Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials.
Dis Colon Rectum. 2004 Nov;47(11):1837-45. doi: 10.1007/s10350-004-0679-8.
Abstract/Text
PURPOSE: This study was designed to determine whether conventional hemorrhoidectomy or stapled hemorrhoidopexy is superior for the management of hemorrhoids.
METHODS: A systematic review of all randomized trials comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched using the terms "hemorrhoid*" or "haemorrhoid*" and "stapl*." A list of clinical outcomes was extracted. Meta-analysis was calculated if possible.
RESULTS: Fifteen trials recruiting 1,077 patients were included. Follow-up ranged from 6 weeks to 37 months. Qualitative analysis showed that stapled hemorrhoidopexy is less painful compared with hemorrhoidectomy. Stapled hemorrhoidopexy has a shorter inpatient stay (weighted mean difference, -1.02 days; 95 percent confidence interval, -1.47 to -0.57; P = 0.0001), operative time (weighted mean difference, -12.82 minutes; 95 percent confidence interval, -22.61 to -3.04; P = 0.01), and return to normal activity (standardized mean difference, -4.03 days; 95 percent confidence interval, -6.95 to -1.10; P = 0.007). Studies in a day-case setting do not prove that stapled hemorrhoidopexy is more feasible than conventional hemorrhoidectomy. Stapled hemorrhoidopexy has a higher recurrence rate (odds ratio, 3.64; 95 percent confidence interval, 1.40-9.47; P = 0.008) at a minimum follow-up of six months.
CONCLUSIONS: Although stapled hemorrhoidopexy is widely used, the data available on long-term outcomes is limited. The variability in case selection and reported end points are difficulties in interpreting results. Stapled hemorrhoidopexy has unique potential complications and is a less effective cure compared with hemorrhoidectomy. With this understanding, it may be offered to patients seeking a less painful alternative to conventional surgery. Hemorrhoidectomy remains the "gold standard" of treatment.
Jayaraman S, Colquhoun PH, Malthaner RA.
Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery.
Dis Colon Rectum. 2007 Sep;50(9):1297-305. doi: 10.1007/s10350-007-0308-4.
Abstract/Text
PURPOSE: The purpose of this systematic review was to compare the long-term results of stapled hemorrhoidopexy with conventional excisional hemorrhoidectomy in patients with internal hemorrhoids.
METHODS: A systematic review of all randomized, controlled trials comparing stapled hemorrhoidopexy and conventional hemorrhoidectomy with long-term results was performed by using the Cochrane methodology. The minimum follow-up was six months. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications, and pain.
RESULTS: Twelve trials were included. Follow-up varied from six months to four years. Conventional hemorrhoidectomy was more effective in preventing long-term recurrence of hemorrhoids (odds ratio (OR), 3.85; 95 percent confidence interval (CI), 1.47-10.07; P < 0.006). Conventional hemorrhoidectomy also prevents hemorrhoids in studies with follow-up of one year or more (OR, 3.6; 95 percent CI, 1.24-10.49; P < 0.02). Conventional hemorrhoidectomy is superior in preventing the symptom of prolapse (OR, 2.96; 95 percent CI, 1.33-6.58; P < 0.008). Conventional hemorrhoidectomy also is more effective at preventing prolapse in studies with follow-up of one year or more (OR, 2.68; 95 percent CI, 0.98-7.34; P < 0.05). Nonsignificant trends in favor of conventional hemorrhoidectomy were seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, the presence of perianal skin tags, and the need for further surgery. Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and symptoms of anal obstruction/stenosis.
CONCLUSIONS: Conventional hemorrhoidectomy is superior to stapled hemorrhoidopexy for prevention of postoperative recurrence of internal hemorrhoids. Fewer patients who received conventional hemorrhoidectomy complained of hemorrhoidal prolapse in long-term follow-up compared with stapled hemorrhoidopexy.