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Meta-Analysis
. 2005 Jul 20;2005(3):CD005034.
doi: 10.1002/14651858.CD005034.pub2.

Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids

V Shanmugam  1 , M A Thaha, K S Rabindranath, K L Campbell, R J C Steele, M A Loudon
Affiliations
Meta-Analysis

Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids

V Shanmugam et al. Cochrane Database Syst Rev. .

Abstract

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.

Search strategy: We searched all the major electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL).

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 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.

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Conflict of interest statement

None known

Figures

1
1
Flow chart for searches October 2010
1.3
1.3. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 3 Number of patients cured of haemorrhoidal disease.
1.6
1.6. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 6 Number of patients required re‐treatment.
1.7
1.7. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 7 Number of patients with post‐operative pain.
1.8
1.8. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 8 Number of patients with urinary retention.
1.9
1.9. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 9 Number of patients with significant post‐operative haemorrhage.
1.10
1.10. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 10 Number of patients complicated with anal stenosis.
1.14
1.14. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 14 Number of patients with faecal incontinence.
1.15
1.15. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 15 Number of patients with flatus incontinence.
1.16
1.16. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 16 Overall complications ‐ Delayed.
1.17
1.17. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 17 Overall complications ‐ Early.
1.19
1.19. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 19 Patient satisfaction ‐ Excellent and satisfactory.
1.20
1.20. Analysis
Comparison 1 Rubber band ligation versus surgical haemorrhoidectomy for haemorrhoids, Outcome 20 Patient satisfaction ‐ Same or worse symptoms.
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