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Rubber band ligation vs haemorrhoidectomy – more evidence required

Wed, 03/24/2021 - 12:12
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A systematic review comparing clinical outcome of haemorrhoidectomy and rubber band ligation in grade II–III haemorrhoids has reported that haemorrhoidectomy seems to provide better symptom control but results in more pain and complications. Moreover, the study researchers from The Netherlands, Denmark and Norway, claim that because of the poor quality of the studies available they were unable to determine which procedure results in the best treatment for grade II–III haemorrhoids.

The study paper, ‘Rubber band ligation versus haemorrhoidectomy for the treatment of grade II–III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials’, was published in the journal Techniques in Coloproctology.

This systematic review that only included randomised clinical trials (RCTs) reported on the clinical effectiveness (including patient-related outcomes) and cost effectiveness of rubber band ligation and haemorrhoidectomy in patients with symptomatic grade II and III haemorrhoids. The primary outcome was control of haemorrhoidal disease (defined by need for retreatment within one year or by self-reported residual complaints).

The secondary outcomes included postoperative pain, postoperative complications (bleeding requiring admission and/or reoperation, sepsis, anal stenosis anal incontinence), anal continence (if measured by a validated patient-reported outcome measure), patient satisfaction, quality of life (if measured by a validated patient-reported outcome measure), and health-costs.


After inclusion and exclusion criteria were applied to a total of 27 full-text studies, eight RCTs were identified and included in the analyses (n=1208: 608 rubber band ligation and 600 haemorrhoidectomy). Recurrence was highlighted as an outcome in half (4/8) of the RCTs and high rates were report after rubber band ligation vs haemorrhoidectomy (322 patients, p<0.001). However, the definition of recurrence of disease varied (need of reintervention, diminishment of bleeding and prolapse, and recurrence of complaints).

Regarding pain, they reported that patients experienced less post-procedural pain after rubber band ligation (seven studies, 1110 patients, p<0.001), but there was moderate heterogeneity between the studies (p< 0.001). Rubber band ligation also resulted in few instances of postoperative bleeding (seven studies, 1110 patients and 84 events; p=0.002], although none of the studies defined this outcome.

Six studies (n=1,054 patients) concluded urinary retention requiring a urinary catheter is more common after haemorrhoidectomy (urinary retention 0–4% after rubber band ligation vs 6.7–56% after haemorrhoidectomy; p<0.001). From three studies that reported instances of anal incontinence, no instances were reported after rubber band ligation (n=236 patients, p=0.080), compared with five instances in the haemorrhoidectomy group.

Five studies reported on anal stenosis (942 patients, p<0.0010. After haemorrhoidectomy, 1–8.3% of patients developed anal stenosis, whilst stenosis following rubber band ligation only occurred in one patient.

“The results of this review suggest that haemorrhoidectomy offers better symptom control compared with rubber band ligation in patients with grade II–III haemorrhoids, but is accompanied by more postoperative pain and complications,” the authors concluded. “The main conclusion, however, must be that the studies analysed are of poor quality, and therefore, no advice about treatment protocol can be given. Good quality trials with an emphasis on economic and patient-related outcomes are needed. A multicentre randomised trial comparing rubber band ligation with haemorrhoidectomy has recently been initiated in the Netherlands.”

To access this paper, please click here