Rubber Band Ligation May Be Best for Low-Grade Hemorrhoids

By Will Boggs MD

June 06, 2016

NEW YORK (Reuters Health) - Rubber band ligation (RBL) is associated with less pain and lower costs than hemorrhoidal artery ligation (HAL) in patients with low-grade hemorrhoids, according to the HubBLe trial.

"HAL is expensive and not cost-effective," Dr. Steven R. Brown from Sheffield Teaching Hospitals in the U.K. told Reuters Health by email. "A course of RBL is just as good and cheaper."

RBL is cheap, but recurrence is common. The alternative, HAL, has gained in popularity due to the conception that it is associated with fewer recurrences. There are, however, no randomized trials comparing HAL with RBL, Dr. Brown and his colleagues note in The Lancet, online May 25.

The researchers compared HAL with RBL in a randomized trial of 372 patients with symptomatic second-degree and third-degree hemorrhoids. The primary outcome was patient-reported symptom recurrence in the 12 months after intervention.

Recurrence rates were significantly lower in the HAL group (30%) than in the RBL group (49%), with the increased recurrence rate in the RBL group attributable mainly to the high rate of additional RBL procedures undertaken following initial intervention.

The proportion of patients reporting recurrence was identical (29%) in the two groups.

At six weeks, hemorrhoidal symptoms were less pronounced following HAL, but there were no differences between the HAL and RBL groups in symptom scores at 12 months.

HAL was associated with more short-term pain than was RBL, but this difference disappeared by day 21.

In a cost-utility analysis, the incremental cost-effectiveness ratio per additional quality-adjusted life-year was £104,427 for HAL, which is well above most accepted thresholds.

In a post hoc analysis, the proportion of "cured" patients did not differ significantly at six weeks (31% RBL versus 38% HAL) or at one year (27% RBL versus 31% HAL).

"In conclusion, HAL is more effective than single RBL," the authors say. "If, however, RBL is considered a course of treatment involving repeat banding, the procedures are equally effective. Similarly, symptom severity score, complications, quality of life, and continence score are no different between HAL and RBL, and patients had more pain in the early postoperative period after HAL. HAL is significantly more expensive and unlikely to be cost-effective. Because of this, patients (and commissioners) might prefer a course of RBL for the treatment of hemorrhoids."

"The results are based on grade II and early grade III piles," Dr. Brown said. "There are other options for grade III and IV."

Dr. Feming Zhang from Nanjing Medical University in Nanjing, China, who has studied endoscopic sclerotherapy for hemorrhoids, told Reuters Health by email that "there is no way to completely cure hemorrhoids without recurrence. However, this study clearly clarified the advantage and disadvantage of hemorrhoidal artery ligation (HAL) and rubber band ligation (RBL) for the management of symptomatic second-degree and third-degree hemorrhoids."


Lancet 2016.