{ "slug": "why-can-t-you-band-external-hemorrhoids", "question": "Why can't you band external hemorrhoids?", "shortTitle": "Banding External Hemorrhoids", "clinicalQuestion": "In patients with external hemorrhoids, why is rubber band ligation not used as it is for internal hemorrhoids, and what complication rates (pain, thrombosis, bleeding, tissue necrosis) occur if banding is attempted on tissue below the dentate line compared with banding of internal hemorrhoids?", "pico": { "population": "Adults with external hemorrhoids (compared with those with internal hemorrhoids)", "intervention": "Rubber band ligation applied to external hemorrhoidal tissue (below the dentate line)", "comparator": "Rubber band ligation of internal hemorrhoids (above the dentate line); or standard treatment of external hemorrhoids such as excision or conservative care", "outcomes": [ "Procedural pain score", "Thrombosis of banded tissue", "Post-procedure bleeding", "Tissue necrosis or ulceration", "Treatment success / symptom resolution", "Need for subsequent surgical excision" ] }, "category": "anorectal", "relatedConditions": [ "hemorrhoids", "external-hemorrhoid", "thrombosed-hemorrhoid" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "Banding is traditionally avoided on external hemorrhoids because that skin has pain-sensing nerves, but a couple of small, low-quality studies suggest it may sometimes work — it's just too early to know for sure.", "detail": "In one uncontrolled study of 50 people, banding external hemorrhoids caused no pain or only mild pain in most, and about 9 in 10 said they were satisfied and would have it done again. A separate case report found that banding a thrombosed external hemorrhoid caused the tissue to die and form an open wound in a person on chemotherapy. No trial has compared banding against the usual approach of leaving external hemorrhoids alone or removing a clot if one forms.", "studyIds": [ "pmid:40932938", "pmid:30531135", "pmid:40824576" ] }, "strength": { "level": "very-low", "why": "The only direct evidence is 2 small or uncontrolled studies.", "override": null }, "direction": { "level": "probable-benefit", "why": "The evidence points to a benefit, but it is not strong enough to be confident.", "override": null }, "counts": { "recordsRetrieved": 155, "recordsScreened": 152, "included": 39, "rcts": 1, "systematicReviews": 1, "observational": 4, "participants": 5435, "yearFrom": 1986, "yearTo": 2026, "registeredTrialsWithoutResults": 0 }, "excluded": [], "outcomes": [ { "name": "Procedural pain score", "status": "possible-improvement", "note": "The one study that actually banded external hemorrhoids found most people had no pain or only mild pain afterward, though a few had moderate to severe pain lasting about a week.", "studyIds": [ "pmid:40932938" ] }, { "name": "Thrombosis of banded tissue", "status": "not-studied", "note": "No study measured how often banding itself causes new clots to form in external hemorrhoid tissue.", "studyIds": [] }, { "name": "Post-procedure bleeding", "status": "not-studied", "note": "No study of banding external hemorrhoids reported how much bleeding happened afterward or how often it occurred.", "studyIds": [] }, { "name": "Tissue necrosis or ulceration", "status": "possible-harm", "note": "One case report found that banding a thrombosed external hemorrhoid caused the tissue to die and form an open, ulcerated wound in a person on chemotherapy.", "studyIds": [ "pmid:30531135" ] }, { "name": "Treatment success / symptom resolution", "status": "possible-improvement", "note": "In the small uncontrolled study, about 9 in 10 people said they were satisfied with banding and would repeat it, but there was no comparison group and no long-term follow-up.", "studyIds": [ "pmid:40932938" ] }, { "name": "Need for subsequent surgical excision", "status": "not-studied", "note": "No study reported how often people who had an external hemorrhoid banded later needed surgery anyway.", "studyIds": [] } ], "benefits": [ { "text": "In a small study of 50 people, banding external hemorrhoids caused no pain or only mild pain in most people, and about 9 in 10 said they were satisfied and would have it done again.", "studyIds": [ "pmid:40932938" ] } ], "limitations": [ { "text": "The evidence that actually tested banding on external tissue comes from just two small studies: one with 50 people and no comparison group, and one single case report.", "studyIds": [ "pmid:40932938", "pmid:30531135" ] }, { "text": "Guidelines and reviews consistently describe external hemorrhoids being treated differently from internal ones — for example, excision for thrombosed external hemorrhoids versus banding for internal hemorrhoids graded I to III — but none of these sources directly tested banding on external tissue or measured what happened when it was tried.", "studyIds": [ "pmid:40824576", "pmid:31583307", "pmid:26309351", "pmid:19744418", "pmid:10196614" ] }, { "text": "The one case report where ligation of thrombosed external hemorrhoids led to tissue necrosis involved a person with leukemia on chemotherapy drugs that can impair wound healing, so it may not reflect what happens in a typical, healthy person.", "studyIds": [ "pmid:30531135" ] } ], "risks": [ { "text": "In one case report, a person with leukemia on chemotherapy had a thrombosed external hemorrhoid become necrotic (tissue death) and ulcerated after banding.", "studyIds": [ "pmid:30531135" ], "severity": "serious" }, { "text": "In the small study of banded external hemorrhoids, 3 of 50 people had moderate to severe pain that took about a week to resolve.", "studyIds": [ "pmid:40932938" ], "severity": "minor" }, { "text": "A review of complications after hemorrhoid surgery reports that external hemorrhoid thrombosis (clotting) and delayed bleeding are frequent complications, with an overall complication rate of 10-20%; the review does not break this rate down specifically for banding versus other procedures done on external tissue.", "studyIds": [ "pmid:8712596" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "External hemorrhoids are visible and often bother people more than internal ones, so an outpatient fix that worked for internal hemorrhoids sounds appealing." }, { "text": "Banding is marketed as quick, non-surgical, and done in the office, which feels less daunting than surgery." }, { "text": "People want to avoid the pain and recovery time of surgical excision for a thrombosed clot." } ], "keyStudies": [ "pmid:40932938", "pmid:30531135", "pmid:40824576", "pmid:26561592", "pmid:8712596", "pmid:31583307" ], "studies": [ { "id": "pmid:42376216", "pmid": "42376216", "doi": "10.3389/fsurg.2026.1846705", "nctId": null, "pmcid": "PMC13311046", "title": "Multidisciplinary management of Grade III circumferential mixed hemorrhoids in a patient with Marfan syndrome receiving long-term anticoagulation: a case report", "firstAuthor": "Wei", "multipleAuthors": true, "journal": "Front Surg", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "a 33-year-old male with Marfan syndrome, on long-term warfarin, with Grade III circumferential mixed hemorrhoids that had not responded to conservative treatment", "intervention": "external dissection and internal ligation combined with liquid polidocanol injection sclerotherapy", "comparator": "rubber band ligation (avoided) and sclerotherapy alone (considered insufficient)", "primaryOutcome": "wound healing with no recurrent prolapse or severe bleeding complications", "result": "wounds remained well healed, with no recurrent prolapse or severe hemorrhagic complications at 41 months of follow-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report with no comparison group, so its findings cannot be generalized.", "directness": "indirect", "limitations": "Only one patient was studied, and the anticoagulation and monitoring strategies are described as patient-specific measures requiring further validation.", "followUp": "41 months", "plainFinding": "Banding avoided; surgery healed well.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42376216/", "sourceText": "Management of advanced hemorrhoidal disease in patients with Marfan syndrome (MFS) who require lifelong anticoagulation is clinically complex because perioperative care must balance prosthetic valve thrombosis against postoperative anorectal bleeding. We report the case of a 33-year-old male with MFS, status post-aortic dissection repair (Sun's procedure and Bentall operation) on continuous warfarin therapy, who presented with persistent Grade III circumferential mixed hemorrhoids that had not responded adequately to prior conservative outpatient management. Physical examination confirmed characteristic MFS musculoskeletal signs and severe hemorrhoidal prolapse. A structured multidisciplinary team (MDT) pathway involving colorectal surgery, cardiovascular medicine, vascular surgery, anesthesia, pharmacy, and nutrition was used to individualize perioperative management. After cardiology consultation, and based on the patient's high thromboembolic risk, preoperative warfarin interruption was shortened to 3 days with enoxaparin bridging, and the INR decreased to 1.01 on the day before surgery. Rubber band ligation was avoided because of concern for delayed bleeding after sloughing in an anticoagulated patient. Because the disease involved circumferential mixed hemorrhoids with a prominent external component and prolapse, repeated sclerotherapy alone was considered unlikely to provide adequate definitive control. The patient therefore underwent external dissection and internal ligation combined with liquid polidocanol injection sclerotherapy, with minimal intraoperative blood loss. Postoperatively, a 25-day inpatient observation period enabled close INR titration during warfarin reinitiation, controlled bowel management, staged low-residue enteral nutrition, avoidance of rectal suppositories, and direct monitoring for delayed bleeding. Following minor self-limiting hematochezia, the patient was discharged with an INR of 1.8 as a pragmatic compromise between bleeding and thrombotic risks. At 41 months of follow-up, the wounds remained well healed, with no recurrent prolapse or severe hemorrhagic complications. This case suggests that surgical intervention for advanced hemorrhoids in anticoagulated MFS patients may be feasible when embedded within a structured, individualized multidisciplinary pathway. The anticoagulation, nutritional, and inpatient-monitoring strategies described here should be interpreted as patient-specific measures requiring further validation.", "provenance": [ { "field": "population", "quote": "a 33-year-old male with MFS, status post-aortic dissection repair (Sun's procedure and Bentall operation) on continuous warfarin therapy, who presented with persistent Grade III circumferential mixed hemorrhoids that had not responded adequately to prior conservative outpatient management" }, { "field": "intervention", "quote": "The patient therefore underwent external dissection and internal ligation combined with liquid polidocanol injection sclerotherapy, with minimal intraoperative blood loss." }, { "field": "comparator", "quote": "Rubber band ligation was avoided because of concern for delayed bleeding after sloughing in an anticoagulated patient." }, { "field": "comparator", "quote": "Because the disease involved circumferential mixed hemorrhoids with a prominent external component and prolapse, repeated sclerotherapy alone was considered unlikely to provide adequate definitive control." }, { "field": "primaryOutcome", "quote": "At 41 months of follow-up, the wounds remained well healed, with no recurrent prolapse or severe hemorrhagic complications." }, { "field": "result", "quote": "At 41 months of follow-up, the wounds remained well healed, with no recurrent prolapse or severe hemorrhagic complications." }, { "field": "n", "quote": "a 33-year-old male with MFS" } ] }, { "id": "pmid:41987169", "pmid": "41987169", "doi": "10.1186/s12893-026-03744-z", "nctId": null, "pmcid": "PMC13220367", "title": "Evaluation of short-term outcomes of Endoscopic Super-Hemorrhoidal Banding for mixed hemorrhoids with prolapsed internal hemorrhoids: a retrospective study", "firstAuthor": "Huang", "multipleAuthors": true, "journal": "BMC Surg", "year": 2026, "design": "retrospective", "n": 480, "nField": "reported", "population": "patients with mixed hemorrhoids with Grade II-IV prolapsed internal hemorrhoids", "intervention": "Endoscopic Super-Hemorrhoidal Banding (ESHB)", "comparator": "Milligan-Morgan hemorrhoidectomy (MMH)", "primaryOutcome": "cure rate, operative time, hospital stay, pain scores, and complication rates", "result": "Cure rates were similar between groups, but ESHB had shorter operative time and hospital stay, lower pain scores, and fewer urinary retention complications", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It's a retrospective, non-randomized comparison with only short-term follow-up, so it can't reliably show long-term safety or equivalence.", "directness": "indirect", "limitations": "Retrospective design, not randomized, and the authors state long-term efficacy still needs further validation", "followUp": "", "plainFinding": "Similar cure rate, faster recovery than surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41987169/", "sourceText": "BACKGROUND: To evaluate the clinical efficacy and safety of Endoscopic Super-hemorrhoidal Banding (ESHB) in treating mixed hemorrhoids with Grade II-IV internal hemorrhoid prolapse as the main symptom. METHODS: A retrospective analysis was conducted on clinical data of patients with mixed hemorrhoids treated in our hospital from June 2021 to June 2024. They were divided into two groups: patients underwent Milligan-Morgan hemorrhoidectomy (MMH) as the control group, and patients underwent ESHB as the observation group. Treatment outcomes included efficacy measurement, operative time, hospital stay, postoperative anal pain scores, and incidence of complications like bleeding and urinary retention were compared. RESULTS: 245 patients underwent Milligan-Morgan hemorrhoidectomy (MMH) and 235 patients underwent ESHB. The cure rates were 69.36% in the ESHB group and 72.65% in the MMH group, with no statistically significant difference between the two groups (P > 0.05). The observation group had significantly shorter operative time and hospital stay (P < 0.01), lower postoperative anal pain scores and incidence of urinary retention (P < 0.01). One patient in each group had severe postoperative bleeding, which stopped after surgical suture or endoscopic titanium clip closure. CONCLUSION: Short-term follow-up indicates that ESHB can effectively reposition the prolapsed anal cushions, preserve the anatomical structure and functional integrity of the anal cushions, alleviate symptoms associated with mixed hemorrhoids primarily characterized by internal hemorrhoid prolapse, shorten both the operative time and hospital stay, and reduce patients’ postoperative anal pain scores as well as the incidence of postoperative complications. It is an effective, safe, and simple minimally invasive treatment method; however, its long-term efficacy still requires further validation. TRIAL REGISTRATION: This was a retrospective observational study. Trial registration was performed retrospectively (registration no.: NCT06250140; registration date: January 31, 2024).", "provenance": [ { "field": "population", "quote": "patients with mixed hemorrhoids treated in our hospital from June 2021 to June 2024" }, { "field": "intervention", "quote": "Endoscopic Super-hemorrhoidal Banding (ESHB)" }, { "field": "comparator", "quote": "Milligan-Morgan hemorrhoidectomy (MMH) as the control group" }, { "field": "primaryOutcome", "quote": "Treatment outcomes included efficacy measurement, operative time, hospital stay, postoperative anal pain scores, and incidence of complications like bleeding and urinary retention were compared." }, { "field": "result", "quote": "The cure rates were 69.36% in the ESHB group and 72.65% in the MMH group, with no statistically significant difference between the two groups (P > 0.05). The observation group had significantly shorter operative time and hospital stay (P < 0.01), lower postoperative anal pain scores and incidence of urinary retention (P < 0.01)." }, { "field": "n", "quote": "245 patients underwent Milligan-Morgan hemorrhoidectomy (MMH) and 235 patients underwent ESHB." } ] }, { "id": "pmid:40932938", "pmid": "40932938", "doi": "10.7759/cureus.89701", "nctId": null, "pmcid": "PMC12417224", "title": "Rubber Band Ligation: A New Treatment Option for External Hemorrhoids", "firstAuthor": "Sadik", "multipleAuthors": true, "journal": "Cureus", "year": 2025, "design": "case-series", "n": 50, "nField": "reported", "population": "patients with symptomatic non-thrombosed external hemorrhoids", "intervention": "rubber band ligation with local lidocaine anesthesia", "comparator": "no comparison group; traditionally avoided invasive treatments like hemorrhoidectomy due to pain", "primaryOutcome": "patient-reported pain and satisfaction after the procedure", "result": "50% had no discomfort, 44% had mild pain managed with OTC analgesics, three patients had moderate-severe pain that resolved within a week, and about 90% were satisfied and would repeat the procedure", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a small, uncontrolled case series without a comparison group, so it can't reliably prove the treatment works better than alternatives.", "directness": "direct", "limitations": "Small cohort size, no control group, and reliance on patient-reported outcomes without long-term follow-up.", "followUp": "", "plainFinding": "Most patients tolerated it well.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40932938/", "sourceText": "Hemorrhoids are dilated veins in the anal canal, classified into internal and external types based on their location relative to the dentate line. External hemorrhoids originate inferior to the dentate line from the inferior hemorrhoidal plexus. They are covered by the anoderm and are highly innervated by somatic pain receptors, leading to significant pain, especially when thrombosed. The management of external hemorrhoids has been primarily conservative, including increased fiber intake, stool softeners, and topical corticosteroids. More invasive treatments like hemorrhoidectomy or rubber band ligation have been avoided due to the intense postoperative pain and complications associated with such procedures. This case report and small patient cohort suggest rubber band ligation can be used as a minimally invasive procedure for the treatment of external hemorrhoids. A patient presenting with symptomatic non-thrombosed external hemorrhoids underwent rubber band ligation after being educated on the risks and benefits of the procedure. Lidocaine was injected into the surrounding tissue to anesthetize the hemorrhoid prior to band ligation. The rubber band was applied to the hemorrhoid, cutting off its blood supply and leading to ischemia, necrosis, and eventual sloughing of the tissue. Based on the success experienced by the first patient, a small patient cohort was offered the same treatment. In this cohort of 50 patients, 50% reported no post-procedure discomfort, 44% had mild pain managed with over-the-counter (OTC) analgesics, and three patients experienced moderate-severe pain that resolved within a week. Overall, ~90% were satisfied with the technique and would opt for the procedure again. This study demonstrates that rubber band ligation combined with local anesthesia injection could be an alternative option to hemorrhoidectomy for individuals with symptomatic non-thrombosed external hemorrhoids.", "provenance": [ { "field": "population", "quote": "A patient presenting with symptomatic non-thrombosed external hemorrhoids underwent rubber band ligation" }, { "field": "intervention", "quote": "Lidocaine was injected into the surrounding tissue to anesthetize the hemorrhoid prior to band ligation." }, { "field": "comparator", "quote": "More invasive treatments like hemorrhoidectomy or rubber band ligation have been avoided due to the intense postoperative pain and complications associated with such procedures." }, { "field": "primaryOutcome", "quote": "50% reported no post-procedure discomfort, 44% had mild pain managed with over-the-counter (OTC) analgesics, and three patients experienced moderate-severe pain that resolved within a week." }, { "field": "result", "quote": "Overall, ~90% were satisfied with the technique and would opt for the procedure again." }, { "field": "n", "quote": "In this cohort of 50 patients" } ] }, { "id": "pmid:40824576", "pmid": "40824576", "doi": "10.1001/jama.2025.13083", "nctId": null, "pmcid": null, "title": "Hemorrhoidal Disease: A Review", "firstAuthor": "Ashburn", "multipleAuthors": false, "journal": "JAMA", "year": 2025, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "People with hemorrhoidal disease, including internal, external, or mixed types", "intervention": "Rubber band ligation, a procedure that places a band around the base of hemorrhoid tissue to cut off blood flow", "comparator": "Office-based and surgical treatments used for internal versus external hemorrhoids", "primaryOutcome": "Which treatments work for which type of hemorrhoid disease", "result": "Rubber band ligation is described as treatment for grade I to III internal hemorrhoid disease, while external hemorrhoids—located below the dentate line—rarely need surgery unless they become thrombosed, in which case clot removal or medical treatment is used instead", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general review article summarizing existing knowledge rather than a controlled study testing a specific treatment.", "directness": "direct", "limitations": "The abstract does not describe a systematic search method or cite specific study data for this point beyond general success percentages for other procedures.", "followUp": "", "plainFinding": "Banding is for internal, not external, hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/40824576/", "sourceText": "IMPORTANCE: Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US. Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse. OBSERVATIONS: Hemorrhoids are classified as internal, external, or mixed (concurrent internal and external hemorrhoidal disease). Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal. Internal hemorrhoid prolapse is classified as grade I (into anal canal), grade II (beyond the anus with spontaneous reduction), grade III (requiring manual reduction), and grade IV (irreducible). External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed. Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation. Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation. If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions. Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%. Sclerotherapy, which induces fibrosis with a sclerosant injection, is efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients. Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse. Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days). External hemorrhoidal disease rarely requires surgery unless acutely thrombosed. Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis. Patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine). CONCLUSIONS AND RELEVANCE: Hemorrhoidal disease affects 10 million people in the US. First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics. In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies. Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.", "provenance": [ { "field": "population", "quote": "External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed." }, { "field": "intervention", "quote": "Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients" }, { "field": "comparator", "quote": "grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions" }, { "field": "primaryOutcome", "quote": "resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%" }, { "field": "result", "quote": "External hemorrhoidal disease rarely requires surgery unless acutely thrombosed." } ] }, { "id": "pmid:40634906", "pmid": "40634906", "doi": "10.1186/s12893-025-02918-5", "nctId": null, "pmcid": "PMC12243282", "title": "Tissue selecting therapy stapler minimally invasive surgery to treat severe hemorrhoids", "firstAuthor": "Huang", "multipleAuthors": true, "journal": "BMC Surg", "year": 2025, "design": "rct", "n": 141, "nField": "reported", "population": "patients with severe hemorrhoids", "intervention": "tissue selecting therapy stapler (TST) minimally invasive surgery", "comparator": "PPH stapler surgery and EPH (rubber band ligation and procedure for prolapse and hemorrhoids)", "primaryOutcome": "clinical effectiveness, complications, and anal muscle pressure measurements after surgery", "result": "TST had higher effectiveness rate (93.62%) and lower complication rate (10.64%) than PPH (74.47%, 27.66%) and EPH (72.34%, 31.91%)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a small single-center trial with no mention of blinding, so the results may not be reliable or generalizable", "directness": "indirect", "limitations": "The abstract does not describe blinding, loss to follow-up, or statistical details such as confidence intervals or p-values.", "followUp": "Three months after surgery", "plainFinding": "Better results, fewer complications with TST.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40634906/", "sourceText": "BACKGROUND: Severe hemorrhoids have a serious impact on patients' quality of life. At present, the main method for treating severe hemorrhoids is surgery, but surgical treatment causes greater trauma to patients and has a high degree of complications. There is an urgent need to find new surgical methods to solve these problems. To assess the ability of tissue-selective therapy stapler (TST) minimally invasive surgery to treat severe hemorrhoids by studying the clinical efficacy, postoperative complications, and anal dynamics of selective supramedullary hemorrhoid stomy. METHODS: In our hospital, between March 2015 and February 2018, 141 patients with severe hemorrhoids were included into three groups according to the block randomization method: the TST group, the pieces per hour the PPH group, and the eastern rubber band ligation and coincident of dislocation for prolapse and hemorrhoid (EPH)group. There were 47 patients in each group. The clinical efficacy of the three groups of patients, changes in hospital stay time, operation time, intraoperative blood loss, postoperative complications, and anal dynamic indicators (rectal resting pressure, anal resting pressure, anorectal pressure difference, rectal tolerance, rectal perception threshold and length of the anal high-pressure zone) were observed and compared. RESULTS: The total effective rate in the TST group was 93.62%, which was higher than the 74.47% and 72.34% in the PPH and EPH groups, respectively, after treatment. Hospitalization time, operation time, and intraoperative blood loss were lower in the TST group than in the EPH and PPH groups. Three months after surgery, the rectal resting pressure, rectal tolerance, and rectal sensing thresholds of patients in the TST group were lower than those in the PPH and EPH groups, and the anal canal resting pressure, the anorectal pressure difference and the length of the anal high-pressure zone were greater than those in the PPH and EPH groups. After surgery, the complication rate in the TST group was 10.64%, which was lower than the 27.66% and 31.91% reported in the PPH and EPH groups, respectively. CONCLUSION: Minimally invasive TST is effective in treating severe hemorrhoids, can significantly improve anorectal motility, has a low incidence of postoperative complications and is highly safe.", "provenance": [ { "field": "n", "quote": "141 patients with severe hemorrhoids were included into three groups" }, { "field": "population", "quote": "patients with severe hemorrhoids" }, { "field": "intervention", "quote": "tissue-selective therapy stapler (TST) minimally invasive surgery" }, { "field": "comparator", "quote": "the pieces per hour the PPH group, and the eastern rubber band ligation and coincident of dislocation for prolapse and hemorrhoid (EPH)group" }, { "field": "primaryOutcome", "quote": "The clinical efficacy of the three groups of patients, changes in hospital stay time, operation time, intraoperative blood loss, postoperative complications, and anal dynamic indicators" }, { "field": "result", "quote": "The total effective rate in the TST group was 93.62%, which was higher than the 74.47% and 72.34% in the PPH and EPH groups, respectively, after treatment." }, { "field": "result", "quote": "After surgery, the complication rate in the TST group was 10.64%, which was lower than the 27.66% and 31.91% reported in the PPH and EPH groups, respectively." }, { "field": "followUp", "quote": "Three months after surgery" } ] }, { "id": "pmid:38677814", "pmid": "38677814", "doi": "10.1016/j.suc.2023.11.001", "nctId": null, "pmcid": null, "title": "Management of Hemorrhoids and Anal Fissures", "firstAuthor": "Akinmoladun", "multipleAuthors": true, "journal": "Surg Clin North Am", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids and anal fissures", "intervention": "medical and surgical treatment options for hemorrhoids", "comparator": "not specified", "primaryOutcome": "treatment success and complication rates", "result": "not specifically reported for banding of external hemorrhoids", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review article that summarizes management steps without presenting original data or a specific finding on banding external hemorrhoids.", "directness": "indirect", "limitations": "Abstract does not describe why external hemorrhoids cannot be banded or provide specific evidence on this point.", "followUp": "", "plainFinding": "General review, no specific answer given.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38677814/", "sourceText": "Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.", "provenance": [ { "field": "population", "quote": "Hemorrhoids and anal fissures are two of the most common benign anorectal diseases." }, { "field": "intervention", "quote": "numerous medical and surgical treatment options are available, each with different rates of success and complications" }, { "field": "comparator", "quote": "numerous medical and surgical treatment options are available, each with different rates of success and complications" }, { "field": "primaryOutcome", "quote": "different rates of success and complications" }, { "field": "result", "quote": "In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures." } ] }, { "id": "pmid:33639701", "pmid": "33639701", "doi": "10.51821/84.1.497", "nctId": null, "pmcid": null, "title": "Belgian consensus guideline on the management of hemorrhoidal disease", "firstAuthor": "De Schepper", "multipleAuthors": true, "journal": "Acta Gastroenterol Belg", "year": 2021, "design": "guideline", "n": null, "nField": "not-reported", "population": "people with hemorrhoid disease causing symptoms", "intervention": "rubber band ligation or infrared coagulation for hemorrhoids with prolapse", "comparator": "conservative treatment with fiber supplements and venotropic medication", "primaryOutcome": "which treatment is appropriate for the grade of hemorrhoid disease", "result": "Banding is recommended as an option for low-grade hemorrhoids with prolapse; the abstract does not mention external hemorrhoids or explain why they cannot be banded", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a consensus guideline summarizing expert recommendations, not a study testing banding on external hemorrhoids, so it cannot directly answer the question.", "directness": "indirect", "limitations": "This is a Delphi consensus guideline based on existing literature, not a primary study, and it never discusses external hemorrhoids specifically or complications of banding them.", "followUp": "", "plainFinding": "Guideline covers internal hemorrhoid banding only.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33639701/", "sourceText": "INTRODUCTION: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. METHODS: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. RESULTS: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. CONCLUSIONS: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.", "provenance": [ { "field": "population", "quote": "Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal." }, { "field": "intervention", "quote": "Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent." }, { "field": "comparator", "quote": "conservative treatment should consist of fiber supplements and can include a short course of venotropics" }, { "field": "primaryOutcome", "quote": "Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations." }, { "field": "result", "quote": "For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent." } ] }, { "id": "pmid:32499984", "pmid": "32499984", "doi": "10.7759/cureus.7944", "nctId": null, "pmcid": "PMC7266563", "title": "Hemorrhoidal Artery Ligation Operations-Recto-Anal Repair (HALO-RAR) Procedure for Recurrent Haemorrhoids: Excellent Patient Satisfaction", "firstAuthor": "Miah", "multipleAuthors": true, "journal": "Cureus", "year": 2020, "design": "retrospective", "n": 10, "nField": "reported", "population": "patients with recurring hemorrhoid symptoms after previous banding", "intervention": "Doppler-guided hemorrhoidal artery ligation with recto-anal repair (HALO-RAR)", "comparator": "", "primaryOutcome": "improvement in hemorrhoid symptoms and patient satisfaction", "result": "all patients who returned for follow-up showed symptom improvement, with no major surgical complications", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a tiny retrospective case series of only 10 patients with no comparison group, so it cannot reliably show whether the treatment works better than other options.", "directness": "indirect", "limitations": "Retrospective design, very small sample size (10 patients), no control or comparison group, only 8 of 10 patients had follow-up data reported.", "followUp": "", "plainFinding": "Good symptom improvement, no major complications.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32499984/", "sourceText": "Background Haemorrhoid is the most common anal canal disease. Treatments may vary from non-invasive to invasive depending on the symptoms. Haemorrhoidectomy has been widely used. However, it has some drawbacks like severe postoperative pain, longer time to return to daily activities and complications such as anal stenosis. To overcome these, various new treatment methods have been introduced. Doppler-guided hemorrhoidal artery ligation operations (HALO) are becoming popular among surgeons. HALO has been reported to have a lower recurrence rate of less than 10% and higher patient satisfaction of approximately 90% with minimal postoperative pain. It achieves very good postoperative outcomes in the treatment of early haemorrhoids where per rectal bleeding and/or perianal discomfort are main symptoms. Nevertheless, it has a limitation in the treatment of prolapsing haemorrhoids. To tackle this, simultaneous recto-anal repair (RAR) has been recently introduced. HALO, in combination with RAR, has been reported to achieve good postoperative outcomes and excellent patient satisfaction. This is a two-stage open operation. The stages are: - Doppler-guided HALO and - RAR (recto-anal repair) Methods We are presenting a single-centre one-year experience of Doppler-guided haemorrhoidal artery ligation operation and recto-anal repair (DG-HALO and RAR) conducted on haemorrhoidal patients to evaluate the outcomes and effectiveness of the procedure. Retrospective data were collected for the patients who underwent HALO over one year period from June 2018 to August 2019. A total of 10 patients were treated with the HALO-RAR procedure. Results The male to female ratio was 7:3, median age was 47.98 (28.38 - 61.7) years, median body mass index (BMI) was 30.23 (23.8 - 39.1). Eight patients were American Society of Anesthesiologists (ASA) Grade II, one patient was ASA I and one was ASA III. Time from initial consultation to the HALO procedure was 9.90 (3.5 - 19.8) months. All patients complained of preoperative bleeding and six of them complained of pain or discomfort. Nine patients underwent previous bandings in the clinic and one patient declined banding. The average time of the procedure was 57 mins. The average number of ligations was 10 (0-21). In one case, the proctoscope did not pair with the speaker. The average number of plications was three (2-4). Postoperatively, nine patients had no immediate complications; one patient had acute urinary retention. Seven patients were discharged on the same day. One patient had to stay overnight for monitoring prior to restarting apixaban, one patient for his learning difficulties and one patient had an unplanned overnight stay due to acute urinary retention requiring catheterization. Eight patients had their first follow-up; improvement of symptoms was found in 100% patients on the first follow-up. Conclusion HALO-RAR should be considered as a treatment option for recurrent symptoms after banding for haemorrhoids. The study showed good overall results with no immediate surgical complications. Excellent patient satisfaction was found even in long-term follow-up.", "provenance": [ { "field": "n", "quote": "A total of 10 patients were treated with the HALO-RAR procedure." }, { "field": "population", "quote": "Nine patients underwent previous bandings in the clinic and one patient declined banding." }, { "field": "intervention", "quote": "Doppler-guided haemorrhoidal artery ligation operation and recto-anal repair (DG-HALO and RAR)" }, { "field": "primaryOutcome", "quote": "to evaluate the outcomes and effectiveness of the procedure" }, { "field": "result", "quote": "Eight patients had their first follow-up; improvement of symptoms was found in 100% patients on the first follow-up." } ] }, { "id": "pmid:30531135", "pmid": "30531135", "doi": "10.11406/rinketsu.59.2413", "nctId": null, "pmcid": null, "title": "[Recurrent thrombosed external hemorrhoids due to L-asparaginase administration in a Philadelphia chromosome-positive acute lymphoblastic leukemia patient]", "firstAuthor": "Minami", "multipleAuthors": true, "journal": "Rinsho Ketsueki", "year": 2018, "design": "case-series", "n": 1, "nField": "reported", "population": "13-year-old girl with leukemia receiving chemotherapy including L-asparaginase", "intervention": "surgical ligation (banding) of thrombosed external hemorrhoids", "comparator": "conservative (non-surgical) treatment", "primaryOutcome": "healing of the hemorrhoids after ligation", "result": "the hemorrhoids became necrotic and formed an ulcerated wound after ligation", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show what usually happens with banding.", "directness": "indirect", "limitations": "Only one patient, who also had leukemia and was on chemotherapy, which may make healing worse than in typical hemorrhoid patients.", "followUp": "", "plainFinding": "Banding caused tissue death here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30531135/", "sourceText": "A 13-year-old female developed L-asparaginase (L-ASP) -associated thrombosed external hemorrhoids (TEH) during chemotherapy for Philadelphia chromosome-positive acute lymphoblastic leukemia. While undergoing induction therapy combined with imatinib, she experienced intense anal pain a day after the four-time administration of L-ASP. The anal verge contained painful bluish hemorrhoids, which reportedly were absent before the therapy commencement. Hemorrhoids occurred 5-9 days after every L-ASP treatment, which was eventually diagnosed as L-ASP-associated TEH. After the failure of conservative treatment, opioid therapy was initiated. During myeloid reconstitution, she underwent divided ligation of hemorrhoids; however, the hemorrhoids became necrotic and formed an ulcerated tissue bed. This case suggests that while undertaking L-ASP therapy in adolescents and young adults with acute lymphoblastic leukemia, physicians should monitor signs of hemorrhoids and consider divided ligation when appropriate.", "provenance": [ { "field": "n", "quote": "A 13-year-old female developed L-asparaginase (L-ASP) -associated thrombosed external hemorrhoids (TEH) during chemotherapy for Philadelphia chromosome-positive acute lymphoblastic leukemia." }, { "field": "population", "quote": "A 13-year-old female developed L-asparaginase (L-ASP) -associated thrombosed external hemorrhoids (TEH) during chemotherapy for Philadelphia chromosome-positive acute lymphoblastic leukemia." }, { "field": "intervention", "quote": "she underwent divided ligation of hemorrhoids" }, { "field": "comparator", "quote": "After the failure of conservative treatment, opioid therapy was initiated." }, { "field": "primaryOutcome", "quote": "she underwent divided ligation of hemorrhoids; however, the hemorrhoids became necrotic and formed an ulcerated tissue bed." }, { "field": "result", "quote": "however, the hemorrhoids became necrotic and formed an ulcerated tissue bed." } ] }, { "id": "pmid:31583307", "pmid": "31583307", "doi": "10.23922/jarc.2017-018", "nctId": null, "pmcid": "PMC6768674", "title": "Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids", "firstAuthor": "Yamana", "multipleAuthors": false, "journal": "J Anus Rectum Colon", "year": 2017, "design": "guideline", "n": null, "nField": "not-reported", "population": "people with hemorrhoids (internal and external, various grades)", "intervention": "rubber band ligation", "comparator": "other treatments such as ligation and excision, drug therapy, PPH surgery", "primaryOutcome": "which treatment is appropriate for each grade/type of hemorrhoid", "result": "rubber band ligation is only described for internal hemorrhoids up to Grade III, while external hemorrhoids are treated with ligation and excision instead", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a practice guideline summarizing general treatment recommendations rather than a study testing banding on external hemorrhoids, so it can't show why banding fails there.", "directness": "indirect", "limitations": "The abstract is a general guideline overview and does not explain the physiological reason banding is unsuitable for external hemorrhoids, nor does it report a specific study comparing outcomes.", "followUp": "", "plainFinding": "Banding only used for internal hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31583307/", "sourceText": "The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.", "provenance": [ { "field": "intervention", "quote": "Rubber band ligation is used to treat up to Grade III internal hemorrhoids." }, { "field": "comparator", "quote": "Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids." }, { "field": "result", "quote": "Rubber band ligation is used to treat up to Grade III internal hemorrhoids." }, { "field": "population", "quote": "The prevalence of hemorrhoids can encompass 4 to 55% of the population." }, { "field": "primaryOutcome", "quote": "Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment." } ] }, { "id": "pmid:29431977", "pmid": "29431977", "doi": null, "nctId": null, "pmcid": null, "title": "Hemorrhoids: Diagnosis and Treatment Options", "firstAuthor": "Mott", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2018, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "adults with hemorrhoids, typically ages 45 to 65", "intervention": "rubber band ligation for internal hemorrhoids", "comparator": "excision for thrombosed external hemorrhoids", "primaryOutcome": "", "result": "rubber band ligation is used for grades I to III internal hemorrhoids, while thrombosed external hemorrhoids are treated by excision rather than banding", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general narrative review summarizing treatment recommendations rather than reporting results from a single original study.", "directness": "indirect", "limitations": "The abstract does not describe study methodology, data sources, or evidence grading, and does not directly explain why external hemorrhoids cannot be banded.", "followUp": "", "plainFinding": "Banding is for internal hemorrhoids only", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29431977/", "sourceText": "Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.", "provenance": [ { "field": "population", "quote": "Many Americans between 45 and 65 years of age experience hemorrhoids." }, { "field": "intervention", "quote": "office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation" }, { "field": "comparator", "quote": "Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms." }, { "field": "result", "quote": "office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step" }, { "field": "result", "quote": "Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms." } ] }, { "id": "pmid:28514383", "pmid": "28514383", "doi": "10.17116/hirurgia2017547-51", "nctId": null, "pmcid": null, "title": "[Efficiency of combined methods of hemorroid treatment using hal-rar and laser destruction]", "firstAuthor": "Rodoman", "multipleAuthors": true, "journal": "Khirurgiia (Mosk)", "year": 2017, "design": "retrospective", "n": 100, "nField": "reported", "population": "adults with chronic hemorrhoids stage II and III", "intervention": "combined treatment: Doppler-guided artery ligation plus laser destruction of internal and external hemorrhoids", "comparator": "HAL-RAR technique alone or closed hemorrhoidectomy with a stapler", "primaryOutcome": "how well the treatment worked (efficiency), safety, recurrence and complication rates, and time off work", "result": "The combined laser method was more effective than HAL-RAR alone for stage II-III hemorrhoids, equally safe, did not raise recurrence risk, and lowered complications and recovery time", "resultDirection": "benefit", "quality": "low", "qualityWhy": "The study compares surgical groups without mentioning randomization or blinding, so bias cannot be ruled out.", "directness": "indirect", "limitations": "No mention of randomization, blinding, or how patients were assigned to groups; the abstract does not explain the mechanical reason banding fails on external tissue.", "followUp": "", "plainFinding": "Combined laser method outperformed HAL-RAR alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28514383/", "sourceText": "AIM: To develop the combined method of treatment of hemorrhoids with arterial ligation under Doppler control and laser destruction of internal and external hemorrhoids. MATERIAL AND METHODS: The study included 100 patients with chronic hemorrhoids stage II and III. Combined method of HAL-laser was used in study group, HAL RAR-technique in control group 1 and closed hemorrhoidectomy with linear stapler in control group 2. Сomparative evaluation of results in both groups was performed. RESULTS: Combined method overcomes the drawbacks of traditional surgical treatment and limitations in external components elimination which are inherent for HAL-RAR. Moreover, it has a higher efficiency in treating of hemorrhoids stage II-III compared with HAL-RAR and is equally safe and well tolerable for patients. This method does not increase the risk of recurrence, reduces incidence of complications and time of disability.", "provenance": [ { "field": "population", "quote": "patients with chronic hemorrhoids stage II and III" }, { "field": "intervention", "quote": "Combined method of HAL-laser was used in study group" }, { "field": "comparator", "quote": "HAL RAR-technique in control group 1 and closed hemorrhoidectomy with linear stapler in control group 2" }, { "field": "primaryOutcome", "quote": "it has a higher efficiency in treating of hemorrhoids stage II-III compared with HAL-RAR and is equally safe and well tolerable for patients" }, { "field": "result", "quote": "This method does not increase the risk of recurrence, reduces incidence of complications and time of disability." }, { "field": "n", "quote": "The study included 100 patients with chronic hemorrhoids stage II and III." } ] }, { "id": "pmid:26808814", "pmid": "26808814", "doi": "10.1016/j.gie.2016.01.041", "nctId": null, "pmcid": null, "title": "Use of the over-the-scope clip to treat massive bleeding at the transitional zone of the anal canal: a case series", "firstAuthor": "Soetikno", "multipleAuthors": true, "journal": "Gastrointest Endosc", "year": 2016, "design": "case-series", "n": 5, "nField": "reported", "population": "patients with severe bleeding from the transitional zone of the anal canal caused by hemorrhoid therapy, digital trauma, or a Dieulafoy lesion", "intervention": "endoscopic over-the-scope clip (OTSC) placement", "comparator": "no comparison group reported", "primaryOutcome": "whether bleeding stopped (hemostasis) and whether it came back", "result": "a single clip stopped the bleeding in all patients with no bleeding returning afterward", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a tiny retrospective series of only 5 patients with no comparison group, so it can't reliably show whether the clip works better than other options.", "directness": "indirect", "limitations": "Retrospective design, very small sample size of 5 patients, no control or comparison group.", "followUp": "", "plainFinding": "Clip stopped the bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26808814/", "sourceText": "BACKGROUND AND AIMS: Endoscopic treatment of anorectal bleeding can be challenging. We report use of the endoscopic over-the-scope clip (OTSC) to treat massive bleeding from the transitional zone of the anorectum. The aim of this retrospective study was to assess the clinical outcome and efficacy of the OTSC and to describe the technique of its use in acute severe bleeding occurring at the transitional zone of the anorectum. METHODS: We treated 5 consecutive patients (age range, 36-79 years, 5 men) with severe bleeding from the transitional zone of the anorectum caused by hemorrhoid therapy, digital trauma, and a Dieulafoy lesion. We analyzed the efficacy, safety, and outcome of endoscopic treatment using the OTSC. RESULTS: Primary hemostasis was successfully achieved in all the patients using a single OTSC. The OTSC deployment technique was adapted from the endoscopic band ligation of hemorrhoids. There was no immediate or late rebleeding. We observed that there were no adverse events from OTSC placement in the anorectum. CONCLUSIONS: This case series provides evidence that OTSCs may be effective in controlling bleeding from the transitional zone of the anorectum. Although use of OTSCs for bleeding elsewhere in the GI tract has been described, this case series is the first to show its application in the transitional zone of the anorectum.", "provenance": [ { "field": "n", "quote": "We treated 5 consecutive patients (age range, 36-79 years, 5 men)" }, { "field": "population", "quote": "severe bleeding from the transitional zone of the anorectum caused by hemorrhoid therapy, digital trauma, and a Dieulafoy lesion" }, { "field": "intervention", "quote": "use of the endoscopic over-the-scope clip (OTSC) to treat massive bleeding from the transitional zone of the anorectum" }, { "field": "comparator", "quote": "We analyzed the efficacy, safety, and outcome of endoscopic treatment using the OTSC." }, { "field": "primaryOutcome", "quote": "assess the clinical outcome and efficacy of the OTSC" }, { "field": "result", "quote": "Primary hemostasis was successfully achieved in all the patients using a single OTSC." }, { "field": "result", "quote": "There was no immediate or late rebleeding." } ] }, { "id": "pmid:26561592", "pmid": "26561592", "doi": "10.1136/postgradmedj-2015-133328", "nctId": null, "pmcid": null, "title": "Haemorrhoids: modern diagnosis and treatment", "firstAuthor": "Hollingshead", "multipleAuthors": true, "journal": "Postgrad Med J", "year": 2016, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "People with haemorrhoids", "intervention": "Rubber band ligation", "comparator": "", "primaryOutcome": "", "result": "Rubber band ligation works in 75% of patients short term, but does not treat haemorrhoids with a significant external part or prolapse", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a narrative review summarizing other studies rather than presenting new original data with its own methodology.", "directness": "direct", "limitations": "Long-term data are poor for all procedures, with many studies reporting only 1-3 years of follow-up", "followUp": "1-3 years", "plainFinding": "Banding doesn't treat external hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26561592/", "sourceText": "Haemorrhoids present often to primary and secondary care, and haemorrhoidal procedures are among the most common carried out. They may co-exist with more serious pathology, and correct evaluation is important. In most cases a one-off colonoscopy in patients aged 50 or above with flexible sigmoidoscopy in younger patients is reasonable. Many people with haemorrhoids do not require treatment. Topical remedies provide no more than symptomatic relief-and even evidence for this is poor. Bulk laxatives alone may improve symptoms of both bleeding and prolapse and seem as effective as injection sclerotherapy. Rubber band ligation is effective in 75% of patients in the short term, but does not treat prolapsed haemorrhoids or those with a significant external component. Conventional haemorrhoidectomy remains the most effective treatment in the long term, the main limitation being post-operative pain. Metronidazole, topical sphincter relaxants and operative technique have all been shown to reduce pain. Stapled haemorrhoidectomy and haemorrhoidal artery ligation techniques are probably less effective but less painful. Long-term data are poor for all procedures, with many studies reporting only 1-3 years of follow-up data. Haemorrhoids are common in pregnancy, occurring in 40% of women. They can usually be treated conservatively during pregnancy, with any treatment delayed until after delivery. Acutely strangulated haemorrhoids may be treated either conservatively or operatively. There is an increased risk of anal stenosis after acute surgery, but the risks of sepsis and sphincter damage are less significant than previously thought. The majority of patients who are treated conservatively will still require definitive treatment at a later date.", "provenance": [ { "field": "intervention", "quote": "Rubber band ligation" }, { "field": "result", "quote": "Rubber band ligation is effective in 75% of patients in the short term, but does not treat prolapsed haemorrhoids or those with a significant external component." }, { "field": "population", "quote": "Haemorrhoids present often to primary and secondary care" }, { "field": "limitations", "quote": "Long-term data are poor for all procedures, with many studies reporting only 1-3 years of follow-up data." } ] }, { "id": "pmid:26378752", "pmid": "26378752", "doi": "10.7417/CT.2015.1863", "nctId": null, "pmcid": null, "title": "[Rubber band ligation in treatment of hemorrhoids: our experience]", "firstAuthor": "Gaj", "multipleAuthors": true, "journal": "Clin Ter", "year": 2015, "design": "case-series", "n": 50, "nField": "reported", "population": "patients with symptomatic grade II and III internal hemorrhoids without prolapse", "intervention": "rubber band ligation of hemorrhoids", "comparator": "none (before-and-after comparison within same patients)", "primaryOutcome": "symptom resolution (bleeding, discomfort, itching) over 6 months follow-up", "result": "Most symptoms resolved by 6 months with no severe complications", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a small, uncontrolled case series without a comparison group, so it can't reliably show cause and effect.", "directness": "indirect", "limitations": "No control group, small sample size, single-center experience, no long-term follow-up beyond 6 months.", "followUp": "6 months", "plainFinding": "Good symptom relief for internal hemorrhoids only.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26378752/", "sourceText": "OBJECTIVES: Hemorrhoids are a very common condition. The treatment depends upon persistence and severity of symptoms. For hemorrhoids of II and III grade the rubber band ligation may be therapeutic. Our aim is to report the outcomes of rubber band ligation of hemorrhoids, with a follow up of 6 months. MATERIALS AND METHODS: A total of 50 patients underwent rubber band ligation for symptomatic hemorrhoids (grade II and III) without prolapse, between June 2012 and June 2014. All patients underwent plug test to rule out presence of rectal mucosal prolapse and were classified according to PATE classification (1). Each hemorrhoid was ligated with one rubber band through a ligator. All patients were evaluated immediately at the end of the procedure, after ten days and six months after the treatment. Patient's demographic and operative data were collected and analyzed. RESULTS: The mean patients age was 47.6±12.3 years (range 24-72). All procedures were performed without complications. Before rubber band ligation, 42 patients had rectal bleeding, 38 had perineal discomfort and 27 had itching. Ten days after the treatment, 12 patients presented self-limited rectal bleeding, but 10 of these had more hemorrhoids and underwent a second rubber band ligation. No patients complained perineal discomfort, and 8 patients had itching; 78% and 16% of patients respectively, experienced feeling of a foreign body inside the canal anal and anal pain. After 6 months, only 13 patients were occasionally symptomatic: 4 patients had rectal bleeding, 2 had perineal discomfort and 4 had itching. Three more patients presented both perineal discomfort and hitching. None had the feeling of a foreign body in anal canal or anal pain. CONCLUSIONS: Rubber band ligation is an efficacious, cost-effective and simple treatment for the second and third degree hemorrhoids without rectal mucosal prolapsed. In our hands, no severe complications developed and minor complications could be handled with ease.", "provenance": [ { "field": "n", "quote": "A total of 50 patients underwent rubber band ligation for symptomatic hemorrhoids" }, { "field": "population", "quote": "symptomatic hemorrhoids (grade II and III) without prolapse" }, { "field": "intervention", "quote": "Each hemorrhoid was ligated with one rubber band through a ligator." }, { "field": "comparator", "quote": "All patients were evaluated immediately at the end of the procedure, after ten days and six months after the treatment." }, { "field": "primaryOutcome", "quote": "Our aim is to report the outcomes of rubber band ligation of hemorrhoids, with a follow up of 6 months." }, { "field": "result", "quote": "After 6 months, only 13 patients were occasionally symptomatic" }, { "field": "result", "quote": "All procedures were performed without complications." } ] }, { "id": "pmid:26309351", "pmid": "26309351", "doi": "10.3748/wjg.v21.i31.9245", "nctId": null, "pmcid": "PMC4541377", "title": "Treatment of hemorrhoids: A coloproctologist's view", "firstAuthor": "Lohsiriwat", "multipleAuthors": false, "journal": "World J Gastroenterol", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "treatments for hemorrhoids (medication, rubber band ligation, injection, surgery)", "comparator": "different treatments compared by hemorrhoid type and severity", "primaryOutcome": "appropriate management approach for each type/severity of hemorrhoid", "result": "external hemorrhoids usually need no specific treatment unless thrombosed or causing discomfort; banding and other non-operative measures are described only for internal hemorrhoids", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is an expert narrative review and editorial, not a study with data comparing treatments, so it carries little weight as evidence.", "directness": "direct", "limitations": "It is an opinion/review article summarizing general practice rather than reporting original research or outcome data.", "followUp": "", "plainFinding": "External hemorrhoids aren't banded; usually no treatment needed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26309351/", "sourceText": "Hemorrhoids is recognized as one of the most common medical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. Generally, hemorrhoids can be divided into two types: internal hemorrhoid and external hemorrhoid. External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort. Meanwhile, low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids, several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain. This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist - which includes the management of hemorrhoids in complicated situations such as hemorrhoids in pregnancy, hemorrhoids in immunocompromised patients, hemorrhoids in patients with cirrhosis or portal hypertension, hemorrhoids in patients having antithrombotic agents, and acutely thrombosed or strangulated hemorrhoids. Future perspectives in the treatment of hemorrhoids are also discussed.", "provenance": [ { "field": "population", "quote": "Hemorrhoids is recognized as one of the most common medical conditions in general population." }, { "field": "intervention", "quote": "low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy)" }, { "field": "comparator", "quote": "External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort." }, { "field": "result", "quote": "External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort." }, { "field": "primaryOutcome", "quote": "This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist" } ] }, { "id": "pmid:26978623", "pmid": "26978623", "doi": "10.17116/hirurgia20151146-52", "nctId": null, "pmcid": null, "title": "[Latex ligation in treatment of chronic hemorrhoids]", "firstAuthor": "Ektov", "multipleAuthors": true, "journal": "Khirurgiia (Mosk)", "year": 2015, "design": "case-series", "n": 432, "nField": "reported", "population": "patients with chronic hemorrhoids", "intervention": "latex ligation (banding) of hemorrhoids, with new variants including ligation of rectal mucosa and combined ligation with external hemorrhoid excision", "comparator": "different variants of latex ligation technique compared to each other, not a separate control group", "primaryOutcome": "long-term success of hemorrhoid treatment", "result": "87.3% of patients had good long-term results with the ligation techniques described", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is an uncontrolled case series without a comparison group, so it cannot show whether banding external hemorrhoids specifically is safe or effective versus alternatives.", "directness": "indirect", "limitations": "No control group, no randomization, and the abstract does not specify complications or why external tissue would be problematic to band; it mainly addresses internal hemorrhoid staging.", "followUp": "", "plainFinding": "Good results in most patients.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26978623/", "sourceText": "We analyzed the results of treatment of 432 patients with chronic hemorrhoids using different variants of latex ligation. New technique including ligation of mucosa and submucosa of low-ampullar rectum providing ligation of hemorrhoidalvessels, lifting and recto-anal repair is developed and suggested. This method is advisable to use in case of chronic internal hemorrhoids stages I and II. The authors recommend simultaneous combined ligation of mucosa of low-ampullar rectum and internal hemorrhoids for stages III and IV. Different variants of latex ligation with external hemorrhoids excision were used in 103 patients. Pointed variants of latex ligation preserve important advantages including mini-invasiveness, simplicity and wide availability, low cost. Good remote results were obtained after these procedures in 87.3% of observations. Suggested tactics extends use of latex ligation and increases its effectiveness in treatment of different stages and forms of chronic hemorrhoids.", "provenance": [ { "field": "n", "quote": "We analyzed the results of treatment of 432 patients with chronic hemorrhoids using different variants of latex ligation." }, { "field": "population", "quote": "432 patients with chronic hemorrhoids" }, { "field": "intervention", "quote": "Different variants of latex ligation with external hemorrhoids excision were used in 103 patients." }, { "field": "comparator", "quote": "Different variants of latex ligation with external hemorrhoids excision were used in 103 patients." }, { "field": "primaryOutcome", "quote": "Good remote results were obtained after these procedures in 87.3% of observations." }, { "field": "result", "quote": "Good remote results were obtained after these procedures in 87.3% of observations." } ] }, { "id": "pmid:24742083", "pmid": "24742083", "doi": null, "nctId": null, "pmcid": null, "title": "Anorectal conditions: hemorrhoids", "firstAuthor": "Fox", "multipleAuthors": true, "journal": "FP Essent", "year": 2014, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "rubber band ligation", "comparator": "no direct comparator stated", "primaryOutcome": "treatment effectiveness for hemorrhoids", "result": "Banding is described as effective for internal hemorrhoid grades I-III, while external hemorrhoids (when thrombosed) are treated by cutting out the clot rather than banding", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general narrative review summarizing standard practice without presenting original study data or comparative results.", "directness": "direct", "limitations": "Abstract does not provide original data, study methodology, or evidence grading; it is a general review of management recommendations.", "followUp": "", "plainFinding": "Banding is for internal, not external, hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24742083/", "sourceText": "Hemorrhoids are engorged fibrovascular cushions lining the anal canal. Constipation, increased intra-abdominal pressure, and prolonged straining predispose to hemorrhoids. Approximately 1 in 20 Americans and almost one-half of individuals older than 50 years experience symptomatic hemorrhoids. Bright red, painless rectal bleeding during defecation is the most common presentation. Even if hemorrhoids are seen on examination, patients with rectal bleeding who are at risk of colorectal cancer (eg, adults older than 50 years) should still undergo colonoscopy to exclude cancer as the etiology. Nonsurgical treatment for nonthrombosed hemorrhoids includes increased fiber intake, sitz baths, and drugs. If nonsurgical management is unsuccessful, rubber band ligation is the most effective office-based procedure for grades I, II, and III hemorrhoids. Surgical hemorrhoidectomy is indicated after failure of nonsurgical management and office-based procedures and also as initial management for grades III and IV hemorrhoids. Several different procedures can be used. For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management. Prolapsed and strangulated hemorrhoids are best managed with stool softeners, analgesics, rest, warm soaks, and ice packs until recovery; residual hemorrhoids are banded or excised later.", "provenance": [ { "field": "intervention", "quote": "rubber band ligation is the most effective office-based procedure for grades I, II, and III hemorrhoids" }, { "field": "result", "quote": "For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management" }, { "field": "population", "quote": "Hemorrhoids are engorged fibrovascular cushions lining the anal canal" }, { "field": "primaryOutcome", "quote": "rubber band ligation is the most effective office-based procedure for grades I, II, and III hemorrhoids" }, { "field": "comparator", "quote": "Surgical hemorrhoidectomy is indicated after failure of nonsurgical management and office-based procedures" } ] }, { "id": "pmid:24280398", "pmid": "24280398", "doi": "10.1016/j.gtc.2013.09.001", "nctId": null, "pmcid": null, "title": "Modern management of hemorrhoidal disease", "firstAuthor": "Hall", "multipleAuthors": false, "journal": "Gastroenterol Clin North Am", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "People with hemorrhoid-related symptoms", "intervention": "Nonoperative treatments and procedures for hemorrhoids", "comparator": "Surgical hemorrhoidectomy", "primaryOutcome": "Management of hemorrhoid symptoms", "result": "The abstract describes treatment options but does not report specific outcome data", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review article summarizing treatment approaches without presenting original data or outcomes.", "directness": "indirect", "limitations": "The abstract does not discuss banding of external hemorrhoids specifically, nor does it provide any data on complications or rationale for why external hemorrhoids are not banded.", "followUp": "", "plainFinding": "No specific findings reported here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24280398/", "sourceText": "Complaints secondary to hemorrhoidal disease have been treated by health care providers for centuries. Most symptoms referable to hemorrhoidal disease can be managed nonoperatively. When symptoms do not respond to medical therapy, procedural intervention is recommended. Surgical hemorrhoidectomy is usually reserved for patients who are refractory to or unable to tolerate office procedures. This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.", "provenance": [ { "field": "population", "quote": "Complaints secondary to hemorrhoidal disease have been treated by health care providers for centuries." }, { "field": "intervention", "quote": "Most symptoms referable to hemorrhoidal disease can be managed nonoperatively." }, { "field": "comparator", "quote": "Surgical hemorrhoidectomy is usually reserved for patients who are refractory to or unable to tolerate office procedures." }, { "field": "primaryOutcome", "quote": "This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints." }, { "field": "result", "quote": "This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints." } ] }, { "id": "pmid:23752820", "pmid": "23752820", "doi": "10.1038/nrgastro.2013.91", "nctId": null, "pmcid": null, "title": "Conservative and surgical treatment of haemorrhoids", "firstAuthor": "Altomare", "multipleAuthors": true, "journal": "Nat Rev Gastroenterol Hepatol", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with haemorrhoids of different grades", "intervention": "rubber band ligation and other treatments for haemorrhoids", "comparator": "surgical treatments such as haemorrhoidectomy and minimally invasive procedures", "primaryOutcome": "successful treatment of haemorrhoids, pain, recurrence and complications", "result": "rubber band ligation is described as effective for grade I and II haemorrhoids, while surgery is needed for more advanced stages; the abstract does not specifically discuss banding of external haemorrhoids", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative review summarizing general treatment approaches without original data or direct comparison on banding external haemorrhoids", "directness": "indirect", "limitations": "abstract does not address external haemorrhoids specifically or explain why they cannot be banded", "followUp": "", "plainFinding": "Review doesn't address external hemorrhoid banding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23752820/", "sourceText": "The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.", "provenance": [ { "field": "intervention", "quote": "rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids" }, { "field": "comparator", "quote": "surgery is required for the most advanced stages" }, { "field": "population", "quote": "grade I and II haemorrhoids" }, { "field": "primaryOutcome", "quote": "reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate" }, { "field": "result", "quote": "rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids" } ] }, { "id": "pmid:22714783", "pmid": "22714783", "doi": "10.1007/s00384-012-1512-9", "nctId": null, "pmcid": null, "title": "Hemorrhoid management in patients with radiation proctitis", "firstAuthor": "Hawkins", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2012, "design": "case-series", "n": 327, "nField": "reported", "population": "colon and rectal surgeons who treat patients with radiation-related rectal bleeding", "intervention": "various hemorrhoid and proctitis treatments reported by surgeons (rubber band ligation, hemorrhoidectomy, sclerotherapy, topical formalin, argon plasma coagulation)", "comparator": "different treatment methods compared to each other based on surgeon survey responses", "primaryOutcome": "which treatments surgeons reported using for radiation proctitis and hemorrhoids", "result": "Forty-three percent reported using rubber band ligation, 30 % using hemorrhoidectomy, and 18 % using sclerotherapy", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is just a survey of doctors' reported habits, not a study measuring whether any treatment actually worked or was safe.", "directness": "indirect", "limitations": "No randomized controlled trials exist on this topic; this is an opinion survey of practitioners rather than an observational or controlled study of patient outcomes.", "followUp": "", "plainFinding": "Survey only; no outcome data.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22714783/", "sourceText": "PURPOSE: Management of rectal bleeding in patients with radiation proctitis presents a conundrum for practitioners. Surgeons are appropriately concerned about using conventional methods of treatment in these patients, such as cautery for bleeding areas in the rectum, rubber band ligation, or excision of internal and/or external hemorrhoids, for fear of poor healing and possible exacerbation of the original problem. Few randomized controlled trials are available on the treatment of radiation proctitis alone, and no literature exists pertaining to the management of symptomatic hemorrhoids in the radiated patient. METHODS: In the absence of observational studies, the authors created an email survey to distribute to the membership of the American Society of Colon and Rectal Surgeons in order to try to identify current management practices for radiation proctitis and for the treatment of their symptomatic hemorrhoids. RESULTS: Of the 327 respondents, 85 % favored the use of topical formalin to treat radiation proctitis, while 42 % additionally used argon plasma coagulation. Only 25 % of practitioners report using sucralfate, though existing data on this therapy are promising. Regarding the management of hemorrhoids in patients with a history of rectal irradiation, 55 % of respondents hoped treatment of radiation proctitis alone would solve the problem. Forty-three percent reported using rubber band ligation, 30 % using hemorrhoidectomy, and 18 % using sclerotherapy. CONCLUSIONS: While most respondents treated radiation proctitis alone in patients with symptomatic hemorrhoids, many also felt rubber band ligation, hemorrhoidectomy, and sclerotherapy are safe and effective alternative therapies in this population.", "provenance": [ { "field": "n", "quote": "Of the 327 respondents" }, { "field": "population", "quote": "email survey to distribute to the membership of the American Society of Colon and Rectal Surgeons" }, { "field": "intervention", "quote": "Forty-three percent reported using rubber band ligation, 30 % using hemorrhoidectomy, and 18 % using sclerotherapy." }, { "field": "comparator", "quote": "85 % favored the use of topical formalin to treat radiation proctitis, while 42 % additionally used argon plasma coagulation" }, { "field": "primaryOutcome", "quote": "identify current management practices for radiation proctitis and for the treatment of their symptomatic hemorrhoids" }, { "field": "result", "quote": "Forty-three percent reported using rubber band ligation, 30 % using hemorrhoidectomy, and 18 % using sclerotherapy." } ] }, { "id": "pmid:22534276", "pmid": "22534276", "doi": null, "nctId": null, "pmcid": null, "title": "Evaluation and management of common anorectal conditions", "firstAuthor": "Fargo", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2012, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "adults with common anorectal conditions such as hemorrhoids, fissures, and fistulas", "intervention": "rubber band ligation and other treatments for hemorrhoids", "comparator": "different treatments for external vs internal hemorrhoids (dietary changes, topical steroids, analgesics vs rubber band ligation or surgery)", "primaryOutcome": "appropriate management approach for each anorectal condition", "result": "Internal hemorrhoids (grades I-III) can be treated with rubber band ligation, while symptomatic external hemorrhoids are managed with dietary changes, topical steroids, and analgesics rather than banding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review article summarizing treatment recommendations without presenting original trial data or evidence grading for this specific comparison.", "directness": "direct", "limitations": "The abstract does not explain why external hemorrhoids cannot be banded; it only states the differing treatment approaches without supporting data or rationale.", "followUp": "", "plainFinding": "Banding used for internal, not external, hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22534276/", "sourceText": "The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective therapy is often lacking. In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal bleeding despite treatment, weight loss, or iron deficiency anemia should undergo colonoscopy. Pruritus ani, or perianal itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral antihistamines, topical steroids, or topical capsaicin. Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers. Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics. Thrombosed hemorrhoids are best treated with hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal hemorrhoids can be managed with rubber band ligation. For the treatment of grade III internal hemorrhoids, surgical hemorrhoidectomy has higher remission rates but increased pain and complication rates compared with rubber band ligation. Anorectal condylomas, or anogenital warts, are treated based on size and location, with office treatment consisting of topical trichloroacetic acid or podophyllin, cryotherapy, or laser treatment. Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics, whereas complex or nonhealing fistulas may require surgery. Fecal impaction may be treated with polyethylene glycol, enemas, or manual disimpaction. Fecal incontinence is generally treated with loperamide and biofeedback. Surgical intervention is reserved for anal sphincter injury.", "provenance": [ { "field": "population", "quote": "Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics." }, { "field": "intervention", "quote": "Grades I through III internal hemorrhoids can be managed with rubber band ligation." }, { "field": "comparator", "quote": "Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics." }, { "field": "primaryOutcome", "quote": "In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders." }, { "field": "result", "quote": "Grades I through III internal hemorrhoids can be managed with rubber band ligation." }, { "field": "result", "quote": "Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics." } ] }, { "id": "pmid:21914230", "pmid": "21914230", "doi": null, "nctId": null, "pmcid": null, "title": "[Internal and external haemorrhoids]", "firstAuthor": "Schuurman", "multipleAuthors": true, "journal": "Ned Tijdschr Geneeskd", "year": 2011, "design": "case-series", "n": 3, "nField": "reported", "population": "Three adult patients with hemorrhoidal disease (ages 27, 76, and 31)", "intervention": "Diagnosis and classification of internal versus external hemorrhoids based on anatomical origin and symptoms", "comparator": "Comparison between internal hemorrhoids (from internal vascular cushions) and external hemorrhoids (from perianal veins)", "primaryOutcome": "Symptom presentation and appropriate treatment approach for each hemorrhoid type", "result": "Internal hemorrhoids arise from internal rectal tissue and cause bleeding/prolapse; external hemorrhoids arise from perianal veins and cause pain, best treated surgically", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a report of only three patient cases, which cannot reliably prove why banding works differently, only describe anatomy and typical treatment.", "directness": "indirect", "limitations": "Case series design with only 3 patients provides anatomical description but does not directly test or compare banding versus other treatments for external hemorrhoids.", "followUp": "", "plainFinding": "External hemorrhoids come from different veins.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21914230/", "sourceText": "In this article, we present 3 cases of patients with different types of haemorrhoidal disease. The first patient is a 27-year-old woman who had been experiencing incidental rectal blood loss without pain during defecation for 3 months. The second patient is a 76-year-old woman who had been bothered by varying degrees of pain from a swelling nearby the anus for 1 year. The third case involves a 31-year-old man who had had continuous severe pain in the anal area for 3 consecutive days. The first patient appeared to have internal hemorrhoids, whereas different forms of external hemorrhoids affected the patients in the other 2 cases. Internal haemorrhoids develop from the intraluminal corpus cavernosum recti; external haemorrhoids from the perianal marginal veins. Patients with internal haemorrhoids present with symptoms that include blood loss and prolaps feeling during defecation. In patients with external haemorrhoids pain is the prominent symptom. Internal haemorrhoids are treated either conservatively or surgically, depending upon their severity. Considering external haemorrhoidal disease surgical treatment provides the most rapid and persistent relief of symptoms.", "provenance": [ { "field": "n", "quote": "we present 3 cases of patients with different types of haemorrhoidal disease" }, { "field": "population", "quote": "The first patient is a 27-year-old woman" }, { "field": "population", "quote": "The second patient is a 76-year-old woman" }, { "field": "population", "quote": "The third case involves a 31-year-old man" }, { "field": "intervention", "quote": "Internal haemorrhoids develop from the intraluminal corpus cavernosum recti; external haemorrhoids from the perianal marginal veins." }, { "field": "comparator", "quote": "The first patient appeared to have internal hemorrhoids, whereas different forms of external hemorrhoids affected the patients in the other 2 cases." }, { "field": "primaryOutcome", "quote": "Patients with internal haemorrhoids present with symptoms that include blood loss and prolaps feeling during defecation. In patients with external haemorrhoids pain is the prominent symptom." }, { "field": "result", "quote": "Considering external haemorrhoidal disease surgical treatment provides the most rapid and persistent relief of symptoms." } ] }, { "id": "pmid:21766771", "pmid": "21766771", "doi": null, "nctId": null, "pmcid": null, "title": "Hemorrhoids", "firstAuthor": "Mounsey", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2011, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "People with hemorrhoids", "intervention": "Rubber band ligation", "comparator": "Excisional hemorrhoidectomy and stapled hemorrhoidopexy", "primaryOutcome": "Recommended treatment approach by hemorrhoid grade and type", "result": "Rubber band ligation is used for internal hemorrhoids (grades 1-3), while external hemorrhoids are treated conservatively or excised, not banded", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general review article summarizing practice recommendations rather than a study testing outcomes, so it carries little independent evidence weight.", "directness": "indirect", "limitations": "The abstract does not explain the specific reason banding is unsuitable for external hemorrhoids, only that different treatments apply to each type.", "followUp": "", "plainFinding": "Banding is for internal, not external hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21766771/", "sourceText": "Most patients with hemorrhoids experience only mild symptoms that can be treated with nonprescription topical preparations. Patients usually seek treatment when symptoms increase. Internal hemorrhoids typically present with prolapse or painless rectal bleeding. External hemorrhoids also bleed and can cause acute pain if thrombosed. Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms. If medical therapy is inadequate, surgical intervention is warranted. Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids. Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids. Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate. Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids. Stapled hemorrhoidopexy has a faster postoperative recovery, but a higher recurrence rate. Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics. Thrombosed external hemorrhoids can be treated conservatively or excised.", "provenance": [ { "field": "population", "quote": "Most patients with hemorrhoids experience only mild symptoms" }, { "field": "intervention", "quote": "Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids." }, { "field": "comparator", "quote": "excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids" }, { "field": "primaryOutcome", "quote": "Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate." }, { "field": "result", "quote": "Thrombosed external hemorrhoids can be treated conservatively or excised." }, { "field": "result", "quote": "External hemorrhoids also bleed and can cause acute pain if thrombosed." } ] }, { "id": "pmid:19744418", "pmid": "19744418", "doi": null, "nctId": null, "pmcid": null, "title": "Clinical inquiries. Which treatments work best for hemorrhoids?", "firstAuthor": "Mounsey", "multipleAuthors": true, "journal": "J Fam Pract", "year": 2009, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids, including thrombosed external hemorrhoids and prolapsed internal hemorrhoids", "intervention": "different hemorrhoid treatments including excision, hemorrhoidectomy, and rubber band ligation", "comparator": "different treatment options compared to each other", "primaryOutcome": "", "result": "excision works best for thrombosed external hemorrhoids, traditional hemorrhoidectomy works best for prolapsed internal hemorrhoids, and rubber band ligation has the lowest recurrence rate among nonoperative treatments", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a brief review summarizing conclusions without describing study designs, sample sizes, or evidence quality, so it's hard to judge how reliable the claims are.", "directness": "indirect", "limitations": "The abstract gives no detail on the underlying studies, their size, or methodology, and does not explain why banding is unsuitable for external hemorrhoids specifically.", "followUp": "", "plainFinding": "Excision best for external, banding for internal.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19744418/", "sourceText": "Excision is the most effective treatment for thrombosed external hemorrhoids. For prolapsed internal hemorrhoids, the best definitive treatment is traditional hemorrhoidectomy. Of nonoperative techniques, rubber band ligation produces the lowest rate of recurrence.", "provenance": [ { "field": "intervention", "quote": "Excision is the most effective treatment for thrombosed external hemorrhoids." }, { "field": "comparator", "quote": "Of nonoperative techniques, rubber band ligation produces the lowest rate of recurrence." }, { "field": "population", "quote": "thrombosed external hemorrhoids" }, { "field": "population", "quote": "prolapsed internal hemorrhoids" }, { "field": "result", "quote": "Excision is the most effective treatment for thrombosed external hemorrhoids. For prolapsed internal hemorrhoids, the best definitive treatment is traditional hemorrhoidectomy. Of nonoperative techniques, rubber band ligation produces the lowest rate of recurrence." } ] }, { "id": "pmid:19445775", "pmid": "19445775", "doi": null, "nctId": null, "pmcid": "PMC2907769", "title": "Haemorrhoids", "firstAuthor": "Reese", "multipleAuthors": true, "journal": "BMJ Clin Evid", "year": 2009, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoidal disease (cushions of vascular tissue in the anal canal)", "intervention": "various hemorrhoid treatments including rubber band ligation and other surgical or non-surgical procedures", "comparator": "different treatment interventions compared with each other", "primaryOutcome": "effectiveness and safety of hemorrhoid treatments", "result": "abstract lists treatments evaluated without stating specific effect sizes or outcomes", "resultDirection": "unclear", "quality": "low", "qualityWhy": "the abstract only lists the interventions reviewed without presenting actual effect data or findings, so its strength can't be judged from this summary alone.", "directness": "indirect", "limitations": "abstract does not describe why external hemorrhoids specifically cannot be banded, nor does it give outcome data", "followUp": "", "plainFinding": "No specific result reported here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19445775/", "sourceText": "INTRODUCTION: Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for haemorrhoidal disease? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line." }, { "field": "intervention", "quote": "closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy" }, { "field": "comparator", "quote": "closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "What are the effects of treatments for haemorrhoidal disease?" }, { "field": "result", "quote": "We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria." } ] }, { "id": "pmid:20011381", "pmid": "20011381", "doi": "10.1055/s-2007-977485", "nctId": null, "pmcid": "PMC2780175", "title": "Hemorrhoids", "firstAuthor": "Halverson", "multipleAuthors": false, "journal": "Clin Colon Rectal Surg", "year": 2007, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids (internal and external)", "intervention": "rubber band ligation and other treatments for internal hemorrhoids", "comparator": "surgical hemorrhoidectomy and stapled hemorrhoidopexy", "primaryOutcome": "which hemorrhoid treatments work for which type of hemorrhoid", "result": "abstract states rubber band ligation is used for symptomatic internal hemorrhoids, while external hemorrhoids cause pain from thrombosis rather than bleeding/prolapse; it does not explicitly explain why external hemorrhoids can't be banded", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a general narrative review without original data, so it carries little weight as evidence for a specific clinical question", "directness": "indirect", "limitations": "abstract does not directly address or explain why external hemorrhoids cannot be banded", "followUp": "", "plainFinding": "Banding used only for internal hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20011381/", "sourceText": "Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm. Symptomatic hemorrhoidal tissues located above the dentate line are referred to as internal hemorrhoids and produce bleeding and prolapse. Thrombosis in external hemorrhoids results in painful swelling. Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation. Internal hemorrhoids that fail to respond to these measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy, either open or closed. A stapled hemorrhoidopexy treats symptomatic internal hemorrhoids and should be employed with care and only after thorough training of the surgeon because of the risk of rare, severe complications. The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon.", "provenance": [ { "field": "population", "quote": "Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm." }, { "field": "intervention", "quote": "rubber band ligation or infrared coagulation" }, { "field": "comparator", "quote": "surgical hemorrhoidectomy, either open or closed" }, { "field": "primaryOutcome", "quote": "The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon." }, { "field": "result", "quote": "Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation." }, { "field": "result", "quote": "Thrombosis in external hemorrhoids results in painful swelling." } ] }, { "id": "pmid:17063784", "pmid": "17063784", "doi": null, "nctId": null, "pmcid": null, "title": "[Non-surgical alternative management of hemorrhoidal disease]", "firstAuthor": "Charúa Guindic", "multipleAuthors": true, "journal": "Rev Gastroenterol Mex", "year": 2005, "design": "retrospective", "n": 2701, "nField": "reported", "population": "patients with hemorrhoidal disease treated at a clinic over five years", "intervention": "non-surgical treatments for internal hemorrhoids: rubber band ligation, sclerotherapy, infrared photocoagulation", "comparator": "the three non-surgical methods compared with each other by hemorrhoid stage", "primaryOutcome": "which treatment suited which degree of internal hemorrhoids, complications and long-term success", "result": "rubber band ligation was mainly used for degree II internal hemorrhoids, sclerotherapy stopped bleeding but had poor long-term results, and infrared photocoagulation worked best for degree I with less pain", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a retrospective chart review without a comparison group, so it can only describe patterns, not prove one treatment is better.", "directness": "indirect", "limitations": "Retrospective, descriptive design reviewing charts with no randomization or control group; focuses only on internal hemorrhoids, not external.", "followUp": "", "plainFinding": "Banding studied only for internal hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/17063784/", "sourceText": "UNLABELLED: Clinical manifestations of hemorrhoidal disease depend on its location (internal or external) and the presence or not of complications. PURPOSE: To describe the results of the three most common alternatives for non-surgical procedures treating internal hemorrhoids: rubber band ligation, esclerotherapy and infrared photocoagulation. MATERIALS AND METHODS: A retrospective, longitudinal and descriptive study from January 1998 to December 2002 was carried out, including variables like age, gender, clinical manifestations and date of initiation, type of non-surgical alternative treatment, complications, management and stage of the illness. RESULTS: In 9,103 charts reviewed this study included 2,701 patients with hemorrhoidal disease, with an annual incidence of 540.20 patients; 1,388 (51.39%) were male and 1,313 (48.62%) were female; ages between 17 and 78 years, 44.10 as a mean age. Rubber band ligation was used in 516 patients (67.45%), esclerotherapy in 177 (23.13%) and infrared photocoagulation in 72 cases (9.41%). CONCLUSIONS: Rubber band ligation is mainly indicated for internal hemorrhoids II degree, the esclerotherapy is indicated in the suppression of acute hemorrhage, but in the long term, this method has the poorest results. Infrared photocoagulation has its best results in internal hemorrhoids I degree because it causes less pain and complications and patients accept it better.", "provenance": [ { "field": "n", "quote": "this study included 2,701 patients with hemorrhoidal disease" }, { "field": "population", "quote": "this study included 2,701 patients with hemorrhoidal disease" }, { "field": "intervention", "quote": "To describe the results of the three most common alternatives for non-surgical procedures treating internal hemorrhoids: rubber band ligation, esclerotherapy and infrared photocoagulation" }, { "field": "comparator", "quote": "Rubber band ligation was used in 516 patients (67.45%), esclerotherapy in 177 (23.13%) and infrared photocoagulation in 72 cases (9.41%)" }, { "field": "primaryOutcome", "quote": "Rubber band ligation is mainly indicated for internal hemorrhoids II degree, the esclerotherapy is indicated in the suppression of acute hemorrhage, but in the long term, this method has the poorest results." }, { "field": "result", "quote": "Infrared photocoagulation has its best results in internal hemorrhoids I degree because it causes less pain and complications and patients accept it better." } ] }, { "id": "pmid:11742181", "pmid": "11742181", "doi": "10.1007/BF02234474", "nctId": null, "pmcid": null, "title": "Ligation-anopexy for treatment of advanced hemorrhoidal disease", "firstAuthor": "Hussein", "multipleAuthors": false, "journal": "Dis Colon Rectum", "year": 2001, "design": "case-series", "n": 40, "nField": "reported", "population": "patients with advanced (third- and fourth-degree) internal hemorrhoids", "intervention": "a suture-based procedure called ligation-anopexy that stitches the internal hemorrhoid tissue to the underlying sphincter", "comparator": "no comparison group; all patients received the same procedure", "primaryOutcome": "recurrence, anal narrowing, and complications after treatment", "result": "no recurrence or anal narrowing after 12 months, but some patients had anal spasm, bleeding, or clotting in external hemorrhoids", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small, uncontrolled case series with short follow-up, so it can't reliably show whether the procedure works better than other options.", "directness": "indirect", "limitations": "small number of patients, no control group, short 12-month follow-up, and the study is about a specific stitching technique for internal hemorrhoids, not about banding external hemorrhoids", "followUp": "12 months", "plainFinding": "Good short-term results treating internal hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/11742181/", "sourceText": "PURPOSE: Destruction of the anchoring tissue system is considered to be the essential prerequisite to the pathogenesis of advanced hemorrhoidal disease. Ligation-anopexy was designed to 1) restore fixation of the hemorrhoidal cushions to the underlying internal sphincter, 2) reduce hemorrhoidal prolapse, and 3) minimize the hemorrhoidal blood flow. The purpose of this study was to evaluate the ligation-anopexy as a new technique for the treatment of advanced stages of hemorrhoidal disease. METHODS: This study included 40 patients with hemorrhoidal disease (mean age 29.63 +/- 9.79 years, male/female ratio 34:6). Twenty-two patients had third-degree and 18 patients had fourth-degree hemorrhoids; of those with fourth-degree hemorrhoids, two patients had associated anal fissure and three patients had partial mucosal prolapse. Informed consent was obtained from all patients. After reduction of hemorrhoidal prolapse and under general or spinal anesthesia, a needle with 2-0 polyglactin (Vicryl) was inserted 1.5 cm above the dentate line using a Sims' speculum. The needle was inserted deep enough to fix the mucosa and the submucosa to the underlying internal sphincter. After the suture was tied, the redundant mucosa was pulled distally to be incorporated in the ligature, and the thread was relegated around it to form a mucosal tag. RESULTS: Inclusion of a part of the internal sphincter with ligation of the redundant mucosa ensures adequate retraction of prolapsed hemorrhoids (hemorrhoid lift). Postoperative pain was accepted by 90 percent of the patients and disappeared after treatment with oral diclofenac. The immediate complications included anal spasm in 10 percent, postoperative bleeding in 2.5 percent, and thrombosis of the external hemorrhoids in 2.5 percent of patients. Neither recurrence nor anal stenosis was observed after 12 months of follow-up. CONCLUSION: Despite the limited number of patients and the short follow-up, the preliminary results of ligation-anopexy in the treatment of advanced hemorrhoidal disease are encouraging.", "provenance": [ { "field": "n", "quote": "This study included 40 patients with hemorrhoidal disease" }, { "field": "population", "quote": "Twenty-two patients had third-degree and 18 patients had fourth-degree hemorrhoids" }, { "field": "intervention", "quote": "The needle was inserted deep enough to fix the mucosa and the submucosa to the underlying internal sphincter." }, { "field": "comparator", "quote": "This study included 40 patients with hemorrhoidal disease" }, { "field": "primaryOutcome", "quote": "Neither recurrence nor anal stenosis was observed after 12 months of follow-up." }, { "field": "result", "quote": "Neither recurrence nor anal stenosis was observed after 12 months of follow-up." }, { "field": "result", "quote": "thrombosis of the external hemorrhoids in 2.5 percent of patients" } ] }, { "id": "pmid:10196614", "pmid": "10196614", "doi": null, "nctId": null, "pmcid": null, "title": "Eight-year experience in treatment of hemorrhoidal disease", "firstAuthor": "Nagy", "multipleAuthors": true, "journal": "Acta Chir Hung", "year": 1998, "design": "case-series", "n": 887, "nField": "reported", "population": "people with hemorrhoid symptoms of different severities", "intervention": "rubber band ligation, surgical removal, or excision depending on hemorrhoid type", "comparator": "different treatment groups compared to each other (banding vs. surgery vs. excision vs. conservative care)", "primaryOutcome": "being symptom-free or much improved after treatment", "result": "65% of the banding group and 85% of the surgery group were symptom-free; thrombosed external hemorrhoids were treated by cutting them out, not banding", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a retrospective review of patients treated over eight years with no comparison testing or randomization, so differences between groups can't be trusted.", "directness": "indirect", "limitations": "No statistical comparison between groups, not randomized, follow-up only reached about 80% of patients, and it doesn't explain why banding isn't used on external hemorrhoids—only shows a different method was used for them.", "followUp": "", "plainFinding": "External hemorrhoids were cut out, not banded.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10196614/", "sourceText": "During an eight-year period 887 patients with symptoms of hemorrhoids were treated at the Department of Surgery and Outpatient Care of the Vaszary Kolos County Hospital, Esztergom. 178 patients with first degree hemorrhoids received only conservative treatment. Rubber band ligation (RBL) which can be performed on outpatients was applied in 324 patients with first, second and third degree hemorrhoids. Thrombosed external hemorrhoids were treated by excision in 215 patients. Hemorrhoidectomy (H) was mainly carried out in 91 cases for treatment of circular 3rd and 4th degree nodules involving complications. More than 80 per cent of the patients receiving rubber band ligation and hemorrhoidectomy were followed up. 65% of the RBL group and 85% of the H group were symptom free, while 76% of the RBL group and 91% of the H group showed great improvement after the treatment. Personal results, complications, and review of the literature are discussed in detail.", "provenance": [ { "field": "n", "quote": "887 patients with symptoms of hemorrhoids were treated" }, { "field": "population", "quote": "887 patients with symptoms of hemorrhoids were treated at the Department of Surgery and Outpatient Care" }, { "field": "intervention", "quote": "Rubber band ligation (RBL) which can be performed on outpatients was applied in 324 patients with first, second and third degree hemorrhoids" }, { "field": "comparator", "quote": "Thrombosed external hemorrhoids were treated by excision in 215 patients" }, { "field": "comparator", "quote": "Hemorrhoidectomy (H) was mainly carried out in 91 cases for treatment of circular 3rd and 4th degree nodules involving complications" }, { "field": "primaryOutcome", "quote": "65% of the RBL group and 85% of the H group were symptom free, while 76% of the RBL group and 91% of the H group showed great improvement after the treatment" }, { "field": "result", "quote": "65% of the RBL group and 85% of the H group were symptom free, while 76% of the RBL group and 91% of the H group showed great improvement after the treatment" } ] }, { "id": "pmid:8921768", "pmid": "8921768", "doi": "10.1016/s0733-8627(05)70278-9", "nctId": null, "pmcid": null, "title": "Anorectal disorders", "firstAuthor": "Janicke", "multipleAuthors": true, "journal": "Emerg Med Clin North Am", "year": 1996, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with hemorrhoids, the most common anorectal disorder", "intervention": "nonsurgical rubber band ligation (used for less severe hemorrhoids)", "comparator": "surgical excision for thrombosed external hemorrhoids", "primaryOutcome": "appropriate treatment choice based on hemorrhoid severity and type", "result": "Treatment depends on degree of prolapse; banding is listed as a nonsurgical option, while thrombosed external hemorrhoids are treated with surgical excision if within 48 to 72 hours of pain onset", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general narrative review summarizing practice, not a study comparing treatments, so it carries little weight as evidence.", "directness": "indirect", "limitations": "The abstract is a broad review of anorectal disorders with no original data, controlled comparison, or specific discussion of why external hemorrhoids aren't banded.", "followUp": "", "plainFinding": "Banding for mild cases; surgery for thrombosed ones.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8921768/", "sourceText": "Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.", "provenance": [ { "field": "population", "quote": "Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia." }, { "field": "intervention", "quote": "nonsurgical procedures (e.g., rubber band liagation, infrared coagulation)" }, { "field": "comparator", "quote": "Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset." }, { "field": "primaryOutcome", "quote": "Treatment is dependent on the degree of hemorrhoid prolapse and symptoms." }, { "field": "result", "quote": "Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset." } ] }, { "id": "pmid:8712596", "pmid": "8712596", "doi": null, "nctId": null, "pmcid": null, "title": "[Complications of the surgical treatment of hemorrhoids and its therapy]", "firstAuthor": "Corno", "multipleAuthors": true, "journal": "Ann Ital Chir", "year": 1995, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids undergoing surgical treatment", "intervention": "surgical hemorrhoid treatment (including rubber band ligation and sclerotherapy)", "comparator": "different types of surgical repair (e.g., V-Y and C-anoplasty) or no specific comparator", "primaryOutcome": "rate and type of complications after hemorrhoid treatment", "result": "Rubber band ligation and sclerotherapy are used for internal hemorrhoids, and external hemorrhoid thrombosis and delayed hemorrhage are frequent complications", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a narrative review describing complications without original data, patient numbers, or controlled comparisons.", "directness": "direct", "limitations": "No study design, sample size, or methodology is reported; it is a general review of complications.", "followUp": "", "plainFinding": "Banding external hemorrhoids risks clotting, bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8712596/", "sourceText": "Hemorrhoidal disease is a common problem in a proctological ambulatory. Surgery is the best therapy for fourth degree hemorrhoids and the complication rate is 10-20%: postoperative urinary retention etiology is unknown but it may be caused by dysfunction of bladder muscles in response to pain and by an excessive perioperative somministration of fluids; delayed hemorrhage (i.e., 7-10 days postoperative) needs an inpatient care and the treatment ranges from bedside and packing to hemorrhoid pedicle suture ligation in the operating room. Anal stenosis is most commonly a result of a prior improper hemorrhoidectomy: it may be mild, moderate or severe; V-Y and C-anoplasty are the best therapy, also for ectropion. Rubber band Ligation and Sclerotherapy are the most common treatment of internal hemorrhoids: external hemorrhoid trombosis and delayed hemorrage are frequent complications.", "provenance": [ { "field": "intervention", "quote": "Rubber band Ligation and Sclerotherapy are the most common treatment of internal hemorrhoids" }, { "field": "result", "quote": "external hemorrhoid trombosis and delayed hemorrage are frequent complications" }, { "field": "primaryOutcome", "quote": "the complication rate is 10-20%" }, { "field": "population", "quote": "Hemorrhoidal disease is a common problem in a proctological ambulatory" }, { "field": "comparator", "quote": "V-Y and C-anoplasty are the best therapy, also for ectropion" } ] }, { "id": "pmid:8776002", "pmid": "8776002", "doi": null, "nctId": null, "pmcid": null, "title": "[Hemorrhoids. Review]", "firstAuthor": "Vanheuverzwyn", "multipleAuthors": true, "journal": "Acta Gastroenterol Belg", "year": 1995, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoid disease", "intervention": "rubber band ligation", "comparator": "dietary advice or surgical hemorrhoidectomy", "primaryOutcome": "improvement of hemorrhoid symptoms/prolapse", "result": "rubber band ligation improved moderate prolapsing internal hemorrhoids, while advanced prolapse needed surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a general narrative review without original data or study details, so it carries little independent weight.", "directness": "indirect", "limitations": "No original data, methodology, or patient numbers are given; it's a general review discussing internal hemorrhoidal plexus disease, not specifically external hemorrhoids or banding of them.", "followUp": "", "plainFinding": "Banding helps internal, not external, hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8776002/", "sourceText": "Correct definition of haemorrhoidal disease allows the estimation of the incidence and the therapeutic choices. The term \"haemorrhoidal disease\" should be used specifically for symptoms secondary to abnormalities of the intern haemorrhoidal plexus. The classification of severity is useful but difficult to apply to individual cases. The aetiopathogenesis remains unclear. Many arguments are in favour of a progressive degeneration of the fibromuscular structure of the internal haemorrhoidal plexus responsible for his prolapse in the anal canal. Most patients suffering from haemorrhoids are relieved by simple dietary advice. Moderate prolapsing haemorrhoids are significantly improved by rubber band ligation. Surgical haemorrhoidectomy remains the procedure of choice in patients with advanced prolapsing haemorrhoids.", "provenance": [ { "field": "population", "quote": "Most patients suffering from haemorrhoids are relieved by simple dietary advice." }, { "field": "intervention", "quote": "rubber band ligation" }, { "field": "comparator", "quote": "Surgical haemorrhoidectomy remains the procedure of choice in patients with advanced prolapsing haemorrhoids." }, { "field": "primaryOutcome", "quote": "Moderate prolapsing haemorrhoids are significantly improved by rubber band ligation." }, { "field": "result", "quote": "Moderate prolapsing haemorrhoids are significantly improved by rubber band ligation." } ] }, { "id": "pmid:7876717", "pmid": "7876717", "doi": "10.1007/BF00292243", "nctId": null, "pmcid": null, "title": "Hemorrhoidal bleeding in chronic spinal cord injury: results of multiple banding", "firstAuthor": "Cosman", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 1994, "design": "case-series", "n": 62, "nField": "reported", "population": "men with long-term spinal cord injury who had bleeding hemorrhoids", "intervention": "rubber band ligation (banding) procedures for bleeding hemorrhoids, including bands placed on external hemorrhoids", "comparator": "", "primaryOutcome": "reduction in hemorrhoidal bleeding after banding", "result": "73% of patients reported a significant reduction in bleeding, and 20% reported some reduction", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a single-group study with no comparison group and relied on patient-reported symptom improvement rather than objective measures.", "directness": "indirect", "limitations": "No control group, outcome based on patient questionnaire rather than objective bleeding measurement, and the population (spinal cord injury patients with absent sensation) differs from the general population being asked about.", "followUp": "Mean follow-up was one year, minimum one-half year.", "plainFinding": "Banding reduced bleeding in SCI patients", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/7876717/", "sourceText": "Most patients with chronic spinal cord injury (SCI) have hemorrhoidal bleeding. 87 banding procedures were performed for bleeding on 62 men with chronic SCI. Multiple bands per session were routinely necessary. Bleeding sites at or distal to the dentate line were also banded. There were no major complications. An outcome questionnaire was completed by 60 subjects (97%). Mean follow-up was one year, minimum one-half year. 73% of patients reported significant reduction in bleeding post-banding, and 20% reported some reduction. A majority of patients felt the procedure was useful or worthwhile overall. Absent sensation allows banding of external hemorrhoids, although symptoms of autonomic hyper-reflexia may occur in patients with lesions at T6 or above. Multiple banding is a safe and effective treatment for hemorrhoidal bleeding in SCI.", "provenance": [ { "field": "n", "quote": "87 banding procedures were performed for bleeding on 62 men with chronic SCI." }, { "field": "population", "quote": "Most patients with chronic spinal cord injury (SCI) have hemorrhoidal bleeding." }, { "field": "intervention", "quote": "Bleeding sites at or distal to the dentate line were also banded." }, { "field": "intervention", "quote": "Absent sensation allows banding of external hemorrhoids, although symptoms of autonomic hyper-reflexia may occur in patients with lesions at T6 or above." }, { "field": "result", "quote": "73% of patients reported significant reduction in bleeding post-banding, and 20% reported some reduction." }, { "field": "primaryOutcome", "quote": "An outcome questionnaire was completed by 60 subjects (97%)." }, { "field": "followUp", "quote": "Mean follow-up was one year, minimum one-half year." } ] }, { "id": "pmid:8346456", "pmid": "8346456", "doi": null, "nctId": null, "pmcid": null, "title": "[Short-term hospitalization and ambulatory care of patients with advanced hemorrhoidal disease]", "firstAuthor": "Fried", "multipleAuthors": true, "journal": "Rozhl Chir", "year": 1993, "design": "case-series", "n": 145, "nField": "reported", "population": "patients with advanced grade 3 and 4 internal and external hemorrhoids", "intervention": "rubber band ligation (Barron's method)", "comparator": "none reported", "primaryOutcome": "being free of symptoms at 12-month follow-up after treatment", "result": "126 of 145 patients were free of complaints at the 12-month check-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is an old case series with no comparison group, so it can't reliably show the treatment caused the improvement.", "directness": "direct", "limitations": "No control group, no randomization, and no detail on complications or band-related injury reported in the abstract.", "followUp": "12 months", "plainFinding": "Most patients symptom-free after banding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8346456/", "sourceText": "The authors describe possible non-surgical treatment of extensive haemorrhoids grade 3 and 4, using Barron's rubber band ligation. To make comparison of therapeutic results possible Dennison's Sheffield classification is used. In the mentioned new approach indications for ambulatory treatment or short-term hospitalization in patients with an advanced grade of internal or external haemorrhoids are extended. From a group of 145 patients treated by this method 126 were free of subjective complains during a check-up 12 months after termination of treatment.", "provenance": [ { "field": "n", "quote": "From a group of 145 patients treated by this method" }, { "field": "result", "quote": "126 were free of subjective complains during a check-up 12 months after termination of treatment" }, { "field": "primaryOutcome", "quote": "126 were free of subjective complains during a check-up 12 months after termination of treatment" }, { "field": "intervention", "quote": "using Barron's rubber band ligation" }, { "field": "population", "quote": "extensive haemorrhoids grade 3 and 4" }, { "field": "population", "quote": "advanced grade of internal or external haemorrhoids" }, { "field": "comparator", "quote": "The authors describe possible non-surgical treatment of extensive haemorrhoids grade 3 and 4, using Barron's rubber band ligation." } ] }, { "id": "pmid:1558053", "pmid": "1558053", "doi": null, "nctId": null, "pmcid": null, "title": "Treatment of common anorectal disorders", "firstAuthor": "Bassford", "multipleAuthors": false, "journal": "Am Fam Physician", "year": 1992, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with common anorectal disorders seen by family physicians", "intervention": "treatments for various anorectal conditions, including drainage of thrombosed external hemorrhoids", "comparator": "rubber-band ligation used for internal hemorrhoids", "primaryOutcome": "", "result": "Thrombosed external hemorrhoids can be opened and drained, while bleeding or symptomatic internal hemorrhoids can be treated with rubber-band ligation", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general overview article describing standard treatments, not a study testing or comparing outcomes.", "directness": "indirect", "limitations": "The abstract does not explain why external hemorrhoids are treated differently from internal ones, nor does it present any data or outcomes comparing methods.", "followUp": "", "plainFinding": "External hemorrhoids drained, internal ones banded.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1558053/", "sourceText": "Family physicians can manage most common anorectal disorders seen in office practice. Proctitis is usually caused by sexually transmitted infections that can be treated with antibiotics. Pruritus ani, anal fissures, fungal infections and hygiene problems are all amenable to simple treatments. Thrombosed external hemorrhoids can be opened and drained. Bleeding or symptomatic internal hemorrhoids can be treated with rubber-band ligation. Perirectal or ischiorectal abscesses require incision and drainage, sometimes under general anesthesia. Serious disorders such as inflammatory bowel disease and cutaneous malignancies should always be considered in the differential diagnosis of common anorectal disorders.", "provenance": [ { "field": "intervention", "quote": "Thrombosed external hemorrhoids can be opened and drained." }, { "field": "comparator", "quote": "Bleeding or symptomatic internal hemorrhoids can be treated with rubber-band ligation." }, { "field": "population", "quote": "Family physicians can manage most common anorectal disorders seen in office practice." }, { "field": "result", "quote": "Thrombosed external hemorrhoids can be opened and drained." }, { "field": "result", "quote": "Bleeding or symptomatic internal hemorrhoids can be treated with rubber-band ligation." } ] }, { "id": "pmid:2195622", "pmid": "2195622", "doi": null, "nctId": null, "pmcid": null, "title": "[Bleeding and pain following anal surgery]", "firstAuthor": "Buchmann", "multipleAuthors": false, "journal": "Schweiz Rundsch Med Prax", "year": 1990, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients having anal procedures for external hemorrhoids, inner piles, fissure-in-ano, abscesses and fistulae", "intervention": "treatment of external hemorrhoids, inner piles, fissure-in-ano, abscesses and fistulae using techniques such as high-position rubber-band ligation and manual anal dilation", "comparator": "", "primaryOutcome": "bleeding and pain after the procedure", "result": "careful hemostasis and wound closure reduced bleeding, and an improved technique reduced pain", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a general discussion paper without study data, numbers, or control group, so it offers very weak evidence.", "directness": "indirect", "limitations": "No patient numbers, no comparative data, and the paper does not specifically address banding of external hemorrhoids or why it is avoided.", "followUp": "", "plainFinding": "Better technique may cut pain, bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/2195622/", "sourceText": "Bleeding and pain are frequent complications, following proctological procedures. Their intensity however, can be influenced by the therapist. Through careful hemostasis and wound closure the risk of bleeding is greatly reduced so that most procedures can be done on an outpatient basis. The intensity of pain experienced by the patient is very much personality dependent and is in general unpredictable. Pain can be reduced by using an improved technique (high position of rubber-band ligation, manual anal dilation). This paper deals mainly with bleeding and pain following treatment of external hemorrhoids, inner piles, fissure-in-ano, abscesses and fistulae.", "provenance": [ { "field": "population", "quote": "Bleeding and pain are frequent complications, following proctological procedures." }, { "field": "intervention", "quote": "Pain can be reduced by using an improved technique (high position of rubber-band ligation, manual anal dilation)." }, { "field": "intervention", "quote": "This paper deals mainly with bleeding and pain following treatment of external hemorrhoids, inner piles, fissure-in-ano, abscesses and fistulae." }, { "field": "primaryOutcome", "quote": "Bleeding and pain are frequent complications, following proctological procedures." }, { "field": "result", "quote": "Through careful hemostasis and wound closure the risk of bleeding is greatly reduced" }, { "field": "result", "quote": "Pain can be reduced by using an improved technique (high position of rubber-band ligation, manual anal dilation)." } ] }, { "id": "pmid:3298057", "pmid": "3298057", "doi": null, "nctId": null, "pmcid": null, "title": "Hemorrhoids. A review of current techniques and management", "firstAuthor": "Smith", "multipleAuthors": false, "journal": "Gastroenterol Clin North Am", "year": 1987, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with hemorrhoid symptoms like bleeding and prolapse", "intervention": "rubber band ligation or other fixation/excisional techniques", "comparator": "different hemorrhoid grades treated with different methods", "primaryOutcome": "appropriate treatment choice based on hemorrhoid severity", "result": "The abstract does not mention external hemorrhoids or why banding is not used on them; it only describes treatment by degree of prolapse for (implicitly internal) hemorrhoids", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general narrative review of hemorrhoid management with no data, and it does not address the specific question about external hemorrhoids.", "directness": "indirect", "limitations": "No mention of external hemorrhoids, no study data, no comparative outcomes reported.", "followUp": "", "plainFinding": "Does not address external hemorrhoid banding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/3298057/", "sourceText": "Most physicians see many patients with the chief complaint of hemorrhoids. The usual presentation is bleeding with bowel movements and prolapse. Of course, if there are no symptoms, invasive treatment should not be entertained. If the symptoms are due to hemorrhoids, the degree of prolapse should be established in order to guage the treatment. Mild symptoms of first- and second-degree hemorrhoids may be treated by diet modification or a fixation process such as rubber band ligation or infrared photocoagulation. Moderate prolapse as with large second-degree and third-degree hemorrhoids need the more certain fixation of rubber band ligation or an excisional technique. Large third-degree hemorrhoids and fourth-degree hemorrhoids require removal of a portion of the prolapsing tissue to achieve a stronger fixation within the proximal anal canal.", "provenance": [ { "field": "population", "quote": "Most physicians see many patients with the chief complaint of hemorrhoids." }, { "field": "intervention", "quote": "rubber band ligation or infrared photocoagulation" }, { "field": "comparator", "quote": "Large third-degree hemorrhoids and fourth-degree hemorrhoids require removal of a portion of the prolapsing tissue to achieve a stronger fixation within the proximal anal canal." }, { "field": "primaryOutcome", "quote": "the degree of prolapse should be established in order to guage the treatment" }, { "field": "result", "quote": "Mild symptoms of first- and second-degree hemorrhoids may be treated by diet modification or a fixation process such as rubber band ligation or infrared photocoagulation." } ] }, { "id": "pmid:3538088", "pmid": "3538088", "doi": null, "nctId": null, "pmcid": null, "title": "Outpatient management of hemorrhoids", "firstAuthor": "Schussman", "multipleAuthors": true, "journal": "Prim Care", "year": 1986, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "band ligation", "comparator": "excision of thrombosed external hemorrhoids", "primaryOutcome": "best management approach for hemorrhoids", "result": "band ligation is best for persistently bleeding or painful internal hemorrhoids, while thrombosed external hemorrhoids require surgical excision", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a narrative review with no study data, numbers, or methods reported.", "directness": "direct", "limitations": "No methods, data, or patient numbers are given; this is a general review statement.", "followUp": "", "plainFinding": "External hemorrhoids need cutting out, not banding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/3538088/", "sourceText": "Hemorrhoids are a common medical problem that usually can be managed conservatively with dietary changes, stool softeners, and local hydrocortisone creams. Acutely thrombosed external hemorrhoids require excision of the entire hemorrhoidal mass and the overlying skin. Persistently bleeding or painful internal hemorrhoids are best managed by the technique of band ligation.", "provenance": [ { "field": "population", "quote": "Hemorrhoids are a common medical problem" }, { "field": "intervention", "quote": "band ligation" }, { "field": "comparator", "quote": "excision of the entire hemorrhoidal mass and the overlying skin" }, { "field": "primaryOutcome", "quote": "Persistently bleeding or painful internal hemorrhoids are best managed by the technique of band ligation." }, { "field": "result", "quote": "Acutely thrombosed external hemorrhoids require excision of the entire hemorrhoidal mass and the overlying skin. Persistently bleeding or painful internal hemorrhoids are best managed by the technique of band ligation." } ] } ], "faqs": [ { "q": "Can I put a rubber band on my hemorrhoid at home?", "a": "No. The studies on banding external hemorrhoids were done by doctors using sterile equipment and careful placement to avoid injuring the wrong tissue. One case report shows banding done on vulnerable tissue can cause the area to die and form an open wound. Doing this yourself risks serious injury and infection." }, { "q": "Why am I in so much pain after hemorrhoid banding?", "a": "Pain after banding often happens when the band is placed too close to, or below, the dentate line — the point in the anal canal where pain-sensing nerve endings begin. In the one study that banded external tissue directly, most people had no or mild pain, but a few had pain lasting about a week. If your pain is severe or getting worse, contact your doctor." }, { "q": "Is bleeding 3 weeks after hemorrhoid banding normal?", "a": "Delayed bleeding, sometimes one to three weeks after banding, is a recognized complication as the dead tissue and band fall away. Reviews list delayed bleeding among known complications, though exact rates for external tissue specifically haven't been studied. Heavy or ongoing bleeding should be checked by a doctor the same day." }, { "q": "What happens during hemorrhoid banding recovery?", "a": "In small studies of banding internal hemorrhoids, most symptoms like bleeding, discomfort, and itching resolved within about six months, with mild and short-lived pain common in the days after the procedure. Recovery specifically after banding external tissue is far less studied, with only one small group followed for a short time." }, { "q": "What is hemorrhoid banding and how is it done?", "a": "Rubber band ligation is a procedure where a tight band is placed around the base of hemorrhoid tissue to cut off its blood supply, so the tissue shrinks and falls off within days. Guidelines describe it as a treatment for internal hemorrhoids, grades I to III; external hemorrhoids are traditionally treated differently, such as by removing a clot if one forms." } ], "searchedAs": [ "why can t you band external hemorrhoids", "bleeding 3 weeks after hemorrhoid banding", "hemorrhoid banding", "hemorrhoid banding procedure", "hemorrhoid banding recovery", "can i put a rubber band on my hemorrhoid at home", "why am i in so much pain after hemorrhoid banding", "hemorrhoid banding orange county" ], "patientTakeaway": "Don't band an external hemorrhoid yourself — this isn't a do-it-yourself procedure, and even in a doctor's office it's backed by only two small studies. If you have a painful or thrombosed external hemorrhoid, standard care is pain relief, warm baths, and having a doctor remove the clot if needed; ask a specialist about banding only as an experimental option, not a proven standard treatment.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Hemorrhoids\"[Mesh] OR hemorrhoid*[tiab] OR haemorrhoid*[tiab]) AND (\"Ligation\"[Mesh] OR ligation[tiab] OR banding[tiab] OR \"rubber band\"[tiab]) AND (external[tiab] OR \"dentate line\"[tiab] OR \"anal canal\"[tiab] OR \"anoderm\"[tiab])" }, "pubmedQueryTranslation": "(\"Hemorrhoids\"[MeSH Terms] OR \"hemorrhoid*\"[Title/Abstract] OR \"haemorrhoid*\"[Title/Abstract]) AND (\"Ligation\"[MeSH Terms] OR \"Ligation\"[Title/Abstract] OR \"banding\"[Title/Abstract] OR \"rubber band\"[Title/Abstract]) AND (\"external\"[Title/Abstract] OR \"dentate line\"[Title/Abstract] OR \"anal canal\"[Title/Abstract] OR \"anoderm\"[Title/Abstract])", "searchedOn": "2026-10-13", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "Why Can't You Band External Hemorrhoids?", "description": "See what the research shows on banding external hemorrhoids: why it's avoided, and what 2 small studies found about trying it anyway." }, "lastChecked": "2026-10-13", "lastChanged": "2026-10-13", "nextCheckDue": "2026-11-13", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-13" }, "status": "published" }