A Stepwise Proposal for Low-Grade Hemorrhoidal Disease: Injection Sclerotherapy as a First-Line Treatment and Rubber Band Ligation for Persistent Relapses

Abstract

Outpatient treatments are actually the techniques of choice in the management of low-grade hemorrhoidal disease. Among these, rubber band ligation (RBL) and injection sclerotherapy (IS) are the most frequently performed. Both techniques are used, without one having been determined to be superior over the other. We analyzed the studies that compare these two techniques in terms of efficacy and safety in order to offer a proposal for treatment choice. RBL seems to be most efficient in terms of symptom resolution for second-degree hemorrhoidal disease and equal or superior for treatment of third-degree disease. However, IS offers lower rates of severe post-operative pain and minor complications. Since outpatient treatments are offered to patients as painless options that allow a prompt recovery, we propose a stepwise protocol using 3% polidocanol or aluminum potassium sulfate and tannic acid IS as the first treatment option, as it has less complications, followed by RBL in cases of relapse.

Sclerotherapy with 3% polidocanol foam to treat second‐degree haemorrhoidal disease: Three‐year follow‐up of a multicentre, single arm, IDEAL phase 2b trial

“…Aside from comparative articles regarding liquid agents [25], only Salgueiro et al [8] compared polidocanol foam sclerotherapy and rubber band ligation in 120 patients with I-III degree HD randomly assigned to receive one technique or the other.…”

Endoscopic approaches to the management of hemorrhoids

“…Although RBL appears superior in symptom control, sclerotherapy is more advantageous in that there is significantly less postprocedural pain. As a result, one can envisage the use of sclerotherapy as an initial treatment, followed by RBL only if there is hemorrhoid recurrence [23]. The use of topical anesthetics before or after RBL may reduce postprocedural pain [24,25] and requires further study.…”

Prevalent Technique and Results of Hemorrhoidal Embolization

“…RBL appears to be more efficient in symptom resolution than SCL; nonetheless, SCL causes less postprocedural pain and minor complications. Some authors propose SCL as a first-line therapy and RBL for recurrent disease [14][15][16]. THD and DGHAL are minimally invasive techniques, with the same rationale as HE.…”

“…However, 10% of all patients will need surgery such as conventional hemorrhoidectomy (CH) [9], circular anopexia [10], or stapled hemorrhoidopexy (SH) [11]. Over the years, less invasive techniques such as rubber band ligation (RBL) [12,13], sclerotherapy (SCL) [14][15][16], and infrared coagulation have been developed, allowing an outpatient setting and a quicker patient recovery, despite an increased recurrence. Recently, minimally invasive techniques based on the hyperflow of hemorrhoidal arteries, such as transanal hemorrhoidal dearterialization (THD) [17], doppler-guided hemorrhoidal artery ligation (DGHAL) [18,19], or its endovascular version, the "Emborrhoid technique" [20,21], have emerged, showing promising results and more patient comfort (Table 3) [22].…”