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Clinical Applications - Optimal Nonsurgical Treatment of Hemorrhoids

Optimal Nonsurgical Treatment of Hemorrhoids: A Comparative Analysis of Infrared Coagulation, Rubber Band Ligation, and Injection Sclerotherapy Methods | Results | Discussion

John F. Johanson, M.D., and Alfred Rimm, Ph.D.
Department of Medicine, University of Illinois College of Medicine, Rockford, Illinois, and Department of Epidemiology and Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin

Despite an abundance of nonsurgical hemorrhoid therapies, none has been consistently more efficacious. By combining data from multiple clinical trials in a meta-analysis, the present study compared the efficacy and complications of infrared coagulation, injection sclerotherapy, and rubber band ligation to determine the optimal nonoperative hemorrhoid treatment. All published clinical trials comparing the three methods were identified by computer search and review of appropriate English language journals. Five trials studying 863 patients satisfied all inclusion criteria. Results demonstrated that similar numbers of patients were asymptomatic 12 months after treatment, regardless of initial therapy. However, significantly fewer patients undergoing rubber band ligation required additional treatment because symptoms had recurred. Although rubber band ligation demonstrated greater long-term efficacy, it was associated with a significantly higher incidence of posttreatment pain. In contrast, infrared coagulation was associated with both fewer and less severe complications. Thus, when all factors are considered, infrared coagulation may in fact be the optimal nonoperative hemorrhoid treatment.

Numerous nonoperative treatments have been proposed for the management of first-degree (nonprolapsing) and second-degree (prolapsing but spontaneously reducing) hemorrhoids. These include cryotherapy, laser therapy, bipolar diathermy, infrared photocoagulation. injection sclerotherapy, and rubber band ligation (1, 2). Despite a number of randomized comparative clinical trials, no single therapy has been shown to be consistently better (3—10). The absence of a clear advantage among the various modalities may indicate that they are equally effective. Alternatively, previous trials may have lacked sufficient statistical power to demonstrate any true differences. The problem of inRecc"ivc"d Mai" 4, 1992; accepted Juh" 6. 1992.
sufficient statistical power can be overcome by performing a meta-analysis—a statistical technique that allows for the combination of data from multiple clinical trials so as to pool their results (11). This study, using a metaanalysis, compares the therapeutic efficacy of infrared photocoagulation and injection sclerotherapy with rubber band ligation in the treatment of first- and second-degree hemorrhoids. Furthermore, we examine the complications of each therapy in order to determine the optimal method for the nonoperative treatment of hemorrhoids.

Presented in part at the 56th Annual Scientific Meeting of the American College of Gastroenterology. Boston, MA, October, 1991. Previously published in abstract form: Am J Gastroenterol 1991:86:1372.

Reprint requests and correspondence: John F. iohanson. M.D.. 401 Roxbury Road. Rockford. IL. 61107-5078.

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