title: Comments to 'Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids'.
abstract: To review the efficacy and safety of the two most popular conventional methods of haemorrhoidal treatment, rubber band ligation and excisional haemorrhoidectomy (EH). The original study has now been updated using the same search strategy.
  
  
  
  We searched MEDLINE, EMBASE, CENTRAL, and CINAHL up to October 2010.
  
  
  
  Randomised controlled trials comparing rubber band ligation with EH for symptomatic haemorrhoids in adult human patients were included.
  
  
  
  We extracted data on to a previously designed data extraction sheet. Dichotomous data were presented as relative risk and 95 % confidence intervals, and continuous outcomes as weighted mean difference and 95 % confidence intervals.
  
  
  
  Three trials (of poor methodological quality) met the inclusion criteria. Complete remission of haemorrhoidal symptom was better with EH (three studies, 202 patients, RR 1.68, 95 % CI 1.00-2.83). There was a significant heterogeneity between the studies (I2 = 90.5 %; P = 0.0001). Similar analysis based on the grading of haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04-1.45; P = 0.01). However, no significant difference was noticed in grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94-1.21; P = 0.32). Fewer patients required re-treatment after EH (three trials, RR 0.20, CI 0.09-0.40; P < 0.00001). Patients undergoing EH were at significantly higher risk of post-operative pain (three trials, fixed effect; 212 patients, RR 1.94, 95 % CI 1.62-2.33, P < 0.00001) and of delayed complications (three trials, 204 patients, RR 6.32, CI 1.15-34.89; P = 0.03).
  
  
  
  The present systematic review confirms the long-term efficacy of EH, at least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the expense of increased pain, higher complications and more time off work. However, despite these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment modalities seem to be similar following both the techniques implying patient's preference for complete long-term cure of symptoms and possibly less concern for minor complications. So, RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results but without the side effects of EH while reserving EH for grade III haemorrhoids or recurrence after RBL. More robust study is required to make definitive conclusions.
authors.affiliation: The HubBLe Trial, Department of Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK. stevebrown@doctors.org.uk.
authors.forename: S R
authors.initials: SR
authors.lastname: Brown
authors.affiliation: The eTHoS Trial, Department of Surgery, Raigmore Hospital, Inverness, Scotland, UK.
authors.forename: A
authors.initials: A
authors.lastname: Watson
mesh_terms: D006801:Humans; D061865:Hemorrhoidectomy; D006484:Hemorrhoids / Q000601:surgery; D008026:Ligation; D012008:Recurrence; D012408:Rubber
chemical_list: D012408:Rubber
keywords: Haemorrhoidectomy; Haemorrhoids; Rubber band ligation