22 June 2016

The treatment of symptomatic second and third degree haemorrhoids has evolved over the years but what constitutes optimum management is still unclear.

Rubber band ligation (RBL) v haemorrhoidal artery ligation (HAL) trial

For many years rubber band ligation (RBL) has been used as an 'office' procedure and, although widely regarded as effective, recurrence is common and patients often require repeat banding.  Furthermore RBL has not been subject to particularly rigorous scientific scrutiny in the past. A more recent procedure, haemorrhoidal artery ligation (HAL), has been proposed as both effective and safe but although there have been at least four systematic reviews of HAL there has been a lack of good quality evidence to support its widespread use. For these reasons, Steve Brown and his colleagues have carried out a randomised trial comparing HAL with RBL in the management of symptomatic 2nd and 3rd degree haemorrhoids.  This was a multi-centre trial and carried the acronym HubBLe.  Between September 2012 and May 2014, 372 patients were randomised and the results of this study were published online by the Lancet on 25 May this year.

Few gains from new technique for haemorrhoids

One year after treatment the recurrence rate was significantly higher in RBL than HAL (49% vs 30%) and further treatment was required in 31% of the RBL compared to 15% of those treated by HAL.  Although this may superficially appear to favour HAL, there was no statistical difference between the groups in terms of improvement or cure at one year i.e. there was no difference between HAL and a course of RBL.  It was also noted that pain was greater and lasted longer after an HAL procedure compared with RBL.  Another striking feature was the cost of the procedure with HAL being approximately £1,000 more expensive than RBL.  This study was carried out to a very high standard and with excellent follow up as evidenced by the fact that 337 of the randomised patients had primary outcome data.  The inescapable conclusion is that a course of RBL provides similar control of symptomatic low-grade haemorrhoids to the more invasive and expensive HAL technique.  This will undoubtedly influence practice and is an extremely good example of how new procedures should be subject to rigorous scientific evaluation before their widespread introduction.

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The HubBLe trial: HALO vs Rubber Band Ligation of Haemorrhoids, will be presented at the ACPGBI Annual Meeting in Edinburgh (Monday 4 July during the Plenary Research Session).

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