Endoscopic rubber band ligation, injection sclerotherapy, and sclerobanding for the treatment of internal hemorrhoids

Abstract

BACKGROUND

The clinical outcomes of endoscopic rubber band ligation (ERBL), injection sclerotherapy (IS), and endoscopic polidocanol sclerobanding (ESB) have not yet been well studied.

AIM

To evaluate the efficacy and safety of ERBL, IS, and ESB for treating grade I-III internal hemorrhoids.

METHODS

This retrospective cohort study was performed on 201 patients, who were grouped according to their endoscopic treatment (ERBL, IS, and ESB groups). Postoperative follow-ups were initially carried out at 1, 3, and 6 months, and then every 6 months, with the longest follow-up extending to 24 months. The study analyzed clinical efficacy, short-term and overall recurrence rates, and postoperative adverse events. Additionally, subgroup analysis was conducted based on the internal hemorrhoid grade (I or II-III).

RESULTS

The patient distribution across the ERBL, IS, and ESB groups was 70, 66, and 65, respectively. Both the ERBL and ESB groups demonstrated lower overall recurrence rates compared with the IS group (post-hoc analysis, P’ = 0.024 and P’ = 0.015, respectively). Subgroup analysis revealed that sclerotherapy resulted in a higher total recurrence rate than that achieved by sclerobanding (45.95% vs 19.57%, P’ = 0.03), specifically for grade II-III internal hemorrhoids. No significant difference was found in grade I hemorrhoids. The ERBL group exhibited a higher incidence of postoperative pain, a worse median visual analog scale score, and a longer median duration of pain compared with those reported by the other groups (P < 0.001). This trend was consistent for grade II-III hemorrhoids. No significant differences were found among the three groups regarding clinical efficacy or recurrence rates within 6 months post-surgery, even when examined by subgroup.

CONCLUSION

The three treatments evaluated (ERBL, IS, and ESB) provide durable clinical outcomes for grade I hemorrhoids, with no significant differences in postoperative adverse events. For grade II-III hemorrhoids, ESB possesses the dual advantages of lower recurrence rates and reduced postoperative pain compared with IS and ERBL.

Key Words: Hemorrhoids; Rubber band ligation; Sclerotherapy; Sclerobanding; Clinical outcomes; Cohort study

Core Tip: The clinical outcomes of endoscopic rubber band ligation (ERBL), injection sclerotherapy (IS), and endoscopic polidocanol sclerobanding (ESB) for treating grade I-III internal hemorrhoids have been limited in previous research. This study evaluated the efficacy and safety of these three methods, revealing that all provided long-term clinical benefits for grade I hemorrhoids. For grade II-III hemorrhoids, ESB demonstrated superior outcomes, including lower recurrence rates and minimal postoperative pain compared with IS and ERBL.

INTRODUCTION

Internal hemorrhoids, one of the most common anorectal conditions, result from the pathological displacement of anal cushions above the dentate line, clinically manifesting as painless rectal bleeding and/or prolapse[1,2]. Epidemiological studies have reported a high prevalence of hemorrhoids in the adult population. In the United States, approximately 10 million people reportedly experience hemorrhoid-related symptoms, with healthcare costs for hemorrhoids exceeding 800 million dollars annually[3,4]. Thus, hemorrhoidal diseases represent a remarkable public health burden.

For grade I-III internal hemorrhoids that do not respond to conservative treatments (e.g., dietary modifications, medications, and sitz baths), minimally invasive endoscopic therapies have become the first-line intervention. Endoscopic rubber band ligation (ERBL) and injection sclerotherapy (IS) are utilized as the primary treatments for grade I-III internal hemorrhoids, owing to their simplicity and favorable safety profiles[1]. Recently, a hybrid technique known as endoscopic polidocanol foam sclerobanding (EFSB), integrating ERBL with sclerotherapy, has been proposed by Qu et al[5], who reported satisfactory clinical outcomes using EFSB, identifying it as another viable therapeutic option. Compared with polidocanol foam, polidocanol liquid is also widely used for internal hemorrhoids because of its higher practical clinical efficacy[6,7]. However, the clinical outcomes of these three techniques [ERBL, IS, and endoscopic polidocanol sclerobanding (ESB)] have not yet been sufficiently evaluated systematically. To address this knowledge gap, in the present study, a retrospective cohort analysis was conducted to evaluate the efficacy and safety of endoscopic treatments, specifically ERBL, IS, and ESB, in patients with grade I-III internal hemorrhoids.

MATERIALS AND METHODS

Study population

This single-center retrospective cohort study was performed at the Affiliated Hospital of Qingdao University (Qingdao, Shandong Province, China). Patients diagnosed with grade I-III internal hemorrhoids based on the Goligher classification, who had not responded to conservative treatment and agreed to undergo endoscopic intervention, were included in the study. The exclusion criteria were as follows: (1) Severe cardiopulmonary insufficiency or coagulopathy; (2) A history of malignancy, inflammatory bowel disease, or other perianal conditions; (3) Autoimmune disorders; (4) Pregnancy; (5) Prior hemorrhoidectomy or endoscopic treatments within the preceding three years; (6) Allergy to polidocanol; and (7) Loss to follow-up or incomplete clinical data. All patients were treated by the same endoscopic physician.

Endoscopic procedures

Before inserting the endoscope, prolapsed internal hemorrhoids were manually repositioned. Subsequently, endoscopic intestinal examination and polypectomy were performed prior to hemorrhoidal treatment. The operative field was sufficiently exposed to identify the dentate line, anorectal line, and hemorrhoidal base, enabling an assessment of the extent and size of the internal hemorrhoids. Using an anteflexed or retroflexed view, the next steps were implemented as follows.

ERBL: A gastroscope (Olympus GIF-Q260J, Japan) with a ligation device (Cook MBL-6-F, United States) was used. The ligation device was placed at the rectal mucosa or hemorrhoidal base. Continuous suction was maintained until the target tissue was drawn into the ligation chamber, indicated by a “full red” sign, and the rubber band was thereafter released.

IS: A 23G, 5-mm endoscopic injection needle (Boston Scientific, United States) prefilled with polidocanol liquid was used to select 1-6 injection sites above the dentate line. The needle was inserted at an angle into the submucosa of the hemorrhoids, or those exhibiting signs of bleeding, and 0.5-1.5 mL of the sclerosant was injected at each site.

ESB: The sclerosant was injected continuously during slow endoscope withdrawal until white foam accumulation or mild mucosal elevation was observed. After sclerotherapy, the ligation device was reattached to the endoscope and reinserted. Once clear whitening of the sclerosed area was confirmed, band ligation was applied to the base of the hemorrhoid (Figure 1).

Figure 1 Three endoscopic methods for the treatment of internal hemorrhoids. A: Endoscopic rubber band ligation: Rubber bands were placed at the rectal mucosa or hemorrhoidal base; B: Injection sclerotherapy: Polidocanol liquid was injected into the hemorrhoidal base; C: Endoscopic polidocanol sclerobanding: Rubber bands were applied following the injection of the sclerosant.

Data collection and outcome

Postoperative follow-up was carried out via structured telephone interviews, outpatient visits, or endoscopic re-evaluations. Clinical efficacy, recurrence, and postoperative adverse events were assessed by separate researchers, each blinded to the treatment method throughout the trial. Since there are no standardized criteria for assessing hemorrhoid symptoms, patient-reported symptom relief and the need for retreatment were utilized as the primary measures of treatment success and recurrence. The following post-surgery adverse events were systematically evaluated at the 1-month follow-up: (1) Presence or absence of pain; (2) Pain severity on the visual analog scale (VAS), with 0 indicating no pain; (3) Pain duration in days, recorded as 0 for asymptomatic patients; (4) Bleeding episodes; (5) Fever; and (6) Dysuria. At 3 months postoperatively, clinical efficacy was categorized as “cured” (complete symptom resolution), “improved” (notable symptom relief), or “ineffective” (no change from the preoperative status). Recurrence was defined as the reappearance or worsening of symptoms, which was indicated by the increased prolapse severity or frequency of prolapse/bleeding episodes compared with the 3-month follow-up, or the need for retreatment beyond 3 months in patients initially classified as “cured” or “improved”. Short-term recurrence was monitored 6 months post-surgery, with subsequent follow-ups conducted every 6 months. The follow-up was stopped upon recurrence. Patients were followed for a minimum of 6 months and a maximum of 24 months. The overall recurrence rate was calculated based on the proportion of patients experiencing recurrence during the follow-up period.

The primary outcome was the overall recurrence during the follow-up period. The secondary outcomes included treatment efficacy, short-term recurrence at 6 months after surgery, and adverse reactions.

Statistical analysis

Based on previous research studies[2,8], recurrence rates for ERBL, IS, and ESB were estimated to be 20%, 35%, and 10%, respectively. With a two-sided significance level of α = 0.05 and 80% power, 52 participants were required per group. To account for a 15% dropout rate, at least 60 patients per group were recruited to ensure an adequate sample size. Statistical analysis was performed using SPSS 27.0 software (IBM Corp., Armonk, NY, United States). Normally distributed data were presented as mean ± SD and analyzed using analysis of variance. Non-normally distributed data were reported as median with interquartile ranges [median (Q1, Q3)]. The Kruskal-Wallis test was employed for non-normal continuous variables and ordinal categorical data. The χ² test was applied to count data with count outcomes. Post-hoc analyses were conducted when P < 0.05, with Bonferroni’s correction applied for multiple comparisons (P’). Statistical significance was set at P or P’ < 0.05 (two-sided).

RESULTS

Patients’ characteristics

From July 1, 2019, to December 31, 2024, 272 patients received treatment for internal hemorrhoids at the Affiliated Hospital of Qingdao University. After applying the aforementioned inclusion and exclusion criteria, 201 patients were finally enrolled in the study and categorized into the following groups: ERBL (n = 70), IS (n = 66), and ESB (n = 65) (Figure 2). The study population included a high proportion of men (126, 62.69%), with an average age of 49.94 years and a mean body mass index (BMI) of 24.19 kg/m². The median duration of the disease was 36 months. Among 201 patients, 61 (30.35%) had grade I, 65 (32.34%) had grade II, and 75 (37.31%) had grade III hemorrhoids. Baseline characteristics, such as sex, age, disease duration, BMI, and hemorrhoid severity, were well-balanced across all the groups (Table 1).

Figure 2 Flowchart of patients’ inclusion, exclusion, and intervention. ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Table 1 Preoperative characteristics, mean ± SD/n (%).

Subgroup	Gender (female/male)	Age (years)	Disease duration [months, median (Q1, Q3)]	BMI (kg/m2)	Hemorrhoid grade
					Grade I	Grade II	Grade III
ERBL	26/44	49.00 ± 11.59	30.00 (6.00, 61.50)	24.46 ± 3.24	22 (31.43)	22 (31.43)	26 (37.14)
IS	19/47	49.94 ± 12.74	36.00 (11.25, 120.00)	23.59 ± 2.54	25 (37.88)	22 (33.33)	19 (28.79)
ESB	30/35	50.59 ± 12.60	48.00 (12.00, 120.00)	24.49 ± 3.02	14 (21.54)	21 (32.31)	30 (46.15)
Total	75/126	49.94 ± 12.27	36.00 (12.00, 120.00)	24.19 ± 2.97	61 (30.35)	65 (32.34)	75 (37.31)
Statistic	χ2 = 4.224	F = 0.425	H = 4.140	F = 1.996	H = 5.527
P value	0.121	0.655	0.126	0.139	0.063

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding; BMI: Body mass index.

Endoscopic treatment

The median number of rubber bands used in the ERBL and ESB groups was 4. For the IS group, the median sclerosant dose was 9.5 mL, while it was 8 mL for the ESB group. A total of 129 (64.18%) cases received endoscopic treatment under local anesthesia. The median follow-up time was 20 months. No significant differences were found among the three groups regarding the number of bands, sclerosant amount, anesthesia method, or follow-up time (Table 2). As the baseline characteristics were similar across the three groups (Supplementary Tables 1-4), subgroup analysis was performed based on the hemorrhoid grade (grades I and II-III).

Table 2 Treatment data.

Subgroup	Rubber bands [number, median (Q1, Q3)]	Sclerosant dosage [mL, median (Q1, Q3)]	Anesthesia method (local/intravenous anesthesia)	Follow-up duration [months, median (Q1, Q3)]
ERBL	4.00 (3.00, 5.00)		42/28	20.50 (9.00, 24.00)
IS		9.5 (6.75, 10.00)	42/24	23.50 (13.00, 24.00)
ESB	4.00 (3.00, 5.00)	8.00 (6.00, 10.00)	45/20	18.00 (11.25, 24.00)
Total	4.00 (3.00, 5.00)	8.00 (6.00, 10.00)	129/72	20.00 (12.00, 24.00)
Statistic	Z = -0.901	Z = -1.496	χ2 = 1.262	H = 0.909
P value	0.367	0.135	0.532	0.635

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Efficacy: No significant difference among the three methods

At the 3-month follow-up, the effective rates for the ERBL, IS, and ESB groups were 87.14%, 90.91%, and 90.77%, respectively. The clinical efficacy of the three methods did not show any difference for the treatment of grade I or grade II-III internal hemorrhoids (Figure 3 and Table 3).

Figure 3 Bar graph illustrating the clinical efficacy rates of the three procedures at 3 months postoperatively. Purple bars represent the “ineffective” rate, blue bars represent the “improved” rate, and orange bars represent the “cured” rate, with numerical values indicating the proportions. ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Table 3 Clinical efficacy analysis, n (%).

Subgroup	Efficacy (no stratification)			Efficacy (grade I)			Efficacy (grade II-III)
	Cured	Improved	Ineffective	Cured	Improved	Ineffective	Cured	Improved	Ineffective
ERBL	40 (57.14)	21 (30.00)	9 (12.86)	16 (72.73)	5 (22.73)	1 (4.54)	24 (50.00)	16 (33.33)	8 (16.67)
IS	27 (40.91)	33 (50.00)	6 (9.09)	15 (60.00)	8 (32.00)	2 (8.00)	12 (29.27)	25 (60.97)	4 (9.76)
ESB	32 (49.23)	27 (41.54)	6 (9.23)	11 (78.57)	2 (14.29)	1 (7.14)	21 (41.18)	25 (49.02)	5 (9.80)
Total	99 (49.25)	81 (40.30)	21 (10.45)	42 (68.85)	15 (24.59)	4 (6.56)	57 (40.72)	66 (47.14)	17 (12.14)
Statistic	H = 1.999			H = 1.527			H = 1.682
P value	0.368			0.466			0.431

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Adverse reactions: The ERBL group exhibited more frequent, severe, and longer-lasting pain during the treatment of grade II-III hemorrhoids

Pain was found as the most common postoperative adverse reaction. The ERBL group exhibited a significantly higher incidence of pain (58.57%), a higher median VAS score of 2, and a longer median pain duration of 2 days compared with those observed for the IS and ESB groups (P < 0.001) (Table 4). Additionally, no significant differences were identified among the three groups regarding bleeding, fever, or dysuria (Table 5). While pain outcomes were similar across all techniques for grade I hemorrhoids (Table 6), the ERBL group had a higher prevalence rate of pain (72.92%), a greater number of high VAS scores, and longer pain durations (median pain duration, 2 days) for grade II-III hemorrhoids than those of the other two groups (Table 7 and Figure 4).

Figure 4 Comparison of the distribution of visual analog scale scores and pain durations for the three methods in grade I and grade II-III hemorrhoids. A: Comparison of visual analog scale scores; B: Comparison of pain durations. Dots represent the actual values for each group, purple pentagrams indicate the mean, black lines denote the median, and the width of the kernel smoothing curve reflects data density. ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Table 4 Postoperative pain characteristics, n (%).

Subgroup	Pain	VAS [median (Q1, Q3)]	Pain duration [days, median (Q1, Q3)]
ERBL	41 (58.57)a	2.00 (0.00, 3.25)a	2.00 (0.00, 3.00)a
IS	8 (12.12)a,b	0.00 (0.00, 0.00)a,b	0.00 (0.00, 0.00)a,b
ESB	18 (27.69)a,b	0.00 (0.00, 2.00)a,b	0.00 (0.00, 1.00)a,b
Total	67 (33.33)	0.00 (0.00, 2.00)	0.00 (0.00, 2.00)
Statistic	χ2 = 34.359	H = 36.950	H = 38.365
P value	< 0.001	< 0.001	< 0.001

^aP < 0.001, post-hoc analyses were performed at P < 0.05.

^bP’ < 0.001 vs endoscopic rubber band ligation.

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding; VAS: Visual analog scale.

Table 5 Other postoperative adverse reactions, n (%).

Subgroup	Bleeding	Fever	Dysuria
ERBL	1 (1.43)	2 (2.86)	3 (4.29)
IS	0 (0.00)	2 (3.03)	0 (0.00)
ESB	1 (1.54)	1 (1.54)	3 (4.62)
Total	2 (1.00)	5 (2.49)	6 (2.99)
Statistic
P value	0.770	1.000	0.221

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Table 6 Postoperative pain characteristics for grade I hemorrhoids, n (%).

Subgroup	Pain	VAS [median (Q1, Q3)]	Pain duration [days, median (Q1, Q3)]
ERBL	6 (27.27)	0.00 (0.00, 2.25)	0.00 (0.00, 2.00)
IS	3 (12.00)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)
ESB	3 (21.43)	0.00 (0.00, 0.75)	0.00 (0.00, 0.50)
Total	12 (19.67)	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)
Statistic		H = 3.308	H = 2.182
P value	0.426	0.191	0.336

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding; VAS: Visual analog scale.

Table 7 Postoperative pain characteristics for grade II-III hemorrhoids, n (%).

Subgroup	Pain	VAS [median (Q1, Q3)]	Pain duration [days, median (Q1, Q3)]
ERBL	35 (72.92)a	2.00 (0.00, 4.00)a	2.00 (0.00, 3.75)a
IS	5 (12.20)a,b	0.00 (0.00, 0.00)a,b	0.00 (0.00, 0.00)a,b
ESB	15 (29.41)a,b	0.00 (0.00, 2.00)a,b	0.00 (0.00, 1.00)a,b
Total	55 (39.29)	0.00 (0.00, 2.75)	0.00 (0.00, 2.00)
Statistic	χ² = 37.461	H = 35.553	H = 41.352
P value	< 0.001	< 0.001	< 0.001

^aP < 0.001, post-hoc analyses were performed at P < 0.05.

^bP’ < 0.001 vs endoscopic rubber band ligation.

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding; VAS: Visual analog scale.

Recurrence: IS had a higher recurrence rate for grade II-III internal hemorrhoids

Among 180 patients who received adequate treatment, 10 experienced disease recurrence within 6 months post-operation. No statistically significant difference was observed among the three groups. The total recurrence rate during the follow-up period was 25%, with the ERBL, IS, and ESB groups showing the recurrence rates of 18.03%, 40%, and 16.95%, respectively. Both the ERBL and ESB groups demonstrated significantly lower total recurrence rates compared with the IS group (P’ = 0.024 and 0.015, respectively). For grade I internal hemorrhoids, the total recurrence rates were not significantly different among the three groups. The total recurrence rates of grade II-III internal hemorrhoids in the three groups were 25% (ERBL), 45.95% (IS), and 19.57% (ESB), respectively (Figure 5). The IS group had a higher recurrence rate than that of the ESB group (P’ = 0.03) (Table 8).

Figure 5 Bar graph depicting the recurrence rates for the three procedures. The left side bars of the figure show short-term recurrence, while the remaining bars indicate total recurrence. Gray bars represent recurrence, and white bars indicate no recurrence. ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

Table 8 Analysis of recurrence rates, n (%).

Subgroup	Short-term recurrence (no stratification)		Total recurrence (no stratification)		Total recurrence (grade I)		Total recurrence (grade II-III)
	Yes	No	Yes	No	Yes	No	Yes	No
ERBL	5 (8.20)	56 (91.80)	11 (18.03)b,c	50 (81.97)b,c	1 (4.76)	20 (95.24)	10 (25.00)a	30 (75.00)a
IS	1 (1.67)	59 (98.33)	24 (40.00)b	36 (60.00)b	7 (30.43)	16 (69.57)	17 (45.95)a	20 (54.05)a
ESB	4 (6.78)	55 (93.22)	10 (16.95)b,c	49 (83.05)b,c	1 (7.69)	12 (92.31)	9 (19.57)a,c	37 (80.43)a,c
Total	10 (5.56)	170 (94.44)	45 (25.00)	135 (75.00)	9 (15.79)	48 (84.21)	36 (29.27)	87 (70.73)
Statistic			χ2 = 10.819				χ2 = 7.415
P value	0.284		0.004		0.050		0.025

^aP < 0.05, post-hoc analyses were performed at P < 0.05.

^bP < 0.01, post-hoc analyses were performed at P < 0.05.

^cP’ < 0.05 vs injection sclerotherapy.

ERBL: Endoscopic rubber band ligation; IS: Injection sclerotherapy; ESB: Endoscopic polidocanol sclerobanding.

DISCUSSION

A deeper comprehension of the role of anal cushions has led to a shift in hemorrhoid treatment from traditional radical surgery to an emphasis on symptom relief while preserving the integrity of the anal cushions[9,10]. The advancement of endoscopic therapies has provided novel clinical options. Both ERBL and IS procedures use rubber bands or sclerosants to induce fibrosis in the hemorrhoidal tissues and occlude vessels, thereby controlling bleeding and reducing prolapse, contributing to symptom improvement. Recently, studies have introduced EFSB as an innovative method, combining 1% or 3% polidocanol foam sclerotherapy with rubber band ligation, applied in two ways: “Ligation followed by sclerotherapy” or “sclerotherapy followed by ligation”[5,11,12]. In the present study, sclerotherapy was initially performed using 1% polidocanol liquid, followed by ligation. The use of a liquid sclerosant eliminated the need for foam preparation, thereby reducing procedural time and mitigating the issues associated with foam instability, as well as the potential for injury to surrounding tissues. Endoscopic treatment for internal hemorrhoids is rapidly evolving. However, recurrence remains a major concern for both clinicians and patients. Although safety and effectiveness are essential when choosing treatment strategies, minimizing the recurrence should also be prioritized. Additional clinical research is therefore needed on the outcomes, safety, and recurrence rates of the three main endoscopic methods mentioned above to obtain solid evidence to support personalized treatment decisions.

This retrospective comparative study assessed the effectiveness and safety of ERBL, IS, and ESB in treating internal hemorrhoids. All three treatments showed significant short-term success at 3- and 6-month follow-ups. Although IS provides adequate short-term control of hemorrhoidal bleeding, it exhibits poorer long-term efficacy and higher recurrence rates for grade II-III hemorrhoids[8,13]. Similar findings were reported by Abiodun et al[14], that is, the IS requires a greater number of retreatments. The present study also indicated that IS was associated with a higher recurrence rate in the treatment of grade II-III internal hemorrhoids, while the difference between groups was not statistically significant in the treatment of grade I internal hemorrhoids. These findings imply that while the IS can temporarily resolve the mucosal issues, it does not sufficiently address the underlying abnormalities of the anal cushions, limiting its therapeutic efficacy for more severe internal hemorrhoids. For grade I internal hemorrhoids characterized by minimal structural abnormalities, the IS can address the majority of anal cushion issues, potentially achieving relatively sustained symptom relief. Additionally, it was confirmed that the long-term efficacy of IS could depend on the extent of tissue fibrosis induced, which could be directly influenced by the operational techniques, specifically, the injected dose and the accuracy of the injection depth, as well as by individual variability in tissue response, collectively influencing the long-term efficacy of IS. Nonetheless, there remains remarkable potential for IS, particularly with the introduction of new sclerosants and advanced techniques, such as foam sclerotherapy and ultrasound-guided injections, which are likely to improve its long-term effectiveness[15,16]. Given its low rate of adverse events and high safety profile, the IS remains a valuable option in clinical practice.

This study reported postoperative pain as the most common adverse reaction post-surgery. The ERBL group exhibited a higher occurrence rate, increased severity, and a longer duration of pain compared with the other groups, while the ESB group did not experience too many adverse reactions. In addition to common pain sources such as anal sphincter spasm and individual differences in pain threshold, key factors contributing to the higher pain levels in the ERBL group included the placement of rubber bands too close to the dentate line and mucosal ischemia between the bands[17,18]. Notably, the local nerve-blocking effect of polidocanol has been shown to reduce postoperative pain associated with IS and ESB treatments[2]. Postoperative pain typically resolves within 7 days in 97% of cases. Other common adverse reactions include: (1) Localized bleeding resulting from trauma to the anal mucosa; (2) Low-grade fever due to inflammatory mediators released in response to the sclerosant or rubber bands; and (3) Temporary dysuria caused by neurogenic irritation of the bladder plexus[19].

Various evaluation criteria, including different symptom scores and follow-up durations, have been used to determine the optimal treatments for different hemorrhoid stages. However, research findings and conclusions remain inconsistent. It is widely accepted that ERBL, causing ischemic necrosis of the hemorrhoidal tissue through mechanical ligation at the hemorrhoid base, is more appropriate for prolapsed grade II-III internal hemorrhoids[20,21]. The IS, which induces localized sterile inflammation and fibrosis to secure prolapsed cushions and occlude vessels, demonstrates more favorable outcomes for mild hemorrhoids and those primarily characterized by bleeding (grade I-II hemorrhoids)[1,21]. Sclerobanding combines band ligation and sclerotherapy, thereby reducing pain caused by rubber bands owing to the local anesthetic effect of the sclerosant. This combined method provides better symptom relief and higher patient satisfaction compared with those achieved by ERBL, making the former a promising therapy for grade II-III internal hemorrhoids[22]. The present study also assessed treatment outcomes based on the efficacy-safety balance and revealed specific advantages for certain hemorrhoid grades. For mild grade I hemorrhoids, all three procedures afforded low recurrence rates and minimal adverse events. For prolapsed grade II-III hemorrhoids, the ESB not only maintains a low recurrence rate but also reduces the incidence of postoperative adverse reactions.

Compared with traditional single therapies, ESB achieves a synergistic effect of “chemical stimulation by sclerosant” and “mechanical ligation by rubber bands”. This dual approach obstructs blood flow and elevates hemorrhoidal tissue, leading to more effective therapeutic outcomes. In addition to its primary role in symptom improvement, the local anesthetic properties of sclerosant help alleviate pain following banding procedures. Furthermore, its submucosal injection creates a fluid cushion that separates the mucosal layer from the muscularis propria, thereby preventing inadvertent muscle ligation or excessive traction and significantly lowering the incidence of postoperative pain[2]. When compared to monotherapy with ERBL, ESB further alleviates postoperative pain. Thus, the combined action of ESB, integrating the local anesthetic effect of the sclerosant with the mechanical obstruction from the rubber bands, highlights its dual clinical benefits: “Low recurrence plus reduced postoperative pain”.

This study has some limitations. Firstly, its retrospective design could introduce potential biases, including selection bias due to the single-center cohort and non-randomized treatment assignments, as well as information bias arising from less precise variables during follow-up and missing data resulting from the extended follow-up period. Secondly, although key confounding factors were accounted for, recurrence and postoperative pain could still be influenced by unmeasured variables, such as individual healing capacity, dietary factors, or adherence to postoperative instructions. Notably, the recurrence rates were higher than initially anticipated. The sample size was calculated based on recurrence rates reported in previous studies, which may not fully reflect the experience at our single-center institution. At the same time, the relatively long-term follow-up allowed for a more thorough recording of recurrence events. While the initial sample size calculation indicated the need for 52 patients per group, over 60 patients per group were recruited (actual n = 65-70) to compensate for potential dropouts. Consequently, the final analyzable sample size in each group exceeded the minimum requirement, further strengthening the reliability of the findings. Moreover, post-hoc analyses confirmed the ability to detect significant differences among the three groups. Future multi-center, prospective studies with standardized protocols and long-term follow-up are required to provide more precise estimates of the outcomes observed in this study and to inform the development of clearer clinical guidelines.

CONCLUSION

For the treatment of grade I internal hemorrhoids, ERBL, IS, and ESB all demonstrated comparable and sustained long-term efficacy, without significant differences in the rates of adverse reactions. ESB exhibited to be the most effective endoscopic approach for managing grade II-III internal hemorrhoids, yielding a significantly lower recurrence rate than IS and fewer postoperative adverse events than ERBL. Preoperative decision-making plays a notable role in the management of hemorrhoids. Clinicians must carefully assess the benefits of long-term success against the risks of short-term discomfort while also considering the potential advantages of repeated procedures for improving long-term outcomes.