Modified Sclerobanding Procedure for Treating Grade II/III Hemorrhoid Disease: clinical efficacy and safety evaluation—a retrospective study

Modified Sclerobanding Procedure for Treating Grade II/III Hemorrhoid Disease: clinical efficacy and safety evaluation—a retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Modified Sclerobanding Procedure for Treating Grade II/III Hemorrhoid Disease: clinical efficacy and safety evaluation—a retrospective study Wei Wang, Jun Lu, Mian Yang, Jiazi Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4555397/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Sclerobanding (SB) combines Rubber Band Ligation (RBL) with 3% Polidocanol Foam Sclerotherapy (PFS) for treating hemorrhoidal disease (HD). This study evaluated a modified SB (mSB) procedure's efficacy and safety for Grade II/III HD. We enrolled patients with Grade II/III HD who received RBL treatments from Jan-Dec 2021 and mSB treatments from Jan 2022-Feb 2023 at Ningbo Medical Center Lihuili Hospital. Primary outcomes included treatment failure rate and delayed bleeding (DB) incidence. Secondary outcomes reviewed postoperative complications like pain, swelling, anal edema, and bleeding grade variation. Long-term follow-up assessed HD Symptom Score (HDSS), Short Health Scale for HD (SHSHD), and Patient Satisfaction (PS). Among 307 patients, 162 received mSB and 125 had traditional RBL. Baseline characteristics were similar, except for anticoagulant history and hospital stay length (P < 0.05). The mSB group had no delayed major bleeding, unlike 5 cases in the RBL group. Recurrence (6.8% vs. 17.0%) and treatment failure rates (6.8% vs. 18.6%) were lower in the mSB group (P < 0.05). Postoperative complications were similar, but the mSB group showed better bleeding improvement by the 7th day (P < 0.05). One-year follow-up indicated no significant differences in HDSS, SHSHD, and PS. The mSB procedure reduces ligation sessions, lowers DB risk, and decreases treatment failure without increasing postoperative complications. Health sciences/Diseases/Gastrointestinal diseases/Anal diseases Health sciences/Diseases/Gastrointestinal diseases/Gastrointestinal bleeding Health sciences/Medical research/Outcomes research Hemorrhoids Rubber band ligation Sclerotherapy Polidocanol foam Complications Figures Figure 1 Figure 2 Introduction HD is a common and frequently occurring condition among humans. When conservative treatments are ineffective, surgical intervention is often required1,2. Over the past century, with the growing acceptance of minimally invasive concepts, significant advancements have been made in minimally invasive surgical techniques for hemorrhoids. These advancements have reduced postoperative pain and complications, and have improved long-term outcomes2. The American Society of Colon and Rectal Surgeons recommends office-based procedures like RBL and sclerotherapy for most grade I to III cases3. However, RBL and sclerotherapy carry potential risks. RBL may lead to complications such as band slippage, pain, or DB, which can be life-threatening4,5. Sclerotherapy may pose risks like mucosal ulceration, fever, rectal stricture and perianal abscess6. Premature band slippage is a significant risk factor for ulceration as it may lead to incomplete tissue necrosis, resulting in ulcer-induced DB and recurrence of hemorrhoid prolapse7,8. To prevent premature slipping of the rubber band can effectively reduce postoperative complications9. Polidocanol in foam form has emerged as a recent addition to HD treatment10. Moser KH et.al believe that compared to traditional liquid sclerosing agents, the foam formulation increases the contact area between the sclerosing agent and the vascular endothelium, thereby enhancing efficacy with a lower dosage of the sclerosing agent11. Recent studies have shown that polidocanol foam sclerotherapy (PFS) is effective for Grade II to IV hemorrhoidal disease, with few complications, which are usually minor12,13. Bracchitta S et al. recently reported a novel technique that combines PFS with RBL, termed Sclerobanding (SB). The core of this technique involves injecting 3% polidocanol foam sclerosing agent into the ligated nodule created by RBL, aiming to reduce postoperative complications and enhance the treatment efficacy for HD14. We believe that the SB technique may reduce the incidence of complications and improve treatment efficacy. However, its primary work is merely injecting the sclerosing agent into the ligated nodule created by RBL, which does not fully utilize the advantages of FPS. We hypothesize that injecting foam sclerosant into the ligated nodule post-RBL, expanding its volume, followed by injecting sclerosant under the mucosa (including both the mucosa under the ligated nodule and non-ligated hemorrhoid mucosa), may better integrate the advantages of both treatment methods. In addition to increasing the volume of the ligated nodule, it can also induce fibrosis of the mucosal tissue at the base of the ligated nodule. Moreover, it can serve as a supplemental treatment with FPS for hemorrhoids unsuitable for RBL. However, there are currently no reports on the application of this approach. Based on the aforementioned hypothesis, our center has modified the Sclerobanding (mSB) procedure since January 2022. In this study, we conducted a retrospective analysis comparing the efficacy and safety of mSB and RBL. Methods Patients In this study, we retrospectively reviewed patients who underwent surgical treatment for hemorrhoidal disease (HD) at Ningbo Medical Center Lihuili Hospital between January 2021 and February 2023. The work adhered to STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement recommended for cohort studies 15 . The hospital's Ethics Committee approved the study. Inclusion criteria were adult patients diagnosed with Grade II to III HD according to Goligher's classification, who had previously undergone at least four weeks of unsuccessful conservative treatment. Patients were excluded if they had any of the following conditions: severe Grade IV hemorrhoids, anal fissures, sinusitis, mental illness, inability to live independently, other perianal disorders, or insufficient clinical/follow-up data. Those treated with conventional RBL procedures from January to December 2021 formed the conventional RBL group, while those receiving modified sclerobanding procedures from January 2022 to February 2023 comprised the mSB group. All patients were enrolled consecutively. Procedures and Techniques Before the procedures, all patients received a cleansing enema. No antibiotics were administered. The surgical treatment was performed with the patient in a knee-chest position, a cushion placed under the abdomen to elevate the hips, and the legs slightly apart. Anesthesia is crucial for obtaining an optimal operating view for correct ligation, with spinal anesthesia often preferred, especially for male, overweight, or muscular patients. In female patients, block anesthesia may suffice for achieving the optimal operating field. If a patient had a coagulation disorder, was on anticoagulant medication, or had a spinal condition unsuitable for spinal anesthesia, we preferred to use block anesthesia. If the block was ineffective, we then switched to general anesthesia with endotracheal intubation. In our study, 23.4% of patients received block anesthesia, 73.3% underwent spinal anesthesia, and 3.3% were administered general intravenous anesthesia. For patients with cardiovascular disease requiring anticoagulant medication, we instructed them to stop taking anticoagulants five days before surgery and to use low-molecular-weight heparin as a substitute. Rivaroxaban was resumed 24 hours after surgery. The surgery can generally be performed by a single surgeon. However, it is preferable to have two surgeons, including a primary surgeon and an assistant. The assistant can help hold the anoscope in place, making it easier for the primary surgeon to perform the procedure. Patients in the RBL group underwent traditional rubber band ligation treatment, following the same procedure as described in our previous study 9 . In brief, the first step involved using an anoscope to assess the distribution of hemorrhoids, identify symptomatic hemorrhoids requiring treatment, and determine the sites for ligation. Next, the ligator was connected to a negative pressure suction device. The hemorrhoid was prolapsed into the anoscope and then aspirated into the ligator using the suction device. When the negative pressure reached 0.08–0.1 MPa, the rubber band on the ligator was released, completing the hemorrhoid ligation. All symptomatic internal hemorrhoids were treated accordingly. In the mSB group, the RBL procedure was performed in the same manner. However, after completing the RBL, we injected foam sclerosant into the ligated nodule, expanding its volume. Subsequently, we injected sclerosant under the mucosa beneath the ligated nodule (Fig. 1 ). After performing rubber band ligation (RBL) on two hemorrhoidal sites, the rectal mucosa in the remaining hemorrhoidal region often appeared relatively flat, rendering further RBL on a third site unnecessary. Moreover, when the mucosa in the hemorrhoidal region was flat and taut, performing RBL would result in an insufficiently large ligated mucosal ball, which could increase the risk of premature rubber band detachment. Therefore, the final step involved injecting foam sclerosant into the non-ligated hemorrhoid mucosa. When injecting the foam sclerosant into the ligated nodules, observe them enlarge and whiten. When injecting the mucosa or internal hemorrhoids, pay attention to the angle and depth of the needle, and observe mucosal swelling and whitening. After injection, minor, self-limiting bleeding often occurs, which requires no treatment. The preparation of polidocanol foam is commonly carried out using the Tessari method, which involves the utilization of a three-way valve connecting two disposable syringes10. In this method, the polidocanol solution is mixed with air to form a foam. Specifically, 2 mL of 3% liquid polidocanol (Aethoxysklerol® Kreussler Pharma) is mixed with 8 mL of air using a three-way tap connected to two 10 mL syringes in a 1:4 ratio, creating the desired foam. We chose a three-way tap with an infusion tube, which allowed us to connect a 1 mL syringe needle to the other end (Fig. 2 ). In our experience, the choice of needle is crucial. The finer the needle, the better. Using a finer needle significantly reduces bleeding or leakage after injecting the foam sclerosant. Postoperatively, patients do not routinely receive antibiotics for infection prevention. If a perianal infection or significant swelling and pain of the hemorrhoidal tissue occur, quinolones or second-generation cephalosporins are used for treatment. For pain management, we routinely use NSAIDs such as celecoxib or indomethacin suppositories. If pain persists, we administer 10 mg of dezocine via intramuscular injection. This pain management regimen effectively alleviates patient discomfort. Patients typically start a clear liquid diet six hours after surgery, gradually transitioning to a semi-liquid diet. Lactulose is regularly administered to prevent constipation. Each patient is advised to take warm sitz baths after bowel movements. Follow-up and data collection The follow-up period was divided into two distinct phases. The first phase encompassed the first month post-surgery, during which patients were closely monitored and receiving essential medications to support their recovery process. The second phase extended from the second month to one year after the surgical intervention. During this latter phase, the surgical wounds had typically healed, and the primary focus was on monitoring for any recurrence of symptoms. The primary outcomes were the post-operative treatment failure rate and the incidence of DB. Therapeutic failure was determined based on two key criteria: Therapeutic failure was determined based on two key criteria: a Patient Global Impression of Change (PGIC) score 16 of ≤ 4 and the recurrence of HD during the latter phase of the follow-up period. PGIC can be used as an external criterion to measure clinically important change when no gold standard is available. On this scale, scores > 4 indicate improvement, and scores ≤ 4 indicate no change or worsening 16 . Recurrence of HD during follow-up was further classified into two categories: Mild recurrence: This was characterized by an increase in the SHSS compared to the scores at the beginning of the follow-up period, but lower than the baseline scores before treatment. In mild recurrence, no intervention was required. Severe recurrence: This was defined as an increase in the SHSS compared to the scores at the latter phase of the follow-up period, indicating the need for further surgical intervention. In this study, severe recurrence was primarily characterized by two situations: the recurrence of prolapsed hemorrhoids or persistent bleeding that could not be alleviated through conservative treatment. As secondary outcomes, we monitored perioperative complications, including pain intensity, anal edema, sensation of prolapse and postoperative bleeding severity. Pain intensity was assessed using a Visual Analog Scale (VAS), allowing patients to self-assess. Anal edge edema was evaluated and recorded by doctors during follow-up examinations. The sensation of prolapse was documented based on patient self-perception during follow-up visits. Additionally, we utilized the Hemorrhoidal Disease Symptom Score (HDSS) 17 and hemorrhoidal disease bleeding grade (HDBG) to evaluate the severity of HD symptoms, and the Simplified Hemorrhoidal Disease Health Score (SHS-HD) 17 to assess the quality of life. Furthermore, we used a 7-point Likert scale (1 = very dissatisfied, 7 = very satisfied) for patients to grade their satisfaction with the operation. Statistical analysis For normally distributed continuous variables, baseline characteristics, primary, and secondary outcomes are presented as mean and standard deviation. Categorical variables are presented as frequencies and percentages. Mean comparisons are conducted using Student's t-test. For categorical variables, the chi-square test or Fisher's exact test is used as appropriate. Statistical analysis was conducted using IBM® SPSS® Statistics 22.0 software. A p-value less than 0.05 was considered statistically significant. Results Patients’ Information Based on the inclusion/exclusion criteria, we consecutively enrolled 307 patients in this study. Among them, 162 patients were enrolled in the mSB group, and 125 patients were enrolled in the RBL group. In the first stage of follow-up, 62 patients did not complete the outpatient follow-up as required. However, they were contacted by phone to inquire about their post-operative recovery. The majority of baseline characteristics of the two groups of patients, such as age, gender, BMI, grade of HD, history of HD surgery, constipation, primary symptoms, treatment reasons, HDBG, HDSS, and SHS-HD score, showed no statistically significant differences(P > 0.05). Nevertheless, notable variances were noted between the two groups regarding the history of anticoagulant usage and duration of hospital stay (P < 0.05). As shown in Table 1 . The reason for the significantly shorter hospital stay in the mSB group is that the majority (53.2%) of patients underwent the procedure in the day-care unit and were discharged within 24 hours, in comparison to 23.4% in the RBL group. Table 1 Information about the patients involved in the study The general information mSB group(162) RBL group (145) Statistics P values Age (years) 38.5 ± 8.9 39.6 ± 10.3 0.99 0.32 Gender male 65(40.1%) 61(42.1%) 0.12 0.73 female 97(59.9%) 84(47.9%) BMI 22.3 ± 4.5 22.7 ± 5.1 0.73 0.47 Hemorrhoid grade grade II 59(35.8%) 51(35.2%) 0.05 0.82 grade III 103(64.2%) 94(64.8%) Previous history of Hemorrhoid surgery There are 15(9.3%) 8(5.5%) 1.55 0.21 There is no 147(90.7%) 137(95.5%) Constipation Yes 19(13.3%) 14(9.7%) 0.34 0.56 No 143(86.7%) 131(90.3%) Main symptom and cause of treatment Bleeding 65(40.1%) 54(37.2%) 0.80 0.67 Prolapse 77(43.2%) 76(52.4%) Pain 20(16.7%) 15(10.4%) Anticoagulant * Yes 15(9.3%) 5(3.4%) 4.23 0.04 No 147(90.7%) 140(96.6%) HD bleeding grade 1.8 ± 0.4 1.9 ± 0.4 2.19 0.03 HDSS 13.2 ± 0.7 13.1 ± 0.9 1.23 0.37 SHS HD 19.3 ± 3.3 19.7 ± 3.1 1.10 0.27 Length of hospitalization * 2.3 ± 1.3 3.4 ± 1.8 6.07 < 0.01 HDSS: Hemorrhoidal Disease Symptom Score SHS-HD: Short Health Scale adapted for hemorrhoidal disease * : Significant different The primary outcomes In the RBL group, 5 patients experienced DB postoperatively. All these patients presented with a sudden onset of blood, with or without stool, occurring 7 to 14 days after the procedure. The blood was very fresh in appearance, often accompanied by blood clots, and was associated with a marked and progressive decline in hemoglobin levels. In contrast, no cases of postoperative DB were observed in the mSB group. The difference in the incidence of DB between the two groups was statistically significant(P < 0.05). Due to thorough pre-discharge education, all 5 patients promptly returned to the hospital and received hemostatic treatment through suturing under anoscopic observation. Because of the timely intervention, none of the patients required a blood transfusion. Notably, 5 patients in the conventional RBL group who were taking anticoagulants did not experience DB. In the mSB group, all patients considered the treatment effective (PGIC scores > 4) after the first phase of follow-up. However, during the later follow-up phase, 11 patients experienced a recurrence of HD, resulting in a treatment failure rate of 6.8%. In the RBL group, two patients reported the treatment as ineffective (PGIC scores ≤ 4), and 25 patients experienced recurrence during the later follow-up phase. The treatment failure rate was 18.6%, and the overall recurrence rate was 17.0%. There was a statistically significant difference in the treatment failure rate and recurrence rate between the two groups (P 0.05). However, there was a significant difference in the comparison of mild recurrence (5.6% vs 13.1%, P 0.05). For grade III hemorrhoids, recurrence occurred in 9 cases in the mSB group and 21 cases in the RBL group, with recurrence rates of 5.6% and 14.5%, respectively. This difference was statistically significant (P < 0.05, as shown in Table 2 ). In the mSB group, two patients experienced severe recurrence and required additional treatment. These patients underwent a second injection of sclerosing foam, which successfully resolved their symptoms and led to a complete recovery. Comparatively, in the RBL group, five patients suffered from severe recurrence and necessitated surgical intervention. The surgical approach primarily consisted of a combination of the traditional Milligan-Morgan (M-M) hemorrhoidectomy and RBL. Following this treatment modality, all five patients achieved a full recovery and were considered cured. Table 2 Incidence of postoperative complications The evaluation index mSB group(162) RBL group (145) Statistics P values Total recurrence * 11 (6.8%) 25 (17.29%) 8.7 P < 0.01 Mild recurrence * 9 (5.6%) 19(13.1%) 5.33 0.02 Severe recurrence 2(1.2%) 6(4.1%) 2.62 0.11 Grade II recurrence hemorrhoids 2 (1.2%) 4(2.8%) 0.92 0.34 Grade III recurrence * hemorrhoids 9 (5.6%) 21 (14.5%) 6.92 P < 0.01 Number of ligated sites 1 52(33.1%) 45(31.0%) 4.63 0.10 2 98(62.4%) 82(57.9%) 3 7(4.5%) 18(11.0%) Massive bleeding * 0 5 - 0.02 Postoperative bleeding grade variation 3 days after -0.8 ± 0.6 -0.7 ± 0.6 1.46 0.14 7 days after * -1.3 ± 0.7 -1.0 ± 0.6 4.04 P < 0.01 Postoperative pain VAS 3 days after 3.1 ± 2.7 3.5 ± 3.3 1.15 0.25 7 days after 1.2 ± 1.4 1.3 ± 1.6 0.58 0.56 Anal edema 3 days after 38 (23.5%) 42 (29.0%) 1.21 0.27 7 days after 13(8.0%) 13 (9.0%) 0.09 0.77 Sensation of prolapse 3 days after 33 (20.3%) 29 (20.0%) 0.073 0.79 7 days after 13 (8.0%) 10 (6.9%) 0.14 0.71 HDSS at the third month 1.8 ± 1.1 1.9 ± 1.4 0.690 0.491 HDSS at the 12th month 1.7 ± 0.8 1.8 ± 1.1 0.902 0.368 SHS at the third month 5.7 ± 1.9 5.9 ± 1.7 0.973 0.331 SHS at the 12th month 5.4 ± 1.3 5.5 ± 1.6 0.597 0.551 PS when discharge 5.1 ± 0.7 5.0 ± 0.8 1.159 0.247 PS at the third month 5.7 ± 0.7 5.6 ± 0.8 1.159 0.247 PS at the 12th month 5.5 ± 0.8 5.4 ± 0.9 1.024 0.307 HDSS: Hemorrhoidal Disease Symptom Score SHS-HD: Short Health Scale adapted for hemorrhoidal disease PS: Patient satisfaction * : Significant different The secondary outcomes In both patient groups, most patients underwent RBL ligation at two sites. The distribution of the number of RBL ligations between the two groups showed no significant difference (P = 0.10). However, fewer patients in the mSB group underwent ligation at three sites compared to the RBL group (4.5% vs. 11.0%). After the procedure, neither group encountered serious infectious complications like perianal abscess or perirectal abscess. Nonetheless, they did report varying degrees of symptoms including pain, bleeding, anal edema, and a sensation of prolapse. The postoperative bleeding grade variation on the 7th postoperative day was the only indicator that showed a significant difference between the groups; other symptoms were comparable on both the 3rd and 7th postoperative days. During the later phase of follow-up, at three and twelve months post-procedure, there were no significant differences observed between the groups in terms of the HDSS, SHS-HD, or PS scores. Discussion The findings of our study indicate that the mSB procedure does not increase the risk of short-term postoperative complications, such as pain, anal swelling, and sensation of prolapse, when compared to conventional RBL. The overall treatment outcomes, including the HDSS, SHS-HD, and PS, were comparable between the two groups. However, the mSB procedure demonstrated a more substantial improvement in postoperative bleeding grade variation on the seventh day following surgery compared to RBL. Furthermore, no instances of delayed massive bleeding were observed in the mSB group postoperatively, and all patients in this group considered the treatment to be effective. Notably, the recurrence rate within one year after surgery was significantly lower in the mSB group compared to the RBL group. Based on these findings, we propose that the mSB technique is a safe and effective approach for the treatment of hemorrhoids, offering a lower rate of treatment failure and enhanced postoperative safety in comparison to the conventional RBL procedure. As minimally invasive interventions gain popularity, an increasing number of innovative office-based procedures are being utilized for the treatment of HD. RBL remains widely recognized as the most effective method for managing second- and third-degree hemorrhoidal disease, particularly in cases of bleeding and prolapsing hemorrhoids, supported by a high level of evidence 3,18,19 . The most significant drawback of RBL is early premature slippage of the rubber band, which can lead to treatment failure, including recurrence of hemorrhoidal prolapse or bleeding, and even DB4. It typically occurs between the 10th and 14th postoperative days, with an incidence of 1.7–2.5%, most frequently in patients on anticoagulants 20 . Post-RBL, the reported recurrence rates of prolapse vary in the literature, ranging from 6.6–18%, with these patients often requiring additional treatment sessions 21 . In our present study, in the RBL group, 2 patients perceived no improvement after treatment, 17.6% of patients experienced recurrence within one year postoperatively, and 5 patients (3.4%) encountered DB after the procedure. The incidence of massive hemorrhage and recurrence in this study exceeded the rates reported in previous literature, which may be related to the larger inner diameter of the RBL ligator used in our study. While a larger ligator inner diameter facilitates the ligation of a greater volume of mucosal tissue, thereby reducing the requisite number of ligation sessions. However, it may also result in an insufficient quantity of ligated mucosal tissue and the formation of a suboptimal mucosal nodule. Consequently, this may elevate the risk of premature rubber band slippage, ultimately culminating in increased rates of DB and recurrence. Our previous study has demonstrated that preventing premature rubber band slippage can effectively reduce bleeding and prolapse recurrence associated with the RBL procedure 9 . Sclerobanding, a technique that combines sclerotherapy injection with RBL, has been reported in the literature as a method to enhance effectiveness and reduce common complications associated with both procedures 21–23 . Injecting a sclerosing agent into the nodules of rubber band ligation not only increases the volume of the ligated nodules but also enhances the inflammatory response of the hemorrhoidal mucosa, thereby providing a “lifting effect” on the prolapsed mucosa. This helps to avoid premature rubber band slippage and reduce the risk of delayed bleeding, which can sometimes be severe. In previous reported Sclerobanding procedures, the sclerosing agents used were primarily in liquid form. However, literature reports indicate that foam sclerosing agents have better efficacy in the treatment of hemorrhoids compared to liquid sclerosing agents. Moser12 et al conducted a comparative study evaluating the efficacy of liquid versus foam polidocanol in a randomized trial involving patients with Grade I hemorrhoids. The results demonstrated significantly superior outcomes with the foam formulation, as 88% of patients achieved successful treatment following just one sclerotherapy session. Additionally, patients treated with polidocanol foam needed fewer sclerotherapy sessions compared to those who received the liquid sclerosant, with an average of 1.08 sessions versus 1.42 sessions, respectively (p = 0.001) 11 . Recently, Francesco Pata reported the first instance of utilizing RBL in conjunction with 3% PFS for the treatment of Second and Third-Degree HD. The study involved 97 patients, with minor complications in four individuals (4.1%) that were successfully resolved with conservative management, and no severe complications were reported 24 . In this study, we referred to Francesco Pata’s Sclerobanding method and similarly employed 3% Polidocanol Foam Sclerotherapy, with some minor modifications. These modifications include: 1) injecting the sclerosant not only into the ligated nodule but also into the the mucosa beneath the ligated nodule. This approach not only increases the volume of the ligated nodule, preventing premature rubber band slippage, but also induces aseptic inflammation within the mucosa at the base of the ligated nodule, serving to locally fixate the mucosa. The submucosa’s small blood vessels also undergo occlusion, reducing postoperative bleeding. Our results confirm that, compared to RBL, mSB demonstrates significantly better improvement in bleeding grade on the 7th postoperative day. 2)We opted for the finest 0.5mm needle for sclerosant injection. The selected three-way connector is equipped with a 5mm inner diameter infusion tube and a switch. Utilizing the finest needle minimizes sclerosant leakage and bleeding after injection. Once the sclerosant is foamed, the pressure within the syringe is relatively high, causing the sclerosant to easily overflow and lead to waste. The infusion tube features a clamp, which can be closed after each injection, reducing the overflow and waste of the foamed sclerosant. This measure prevents situations where one vial of sclerosant is insufficient for the procedure. 3༉Based on the principle of not exceeding three rubber band ligation (RBL) sites, we aimed to reduce one ligation as much as possible and replace it with sclerosant injection. The results of this study showed that grade II/III internal hemorrhoids generally required only one or two ligation sites, and rarely needed three sites. After two ligations, the mucosa in the hemorrhoidal area was no longer lax. If RBL was performed on the third internal hemorrhoid, the ligated nodule was often not large enough, which could increase the risk of RBL surgery. However, abandoning ligation would mean forgoing the opportunity to treat one site of the hemorrhoids. In instances where the ligated nodule proves to be smaller than optimal following the third ligation, the use of a sclerosing agent injection to augment the volume of the nodule as a remedial measure may be considered. However, we contend that this approach to treatment is potentially excessive. It is our belief that a singular injection of the sclerosing agent could serve as an effective substitute for supplementary ligation in these cases, thereby rendering the need for additional ligation unnecessary. We replaced the third planned ligation site with simple sclerosant injection, which reduced the number of RBL procedures while ensuring the effectiveness of the treatment. After the aforementioned modifications, our results also confirmed that although the number of RBL ligations in the mSB procedure was reduced (especially the number of cases requiring three ligations), the treatment success rate was actually higher. We observed that among the baseline characteristics of the patients included in this study, the RBL group had significantly fewer patients receiving anticoagulant therapy. This was related to our cautious approach in selecting treatment methods for patients on anticoagulant medications. Before we started using sclerotherapy for HD, we would likely combine hemorrhoidal artery ligation (HAL) with RBL or opt for HAL alone in these patients. HAL is theoretically the safest choice because it involves only ligation without additional incisions. Moreover, HAL is one of the most effective methods for treating hemorrhoidal bleeding. We only perform RBL alone when HD patients present with significant prolapse symptoms, large internal hemorrhoids, or lax mucosa in the hemorrhoidal region. This is because we need to ensure that the ligated nodes after RBL are sufficiently large to prevent premature slippage of the rubber bands, which could lead to delayed massive bleeding. Additionally, patients in the RBL group had a longer hospital duration. This is because we believe the mSB procedure is minimally invasive, causes less postoperative pain, and theoretically carries no risk of severe bleeding. Therefore, we prefer to perform the mSB procedure in a day-care unit because of the simple postoperative management. As a result, 53.2% of patients in the mSB group were discharged within 24 hours, compared to only 23.4% in the RBL group. Conclusion The findings of this study highlight several advantages of our modified Sclerobanding procedure. Firstly, the procedure increases the volume of the ligated nodule after RBL, preventing slippage. Secondly, injecting foam sclerosing agent into the base of the ligated nodule reduces bleeding during the rubber band excision process. Thirdly, the number of RBL ligations required is reduced, as the foam sclerosing agent can serve as a supplementary treatment for untreated hemorrhoids. Fourthly, the procedure offers a safe primary treatment option for patients on anticoagulant medications. Fifthly, foam sclerosing agent can be re-injected as a salvage treatment after failed HD surgery. Moreover, the procedure is simple to perform, facilitating its widespread adoption. Lastly, adverse reactions and side effects are minimal. Limitation Similar to other retrospective studies, this study inherently comes with its own limitations. Additionally, all procedures were conducted by two colorectal surgical teams within a single institution, which may limit the generalizability of our findings to other populations. Furthermore, there was no comparison with alternative treatments, and long-term outcomes were not assessed. Therefore, further studies are required to compare mSB with other therapeutic modalities to establish the optimal strategy for minimizing postoperative complications. Notably, both PFS and RBL are office-based procedures that can be performed in a clinic setting without the need for general or regional anesthesia. However, to ensure patient comfort and procedural accuracy, the majority of patients in this study opted for spinal anesthesia. Future research will investigate the feasibility of performing these procedures without anesthesia or with regional anesthesia. Declarations Author contributions Wei Wang: Study design, Patient recruitment, data collection, manuscript writing. Jun Lu, and Mian Yang: Patient recruitment, data collection, interpretation. Jiazi Yu: Patient recruitment, Data collection, Statistical analysis. Manuscript writing. All authors reviewed and approved the final manuscript. Funding Declaration This work was funded by Ningbo medical and health brand discipline, 2022-F01. Data availability The datasets analyzed during the current study are available from the corresponding author on reasonable request. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Ningbo medical center Lihuili hospital (KY2021PJ256). Informed consent to participate Informed consent was obtained from all individual participants included in the study. Informed consent for publication Patients signed informed consent regarding publishing their data and photographs. All hand-drawn illustrations in this manuscript are original works by the authors, who grant permission for their publication as part of this paper. References Sneider EB, Maykel JA. Diagnosis and management of symptomatic hemorrhoids. Surg Clin North Am 2010; 90(1): 17–32, Table of Contents. Pata F, Gallo G, Pellino G, et al. Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview. Front Surg 2021; 8: 727059. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018; 61(3): 284–92. Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg 2016; 8(9): 614–20. Chen HH, Wang JY, Changchien CR, et al. Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies. Dis Colon Rectum 2002; 45(8): 1096–9. Abe T, Kunimoto M, Hachiro Y, Ohara K, Inagaki M. Long-term Outcomes of Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy for Prolapsed Hemorrhoids: A Single-Center, Observational Study. Dis Colon Rectum 2022; 65(2): 271–5. Hite N, Klinger AL, Miller P, et al. Clopidogrel bisulfate (Plavix) does not increase bleeding complications in patients undergoing rubber band ligation for symptomatic hemorrhoids. J Surg Res 2018; 229: 230–3. Jacobs D. Clinical practice. Hemorrhoids. N Engl J Med 2014; 371(10): 944–51. Yu J, Zhong J, Peng T, Jin L, Shen L, Yang M. Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study. BMC Surg 2022; 22(1): 238. Nastasa V, Samaras K, Ampatzidis C, et al. Properties of polidocanol foam in view of its use in sclerotherapy. Int J Pharm 2015; 478(2): 588–96. Moser KH, Mosch C, Walgenbach M, et al. Efficacy and safety of sclerotherapy with polidocanol foam in comparison with fluid sclerosant in the treatment of first-grade haemorrhoidal disease: a randomised, controlled, single-blind, multicentre trial. Int J Colorectal Dis 2013; 28(10): 1439–47. Fernandes V, Fonseca J. Polidocanol Foam Injected at High Doses with Intravenous Needle: The (Almost) Perfect Treatment of Symptomatic Internal Hemorrhoids. GE Port J Gastroenterol 2019; 26(3): 169–75. Lobascio P, Laforgia R, Novelli E, et al. Short-Term Results of Sclerotherapy with 3% Polidocanol Foam for Symptomatic Second- and Third-Degree Hemorrhoidal Disease. J Invest Surg 2021; 34(10): 1059–65. Bracchitta S, Bracchitta LM, Pata F. Combined rubber band ligation with 3% polidocanol foam sclerotherapy (ScleroBanding) for the treatment of second-degree haemorrhoidal disease: a video vignette. Colorectal Dis 2021; 23(6): 1585–6. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Bmj 2007; 335(7624): 806–8. e Vet HCW TC, Mokkink LB, Knol DL. Measurement in Medicine. Cambridge , United Kingdom: Cambridge University Press 2011. Rørvik HD, Styr K, Ilum L, et al. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum 2019; 62(3): 333–42. Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician 2018; 97(3): 172–9. Trompetto M, Clerico G, Cocorullo GF, et al. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement. Tech Coloproctol 2015; 19(10): 567–75. Bat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Complications of rubber band ligation of symptomatic internal hemorrhoids. Dis Colon Rectum 1993; 36(3): 287–90. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47(8): 1364–70. Chew SS, Marshall L, Kalish L, et al. Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids and mucosal prolapse. Dis Colon Rectum 2003; 46(9): 1232–7. Kanellos I, Goulimaris I, Christoforidis E, Kelpis T, Betsis D. A comparison of the simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately, for the treatment of haemorrhoids: a prospective randomized trial. Colorectal Dis 2003; 5(2): 133–8. Pata F, Bracchitta LM, D'Ambrosio G, Bracchitta S. Sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy) for the Treatment of Second- and Third-Degree Hemorrhoidal Disease: Feasibility and Short-Term Outcomes. J Clin Med 2021; 11(1). Additional Declarations No competing interests reported. Supplementary Files strobestatement.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4555397","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":318931266,"identity":"bf271bdb-9078-4fa1-9641-7b5adaa41c46","order_by":0,"name":"Wei Wang","email":"","orcid":"","institution":"Ningbo Medical Center Lihuili Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":318931267,"identity":"4ece7a67-4adf-40b4-a6a9-c81e640ad77f","order_by":1,"name":"Jun Lu","email":"","orcid":"","institution":"Ningbo Medical Center Lihuili Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Lu","suffix":""},{"id":318931268,"identity":"844bb471-ab8e-4b74-ac32-120afe0344c8","order_by":2,"name":"Mian Yang","email":"","orcid":"","institution":"Ningbo Medical Center Lihuili Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mian","middleName":"","lastName":"Yang","suffix":""},{"id":318931269,"identity":"79ad9fe8-ac52-4921-9849-5a1d269a5d7b","order_by":3,"name":"Jiazi Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBACPgnmBgYGHgkGBmbmA8xgoQMEtLBJMMK0sCWQogUMeAyI1CLd2CbNI2MhL9/O8+1xYRuDHN+NBMbPBfi0yBwEauGRMGxs5t1uPLONwVjyRgKz9Ay8DksEa2FsZubdJs3bxpC44UYCGzMPEVrs25h5noG01BOtJbGHmYcNpCXBgAgtzZZzeCSSZzCzmUnPOCdhOPPMw2ZpfFr4JZIP3njbU2c7v//wM+mCMht5vuPJBz/j0wIELBKMPXAOME4Z4DGFEzB/YPhBSM0oGAWjYBSMaAAAQVs8fonKyp4AAAAASUVORK5CYII=","orcid":"","institution":"Ningbo Medical Center Lihuili Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jiazi","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2024-06-10 02:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4555397/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4555397/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59435760,"identity":"fcd76b24-2c87-4e9f-afed-14b95fb98c8f","added_by":"auto","created_at":"2024-07-01 19:12:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1254068,"visible":true,"origin":"","legend":"\u003cp\u003eThe sclerobanding modified technique proposed by the authors. (A) Inject foam sclerosant into the RBL ligated nodule. (B) Clamp the tube, adjust the injection site. (C) Inject foam sclerosant into the mucosa at the base of the ligated nodule. (D) Inject foam sclerosant into the internal hemorrhoids that do not need to be ligated.\u003c/p\u003e","description":"","filename":"FIG1.png","url":"https://assets-eu.researchsquare.com/files/rs-4555397/v1/28f8291aea71186ea515d1c7.png"},{"id":59435762,"identity":"c9f74dd6-7ca9-4a72-9eb6-9f3952b69cc2","added_by":"auto","created_at":"2024-07-01 19:12:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1729169,"visible":true,"origin":"","legend":"\u003cp\u003eThe equipment and preparation method used for intraoperative foam sclerosant preparation. (A) The syringe and three-way tap used for preparing foam sclerosant. (B) To prepare foam sclerosant, mix 2 mL of liquid polidocanol with 8 mL of air. (C) Use a three-way tap with an infusion tube, and connect a 1 mL syringe needle to the other end. (D) After the RBL procedure, inject foam sclerosant.\u003c/p\u003e","description":"","filename":"FIG2.png","url":"https://assets-eu.researchsquare.com/files/rs-4555397/v1/4d6757f15f54aeccd12d2c62.png"},{"id":67086647,"identity":"3d801ac8-7344-4b66-875e-21b3caa5280c","added_by":"auto","created_at":"2024-10-21 06:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4379136,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4555397/v1/73d83313-ac0e-47e1-b230-49af6aefa549.pdf"},{"id":59435763,"identity":"80156577-7ee6-40f2-a742-a0f74c5fbbb6","added_by":"auto","created_at":"2024-07-01 19:12:09","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2479249,"visible":true,"origin":"","legend":"","description":"","filename":"strobestatement.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4555397/v1/a9c28953894e8e41382b3ada.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Sclerobanding Procedure for Treating Grade II/III Hemorrhoid Disease: clinical efficacy and safety evaluation—a retrospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHD is a common and frequently occurring condition among humans. When conservative treatments are ineffective, surgical intervention is often required1,2. Over the past century, with the growing acceptance of minimally invasive concepts, significant advancements have been made in minimally invasive surgical techniques for hemorrhoids. These advancements have reduced postoperative pain and complications, and have improved long-term outcomes2. The American Society of Colon and Rectal Surgeons recommends office-based procedures like RBL and sclerotherapy for most grade I to III cases3. However, RBL and sclerotherapy carry potential risks. RBL may lead to complications such as band slippage, pain, or DB, which can be life-threatening4,5. Sclerotherapy may pose risks like mucosal ulceration, fever, rectal stricture and perianal abscess6.\u003c/p\u003e \u003cp\u003ePremature band slippage is a significant risk factor for ulceration as it may lead to incomplete tissue necrosis, resulting in ulcer-induced DB and recurrence of hemorrhoid prolapse7,8. To prevent premature slipping of the rubber band can effectively reduce postoperative complications9. Polidocanol in foam form has emerged as a recent addition to HD treatment10. Moser KH et.al believe that compared to traditional liquid sclerosing agents, the foam formulation increases the contact area between the sclerosing agent and the vascular endothelium, thereby enhancing efficacy with a lower dosage of the sclerosing agent11. Recent studies have shown that polidocanol foam sclerotherapy (PFS) is effective for Grade II to IV hemorrhoidal disease, with few complications, which are usually minor12,13. Bracchitta S et al. recently reported a novel technique that combines PFS with RBL, termed Sclerobanding (SB). The core of this technique involves injecting 3% polidocanol foam sclerosing agent into the ligated nodule created by RBL, aiming to reduce postoperative complications and enhance the treatment efficacy for HD14. We believe that the SB technique may reduce the incidence of complications and improve treatment efficacy. However, its primary work is merely injecting the sclerosing agent into the ligated nodule created by RBL, which does not fully utilize the advantages of FPS. We hypothesize that injecting foam sclerosant into the ligated nodule post-RBL, expanding its volume, followed by injecting sclerosant under the mucosa (including both the mucosa under the ligated nodule and non-ligated hemorrhoid mucosa), may better integrate the advantages of both treatment methods. In addition to increasing the volume of the ligated nodule, it can also induce fibrosis of the mucosal tissue at the base of the ligated nodule. Moreover, it can serve as a supplemental treatment with FPS for hemorrhoids unsuitable for RBL. However, there are currently no reports on the application of this approach.\u003c/p\u003e \u003cp\u003eBased on the aforementioned hypothesis, our center has modified the Sclerobanding (mSB) procedure since January 2022. In this study, we conducted a retrospective analysis comparing the efficacy and safety of mSB and RBL.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e In this study, we retrospectively reviewed patients who underwent surgical treatment for hemorrhoidal disease (HD) at Ningbo Medical Center Lihuili Hospital between January 2021 and February 2023. The work adhered to STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement recommended for cohort studies\u003csup\u003e15\u003c/sup\u003e. The hospital's Ethics Committee approved the study. Inclusion criteria were adult patients diagnosed with Grade II to III HD according to Goligher's classification, who had previously undergone at least four weeks of unsuccessful conservative treatment. Patients were excluded if they had any of the following conditions: severe Grade IV hemorrhoids, anal fissures, sinusitis, mental illness, inability to live independently, other perianal disorders, or insufficient clinical/follow-up data. Those treated with conventional RBL procedures from January to December 2021 formed the conventional RBL group, while those receiving modified sclerobanding procedures from January 2022 to February 2023 comprised the mSB group. All patients were enrolled consecutively.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures and Techniques\u003c/h3\u003e\n\u003cp\u003eBefore the procedures, all patients received a cleansing enema. No antibiotics were administered. The surgical treatment was performed with the patient in a knee-chest position, a cushion placed under the abdomen to elevate the hips, and the legs slightly apart. Anesthesia is crucial for obtaining an optimal operating view for correct ligation, with spinal anesthesia often preferred, especially for male, overweight, or muscular patients. In female patients, block anesthesia may suffice for achieving the optimal operating field. If a patient had a coagulation disorder, was on anticoagulant medication, or had a spinal condition unsuitable for spinal anesthesia, we preferred to use block anesthesia. If the block was ineffective, we then switched to general anesthesia with endotracheal intubation. In our study, 23.4% of patients received block anesthesia, 73.3% underwent spinal anesthesia, and 3.3% were administered general intravenous anesthesia. For patients with cardiovascular disease requiring anticoagulant medication, we instructed them to stop taking anticoagulants five days before surgery and to use low-molecular-weight heparin as a substitute. Rivaroxaban was resumed 24 hours after surgery. The surgery can generally be performed by a single surgeon. However, it is preferable to have two surgeons, including a primary surgeon and an assistant. The assistant can help hold the anoscope in place, making it easier for the primary surgeon to perform the procedure.\u003c/p\u003e \u003cp\u003ePatients in the RBL group underwent traditional rubber band ligation treatment, following the same procedure as described in our previous study\u003csup\u003e9\u003c/sup\u003e. In brief, the first step involved using an anoscope to assess the distribution of hemorrhoids, identify symptomatic hemorrhoids requiring treatment, and determine the sites for ligation. Next, the ligator was connected to a negative pressure suction device. The hemorrhoid was prolapsed into the anoscope and then aspirated into the ligator using the suction device. When the negative pressure reached 0.08\u0026ndash;0.1 MPa, the rubber band on the ligator was released, completing the hemorrhoid ligation. All symptomatic internal hemorrhoids were treated accordingly.\u003c/p\u003e \u003cp\u003eIn the mSB group, the RBL procedure was performed in the same manner. However, after completing the RBL, we injected foam sclerosant into the ligated nodule, expanding its volume. Subsequently, we injected sclerosant under the mucosa beneath the ligated nodule (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After performing rubber band ligation (RBL) on two hemorrhoidal sites, the rectal mucosa in the remaining hemorrhoidal region often appeared relatively flat, rendering further RBL on a third site unnecessary. Moreover, when the mucosa in the hemorrhoidal region was flat and taut, performing RBL would result in an insufficiently large ligated mucosal ball, which could increase the risk of premature rubber band detachment. Therefore, the final step involved injecting foam sclerosant into the non-ligated hemorrhoid mucosa. When injecting the foam sclerosant into the ligated nodules, observe them enlarge and whiten. When injecting the mucosa or internal hemorrhoids, pay attention to the angle and depth of the needle, and observe mucosal swelling and whitening. After injection, minor, self-limiting bleeding often occurs, which requires no treatment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe preparation of polidocanol foam is commonly carried out using the Tessari method, which involves the utilization of a three-way valve connecting two disposable syringes10. In this method, the polidocanol solution is mixed with air to form a foam. Specifically, 2 mL of 3% liquid polidocanol (Aethoxysklerol\u0026reg; Kreussler Pharma) is mixed with 8 mL of air using a three-way tap connected to two 10 mL syringes in a 1:4 ratio, creating the desired foam. We chose a three-way tap with an infusion tube, which allowed us to connect a 1 mL syringe needle to the other end (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In our experience, the choice of needle is crucial. The finer the needle, the better. Using a finer needle significantly reduces bleeding or leakage after injecting the foam sclerosant.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperatively, patients do not routinely receive antibiotics for infection prevention. If a perianal infection or significant swelling and pain of the hemorrhoidal tissue occur, quinolones or second-generation cephalosporins are used for treatment. For pain management, we routinely use NSAIDs such as celecoxib or indomethacin suppositories. If pain persists, we administer 10 mg of dezocine via intramuscular injection. This pain management regimen effectively alleviates patient discomfort. Patients typically start a clear liquid diet six hours after surgery, gradually transitioning to a semi-liquid diet. Lactulose is regularly administered to prevent constipation. Each patient is advised to take warm sitz baths after bowel movements.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up and data collection\u003c/h2\u003e \u003cp\u003eThe follow-up period was divided into two distinct phases. The first phase encompassed the first month post-surgery, during which patients were closely monitored and receiving essential medications to support their recovery process. The second phase extended from the second month to one year after the surgical intervention. During this latter phase, the surgical wounds had typically healed, and the primary focus was on monitoring for any recurrence of symptoms.\u003c/p\u003e \u003cp\u003eThe primary outcomes were the post-operative treatment failure rate and the incidence of DB. Therapeutic failure was determined based on two key criteria: Therapeutic failure was determined based on two key criteria: a Patient Global Impression of Change (PGIC) score\u003csup\u003e16\u003c/sup\u003e of \u0026le;\u0026thinsp;4 and the recurrence of HD during the latter phase of the follow-up period. PGIC can be used as an external criterion to measure clinically important change when no gold standard is available. On this scale, scores\u0026thinsp;\u0026gt;\u0026thinsp;4 indicate improvement, and scores\u0026thinsp;\u0026le;\u0026thinsp;4 indicate no change or worsening\u003csup\u003e16\u003c/sup\u003e. Recurrence of HD during follow-up was further classified into two categories:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMild recurrence: This was characterized by an increase in the SHSS compared to the scores at the beginning of the follow-up period, but lower than the baseline scores before treatment. In mild recurrence, no intervention was required.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSevere recurrence: This was defined as an increase in the SHSS compared to the scores at the latter phase of the follow-up period, indicating the need for further surgical intervention. In this study, severe recurrence was primarily characterized by two situations: the recurrence of prolapsed hemorrhoids or persistent bleeding that could not be alleviated through conservative treatment.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAs secondary outcomes, we monitored perioperative complications, including pain intensity, anal edema, sensation of prolapse and postoperative bleeding severity. Pain intensity was assessed using a Visual Analog Scale (VAS), allowing patients to self-assess. Anal edge edema was evaluated and recorded by doctors during follow-up examinations. The sensation of prolapse was documented based on patient self-perception during follow-up visits. Additionally, we utilized the Hemorrhoidal Disease Symptom Score (HDSS)\u003csup\u003e17\u003c/sup\u003e and hemorrhoidal disease bleeding grade (HDBG) to evaluate the severity of HD symptoms, and the Simplified Hemorrhoidal Disease Health Score (SHS-HD)\u003csup\u003e17\u003c/sup\u003e to assess the quality of life. Furthermore, we used a 7-point Likert scale (1\u0026thinsp;=\u0026thinsp;very dissatisfied, 7\u0026thinsp;=\u0026thinsp;very satisfied) for patients to grade their satisfaction with the operation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFor normally distributed continuous variables, baseline characteristics, primary, and secondary outcomes are presented as mean and standard deviation. Categorical variables are presented as frequencies and percentages. Mean comparisons are conducted using Student's t-test. For categorical variables, the chi-square test or Fisher's exact test is used as appropriate. Statistical analysis was conducted using IBM\u0026reg; SPSS\u0026reg; Statistics 22.0 software. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; Information\u003c/h2\u003e \u003cp\u003eBased on the inclusion/exclusion criteria, we consecutively enrolled 307 patients in this study. Among them, 162 patients were enrolled in the mSB group, and 125 patients were enrolled in the RBL group. In the first stage of follow-up, 62 patients did not complete the outpatient follow-up as required. However, they were contacted by phone to inquire about their post-operative recovery. The majority of baseline characteristics of the two groups of patients, such as age, gender, BMI, grade of HD, history of HD surgery, constipation, primary symptoms, treatment reasons, HDBG, HDSS, and SHS-HD score, showed no statistically significant differences(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Nevertheless, notable variances were noted between the two groups regarding the history of anticoagulant usage and duration of hospital stay (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The reason for the significantly shorter hospital stay in the mSB group is that the majority (53.2%) of patients underwent the procedure in the day-care unit and were discharged within 24 hours, in comparison to 23.4% in the RBL group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation about the patients involved in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe general information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emSB group(162)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRBL group (145)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(40.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61(42.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97(59.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84(47.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhoid grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59(35.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(35.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103(64.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94(64.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious history of Hemorrhoid surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere are\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere is no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147(90.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137(95.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143(86.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131(90.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain symptom and cause of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(40.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54(37.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProlapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77(43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(52.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147(90.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140(96.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD bleeding grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSHS\u003csub\u003eHD\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospitalization\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eHDSS: Hemorrhoidal Disease Symptom Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSHS-HD: Short Health Scale adapted for hemorrhoidal disease\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003e: Significant different\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eThe primary outcomes\u003c/h2\u003e \u003cp\u003eIn the RBL group, 5 patients experienced DB postoperatively. All these patients presented with a sudden onset of blood, with or without stool, occurring 7 to 14 days after the procedure. The blood was very fresh in appearance, often accompanied by blood clots, and was associated with a marked and progressive decline in hemoglobin levels. In contrast, no cases of postoperative DB were observed in the mSB group. The difference in the incidence of DB between the two groups was statistically significant(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Due to thorough pre-discharge education, all 5 patients promptly returned to the hospital and received hemostatic treatment through suturing under anoscopic observation. Because of the timely intervention, none of the patients required a blood transfusion. Notably, 5 patients in the conventional RBL group who were taking anticoagulants did not experience DB. In the mSB group, all patients considered the treatment effective (PGIC scores\u0026thinsp;\u0026gt;\u0026thinsp;4) after the first phase of follow-up. However, during the later follow-up phase, 11 patients experienced a recurrence of HD, resulting in a treatment failure rate of 6.8%. In the RBL group, two patients reported the treatment as ineffective (PGIC scores\u0026thinsp;\u0026le;\u0026thinsp;4), and 25 patients experienced recurrence during the later follow-up phase. The treatment failure rate was 18.6%, and the overall recurrence rate was 17.0%. There was a statistically significant difference in the treatment failure rate and recurrence rate between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference in the comparison of severe recurrence between the two groups (1.2% vs 4.1%, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, there was a significant difference in the comparison of mild recurrence (5.6% vs 13.1%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The recurrence of grade II hemorrhoids was observed in 2 cases in the mSB group and 4 cases in the RBL group, with no statistically significant difference between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). For grade III hemorrhoids, recurrence occurred in 9 cases in the mSB group and 21 cases in the RBL group, with recurrence rates of 5.6% and 14.5%, respectively. This difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the mSB group, two patients experienced severe recurrence and required additional treatment. These patients underwent a second injection of sclerosing foam, which successfully resolved their symptoms and led to a complete recovery. Comparatively, in the RBL group, five patients suffered from severe recurrence and necessitated surgical intervention. The surgical approach primarily consisted of a combination of the traditional Milligan-Morgan (M-M) hemorrhoidectomy and RBL. Following this treatment modality, all five patients achieved a full recovery and were considered cured.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence of postoperative complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe evaluation index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emSB group(162)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRBL group (145)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal recurrence\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (17.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild recurrence\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(13.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade II recurrence hemorrhoids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III recurrence\u003csup\u003e*\u003c/sup\u003e hemorrhoids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (14.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ligated sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52(33.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(31.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98(62.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82(57.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(11.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive bleeding\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative bleeding grade variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days after\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative pain VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnal edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensation of prolapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days after\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDSS at the third month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDSS at the 12th month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.902\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSHS at the third month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSHS at the 12th month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePS when discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePS at the third month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePS at the 12th month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eHDSS: Hemorrhoidal Disease Symptom Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSHS-HD: Short Health Scale adapted for hemorrhoidal disease\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePS: Patient satisfaction\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003e: Significant different\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eThe secondary outcomes\u003c/h2\u003e \u003cp\u003eIn both patient groups, most patients underwent RBL ligation at two sites. The distribution of the number of RBL ligations between the two groups showed no significant difference (P\u0026thinsp;=\u0026thinsp;0.10). However, fewer patients in the mSB group underwent ligation at three sites compared to the RBL group (4.5% vs. 11.0%). After the procedure, neither group encountered serious infectious complications like perianal abscess or perirectal abscess. Nonetheless, they did report varying degrees of symptoms including pain, bleeding, anal edema, and a sensation of prolapse. The postoperative bleeding grade variation on the 7th postoperative day was the only indicator that showed a significant difference between the groups; other symptoms were comparable on both the 3rd and 7th postoperative days. During the later phase of follow-up, at three and twelve months post-procedure, there were no significant differences observed between the groups in terms of the HDSS, SHS-HD, or PS scores.\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cp\u003eThe findings of our study indicate that the mSB procedure does not increase the risk of short-term postoperative complications, such as pain, anal swelling, and sensation of prolapse, when compared to conventional RBL. The overall treatment outcomes, including the HDSS, SHS-HD, and PS, were comparable between the two groups. However, the mSB procedure demonstrated a more substantial improvement in postoperative bleeding grade variation on the seventh day following surgery compared to RBL. Furthermore, no instances of delayed massive bleeding were observed in the mSB group postoperatively, and all patients in this group considered the treatment to be effective. Notably, the recurrence rate within one year after surgery was significantly lower in the mSB group compared to the RBL group. Based on these findings, we propose that the mSB technique is a safe and effective approach for the treatment of hemorrhoids, offering a lower rate of treatment failure and enhanced postoperative safety in comparison to the conventional RBL procedure.\u003c/p\u003e \u003cp\u003eAs minimally invasive interventions gain popularity, an increasing number of innovative office-based procedures are being utilized for the treatment of HD. RBL remains widely recognized as the most effective method for managing second- and third-degree hemorrhoidal disease, particularly in cases of bleeding and prolapsing hemorrhoids, supported by a high level of evidence\u003csup\u003e3,18,19\u003c/sup\u003e. The most significant drawback of RBL is early premature slippage of the rubber band, which can lead to treatment failure, including recurrence of hemorrhoidal prolapse or bleeding, and even DB4. It typically occurs between the 10th and 14th postoperative days, with an incidence of 1.7\u0026ndash;2.5%, most frequently in patients on anticoagulants\u003csup\u003e20\u003c/sup\u003e. Post-RBL, the reported recurrence rates of prolapse vary in the literature, ranging from 6.6\u0026ndash;18%, with these patients often requiring additional treatment sessions\u003csup\u003e21\u003c/sup\u003e. In our present study, in the RBL group, 2 patients perceived no improvement after treatment, 17.6% of patients experienced recurrence within one year postoperatively, and 5 patients (3.4%) encountered DB after the procedure. The incidence of massive hemorrhage and recurrence in this study exceeded the rates reported in previous literature, which may be related to the larger inner diameter of the RBL ligator used in our study. While a larger ligator inner diameter facilitates the ligation of a greater volume of mucosal tissue, thereby reducing the requisite number of ligation sessions. However, it may also result in an insufficient quantity of ligated mucosal tissue and the formation of a suboptimal mucosal nodule. Consequently, this may elevate the risk of premature rubber band slippage, ultimately culminating in increased rates of DB and recurrence.\u003c/p\u003e \u003cp\u003eOur previous study has demonstrated that preventing premature rubber band slippage can effectively reduce bleeding and prolapse recurrence associated with the RBL procedure\u003csup\u003e9\u003c/sup\u003e. Sclerobanding, a technique that combines sclerotherapy injection with RBL, has been reported in the literature as a method to enhance effectiveness and reduce common complications associated with both procedures\u003csup\u003e21\u0026ndash;23\u003c/sup\u003e. Injecting a sclerosing agent into the nodules of rubber band ligation not only increases the volume of the ligated nodules but also enhances the inflammatory response of the hemorrhoidal mucosa, thereby providing a \u0026ldquo;lifting effect\u0026rdquo; on the prolapsed mucosa. This helps to avoid premature rubber band slippage and reduce the risk of delayed bleeding, which can sometimes be severe. In previous reported Sclerobanding procedures, the sclerosing agents used were primarily in liquid form. However, literature reports indicate that foam sclerosing agents have better efficacy in the treatment of hemorrhoids compared to liquid sclerosing agents. Moser12 et al conducted a comparative study evaluating the efficacy of liquid versus foam polidocanol in a randomized trial involving patients with Grade I hemorrhoids. The results demonstrated significantly superior outcomes with the foam formulation, as 88% of patients achieved successful treatment following just one sclerotherapy session. Additionally, patients treated with polidocanol foam needed fewer sclerotherapy sessions compared to those who received the liquid sclerosant, with an average of 1.08 sessions versus 1.42 sessions, respectively (p\u0026thinsp;=\u0026thinsp;0.001)\u003csup\u003e11\u003c/sup\u003e. Recently, Francesco Pata reported the first instance of utilizing RBL in conjunction with 3% PFS for the treatment of Second and Third-Degree HD. The study involved 97 patients, with minor complications in four individuals (4.1%) that were successfully resolved with conservative management, and no severe complications were reported\u003csup\u003e24\u003c/sup\u003e. In this study, we referred to Francesco Pata\u0026rsquo;s Sclerobanding method and similarly employed 3% Polidocanol Foam Sclerotherapy, with some minor modifications. These modifications include: 1) injecting the sclerosant not only into the ligated nodule but also into the the mucosa beneath the ligated nodule. This approach not only increases the volume of the ligated nodule, preventing premature rubber band slippage, but also induces aseptic inflammation within the mucosa at the base of the ligated nodule, serving to locally fixate the mucosa. The submucosa\u0026rsquo;s small blood vessels also undergo occlusion, reducing postoperative bleeding. Our results confirm that, compared to RBL, mSB demonstrates significantly better improvement in bleeding grade on the 7th postoperative day. 2)We opted for the finest 0.5mm needle for sclerosant injection. The selected three-way connector is equipped with a 5mm inner diameter infusion tube and a switch. Utilizing the finest needle minimizes sclerosant leakage and bleeding after injection. Once the sclerosant is foamed, the pressure within the syringe is relatively high, causing the sclerosant to easily overflow and lead to waste. The infusion tube features a clamp, which can be closed after each injection, reducing the overflow and waste of the foamed sclerosant. This measure prevents situations where one vial of sclerosant is insufficient for the procedure. 3༉Based on the principle of not exceeding three rubber band ligation (RBL) sites, we aimed to reduce one ligation as much as possible and replace it with sclerosant injection. The results of this study showed that grade II/III internal hemorrhoids generally required only one or two ligation sites, and rarely needed three sites. After two ligations, the mucosa in the hemorrhoidal area was no longer lax. If RBL was performed on the third internal hemorrhoid, the ligated nodule was often not large enough, which could increase the risk of RBL surgery. However, abandoning ligation would mean forgoing the opportunity to treat one site of the hemorrhoids. In instances where the ligated nodule proves to be smaller than optimal following the third ligation, the use of a sclerosing agent injection to augment the volume of the nodule as a remedial measure may be considered. However, we contend that this approach to treatment is potentially excessive. It is our belief that a singular injection of the sclerosing agent could serve as an effective substitute for supplementary ligation in these cases, thereby rendering the need for additional ligation unnecessary. We replaced the third planned ligation site with simple sclerosant injection, which reduced the number of RBL procedures while ensuring the effectiveness of the treatment. After the aforementioned modifications, our results also confirmed that although the number of RBL ligations in the mSB procedure was reduced (especially the number of cases requiring three ligations), the treatment success rate was actually higher.\u003c/p\u003e \u003cp\u003eWe observed that among the baseline characteristics of the patients included in this study, the RBL group had significantly fewer patients receiving anticoagulant therapy. This was related to our cautious approach in selecting treatment methods for patients on anticoagulant medications. Before we started using sclerotherapy for HD, we would likely combine hemorrhoidal artery ligation (HAL) with RBL or opt for HAL alone in these patients. HAL is theoretically the safest choice because it involves only ligation without additional incisions. Moreover, HAL is one of the most effective methods for treating hemorrhoidal bleeding. We only perform RBL alone when HD patients present with significant prolapse symptoms, large internal hemorrhoids, or lax mucosa in the hemorrhoidal region. This is because we need to ensure that the ligated nodes after RBL are sufficiently large to prevent premature slippage of the rubber bands, which could lead to delayed massive bleeding. Additionally, patients in the RBL group had a longer hospital duration. This is because we believe the mSB procedure is minimally invasive, causes less postoperative pain, and theoretically carries no risk of severe bleeding. Therefore, we prefer to perform the mSB procedure in a day-care unit because of the simple postoperative management. As a result, 53.2% of patients in the mSB group were discharged within 24 hours, compared to only 23.4% in the RBL group.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study highlight several advantages of our modified Sclerobanding procedure. Firstly, the procedure increases the volume of the ligated nodule after RBL, preventing slippage. Secondly, injecting foam sclerosing agent into the base of the ligated nodule reduces bleeding during the rubber band excision process. Thirdly, the number of RBL ligations required is reduced, as the foam sclerosing agent can serve as a supplementary treatment for untreated hemorrhoids. Fourthly, the procedure offers a safe primary treatment option for patients on anticoagulant medications. Fifthly, foam sclerosing agent can be re-injected as a salvage treatment after failed HD surgery. Moreover, the procedure is simple to perform, facilitating its widespread adoption. Lastly, adverse reactions and side effects are minimal.\u003c/p\u003e "},{"header":"Limitation","content":"\u003cp\u003eSimilar to other retrospective studies, this study inherently comes with its own limitations. Additionally, all procedures were conducted by two colorectal surgical teams within a single institution, which may limit the generalizability of our findings to other populations. Furthermore, there was no comparison with alternative treatments, and long-term outcomes were not assessed. Therefore, further studies are required to compare mSB with other therapeutic modalities to establish the optimal strategy for minimizing postoperative complications. Notably, both PFS and RBL are office-based procedures that can be performed in a clinic setting without the need for general or regional anesthesia. However, to ensure patient comfort and procedural accuracy, the majority of patients in this study opted for spinal anesthesia. Future research will investigate the feasibility of performing these procedures without anesthesia or with regional anesthesia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWei Wang: Study design, Patient recruitment, data collection, manuscript writing. Jun Lu, and Mian Yang: Patient recruitment, data collection, interpretation. Jiazi Yu: Patient recruitment, Data collection, Statistical analysis. Manuscript writing. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by Ningbo medical and health brand discipline, 2022-F01.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Ningbo medical center Lihuili hospital (KY2021PJ256).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients signed informed consent regarding publishing their data and photographs. All hand-drawn illustrations in this manuscript are original works by the authors, who grant permission for their publication as part of this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSneider EB, Maykel JA. Diagnosis and management of symptomatic hemorrhoids. Surg Clin North Am 2010; 90(1): 17\u0026ndash;32, Table of Contents.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePata F, Gallo G, Pellino G, et al. Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview. Front Surg 2021; 8: 727059.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018; 61(3): 284\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg 2016; 8(9): 614\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen HH, Wang JY, Changchien CR, et al. Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies. Dis Colon Rectum 2002; 45(8): 1096\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbe T, Kunimoto M, Hachiro Y, Ohara K, Inagaki M. Long-term Outcomes of Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy for Prolapsed Hemorrhoids: A Single-Center, Observational Study. Dis Colon Rectum 2022; 65(2): 271\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHite N, Klinger AL, Miller P, et al. Clopidogrel bisulfate (Plavix) does not increase bleeding complications in patients undergoing rubber band ligation for symptomatic hemorrhoids. J Surg Res 2018; 229: 230\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobs D. Clinical practice. Hemorrhoids. N Engl J Med 2014; 371(10): 944\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu J, Zhong J, Peng T, Jin L, Shen L, Yang M. Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study. BMC Surg 2022; 22(1): 238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNastasa V, Samaras K, Ampatzidis C, et al. Properties of polidocanol foam in view of its use in sclerotherapy. Int J Pharm 2015; 478(2): 588\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoser KH, Mosch C, Walgenbach M, et al. Efficacy and safety of sclerotherapy with polidocanol foam in comparison with fluid sclerosant in the treatment of first-grade haemorrhoidal disease: a randomised, controlled, single-blind, multicentre trial. Int J Colorectal Dis 2013; 28(10): 1439\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes V, Fonseca J. Polidocanol Foam Injected at High Doses with Intravenous Needle: The (Almost) Perfect Treatment of Symptomatic Internal Hemorrhoids. GE Port J Gastroenterol 2019; 26(3): 169\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLobascio P, Laforgia R, Novelli E, et al. Short-Term Results of Sclerotherapy with 3% Polidocanol Foam for Symptomatic Second- and Third-Degree Hemorrhoidal Disease. J Invest Surg 2021; 34(10): 1059\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBracchitta S, Bracchitta LM, Pata F. Combined rubber band ligation with 3% polidocanol foam sclerotherapy (ScleroBanding) for the treatment of second-degree haemorrhoidal disease: a video vignette. Colorectal Dis 2021; 23(6): 1585\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Bmj 2007; 335(7624): 806\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ee Vet HCW TC, Mokkink LB, Knol DL. Measurement in Medicine. \u003cem\u003eCambridge\u003c/em\u003e, \u003cem\u003eUnited Kingdom: Cambridge University Press\u003c/em\u003e 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026oslash;rvik HD, Styr K, Ilum L, et al. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum 2019; 62(3): 333\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician 2018; 97(3): 172\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrompetto M, Clerico G, Cocorullo GF, et al. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement. Tech Coloproctol 2015; 19(10): 567\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Complications of rubber band ligation of symptomatic internal hemorrhoids. Dis Colon Rectum 1993; 36(3): 287\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47(8): 1364\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChew SS, Marshall L, Kalish L, et al. Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids and mucosal prolapse. Dis Colon Rectum 2003; 46(9): 1232\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanellos I, Goulimaris I, Christoforidis E, Kelpis T, Betsis D. A comparison of the simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately, for the treatment of haemorrhoids: a prospective randomized trial. Colorectal Dis 2003; 5(2): 133\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePata F, Bracchitta LM, D'Ambrosio G, Bracchitta S. Sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy) for the Treatment of Second- and Third-Degree Hemorrhoidal Disease: Feasibility and Short-Term Outcomes. J Clin Med 2021; 11(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hemorrhoids, Rubber band ligation, Sclerotherapy, Polidocanol foam, Complications","lastPublishedDoi":"10.21203/rs.3.rs-4555397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4555397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSclerobanding (SB) combines Rubber Band Ligation (RBL) with 3% Polidocanol Foam Sclerotherapy (PFS) for treating hemorrhoidal disease (HD). This study evaluated a modified SB (mSB) procedure's efficacy and safety for Grade II/III HD. We enrolled patients with Grade II/III HD who received RBL treatments from Jan-Dec 2021 and mSB treatments from Jan 2022-Feb 2023 at Ningbo Medical Center Lihuili Hospital. Primary outcomes included treatment failure rate and delayed bleeding (DB) incidence. Secondary outcomes reviewed postoperative complications like pain, swelling, anal edema, and bleeding grade variation. Long-term follow-up assessed HD Symptom Score (HDSS), Short Health Scale for HD (SHSHD), and Patient Satisfaction (PS). Among 307 patients, 162 received mSB and 125 had traditional RBL. Baseline characteristics were similar, except for anticoagulant history and hospital stay length (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The mSB group had no delayed major bleeding, unlike 5 cases in the RBL group. Recurrence (6.8% vs. 17.0%) and treatment failure rates (6.8% vs. 18.6%) were lower in the mSB group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Postoperative complications were similar, but the mSB group showed better bleeding improvement by the 7th day (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). One-year follow-up indicated no significant differences in HDSS, SHSHD, and PS. The mSB procedure reduces ligation sessions, lowers DB risk, and decreases treatment failure without increasing postoperative complications.\u003c/p\u003e","manuscriptTitle":"Modified Sclerobanding Procedure for Treating Grade II/III Hemorrhoid Disease: clinical efficacy and safety evaluation—a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 19:12:05","doi":"10.21203/rs.3.rs-4555397/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e844c10a-b34b-42ae-a7f9-c3f467ef80b0","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33724988,"name":"Health sciences/Diseases/Gastrointestinal diseases/Anal diseases"},{"id":33724989,"name":"Health sciences/Diseases/Gastrointestinal diseases/Gastrointestinal bleeding"},{"id":33724990,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2024-10-21T06:08:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 19:12:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4555397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4555397","identity":"rs-4555397","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}