Efficacy and Safety of Endoscopic Super-Hemorrhoidal Banding for Mixed Hemorrhoids with Prolapse

Efficacy and Safety of Endoscopic Super-Hemorrhoidal Banding for Mixed Hemorrhoids with Prolapse | 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 Research Article Efficacy and Safety of Endoscopic Super-Hemorrhoidal Banding for Mixed Hemorrhoids with Prolapse Xiu-jiang Huang, Wen Xu, Hao Lin, Ping Jiang, Hong-jing Yang, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4534422/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 Objective Traditional miligan-organ hemorrhoidectomy (MMH) has disadvantages for mixed hemorrhoids with prolapse. Strategies to further improve the therapeutic effect, reduce postoperative anal pain, and decrease the complication rate are urgently required. We investigated the efficacy and safety of endoscopic superhemorrhoidal banding (ESHB) for mixed hemorrhoids with prolapse. Methods The clinical data of 130 consecutive patients with mixed hemorrhoids and prolapse at the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture from June 2021 to June 2023 were retrospectively collected and analyzed. Sixty-five patients who underwent MMH and 65 who underwent ESHB were categorized into MMH and ESHB groups, respectively. The outcomes, length of the procedure, hospitalization time, postoperative pain (evaluated using the visual analog scale [VAS]), and incidence of urinary retention were compared. Results The efficacy was 100% in both groups, with no statistically significant difference ( P > 0.05). Operation length and hospitalization time were significantly shorter in the ESHB group than in the MMH group ( P < 0.01). The VAS scores for postoperative pain and incidence of urinary pain were significantly lower in the ESHB group than in the MMH group ( P < 0.01). Conclusions ESHB can effectively restore the weakened anal cushion and protect its structural and functional integrity, improve symptoms related to mixed hemorrhoids with prolapse, shorten operative time and hospital stay, and reduce the incidence of postoperative complications. It is a safe and simple minimally invasive endoscopic treatment with an efficacy similar to that of MMH. Trial registration : The clinical trial registration was completed (registration no.: NCT06250140; registration date: January 31, 2024). Endoscopic super-hemorrhoidal banding Endoscopy Milligan-Morgan hemorrhoidectomy Mixed hemorrhoids Prolapse Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Hemorrhoids can be classified as internal, external, or mixed. Mixed hemorrhoids form as a result of the fusion of internal and external hemorrhoids through the vascular plexus [1]. Mixed hemorrhoids with prolapse are often accompanied by symptoms such as bleeding, pain, swelling, and itching [2], which adversely affect patients’ quality of life and are difficult to relieve with conservative treatment. Most symptomatic mixed hemorrhoids require surgical treatment, with Milligan–Morgan hemorrhoidectomy (MMH) being the most common procedure. However, MMH has disadvantages and is associated with difficulties in achieving satisfactory clinical outcomes [3]. Strategies to further improve the therapeutic effect, reduce postoperative anal pain, and decrease the incidence of complications are urgent issues that need to be addressed. Among the minimally invasive treatments being developed, endoscopic diagnosis and treatment of hemorrhoids has become prevalent; this treatment is considered effective, safe, and simple. This study aimed to explore the effectiveness and safety of endoscopic super-hemorrhoidal banding (ESHB) by retrospectively analyzing patients with mixed hemorrhoids and prolapse who underwent ESHB or MMH between June 2021 and June 2023 at our center. METHODS Study design and population The clinical data of 142 patients with mixed hemorrhoids and prolapse treated at the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture from June 2021 to June 2023 were collected. The inclusion criteria were as follows: (i) a diagnosis of mixed hemorrhoids that met the relevant criteria of the American Society of Colorectal Surgeons’ 2018 Clinical Practice Guidelines for the Management of Hemorrhoids (the grade of internal hemorrhoids in patients with mixed hemorrhoids and prolapse was grade III or IV) [4]; (ii) external hemorrhoids manifesting as either connective-tissue external hemorrhoids or varicose external hemorrhoids; and (iii) age between 18 and 75 years. The exclusion criteria were as follows: (i) thrombotic external hemorrhoids, anal fissure, perianal abscess, anal fistula, and malignant anal tumor; (ii) previous history of lower rectal or anal surgery; (iii) immunodeficiency or inflammatory bowel disease; (iv) severe diseases in other organs or systems and coagulopathy; and (v) puerperal women. Following the inclusion and exclusion criteria, initially, 140 patients were enrolled, with 10 subsequently excluded due to loss to follow-up. Among them, 65 patients were allocated to the MMH treatment group, while 65 were assigned to the ESHB treatment group based on their chosen treatment modality. This retrospective cohort study was approved by the Medical Ethics Committee of the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture (Approval No. : QDNYYEC2021006; approval date: March 15, 2021), conducted in accordance with the 1964 Declaration of Helsinki. Furthermore, clinical trial registration was completed (registration no. : NCT06250140; registration date: January 31, 2024), and written informed consent was obtained from all patients. Therapeutic methods MMH The MMH was performed by an anorectal surgeon. Intestinal cleansing and complete colonoscopy (EG29-i10, PENTAX Corp., Tokyo, Japan) were performed preoperatively. During surgery, the patient received epidural anesthesia and was placed in the lithotomy position. Routine disinfection and draping were performed. The skin of the hemorrhoid mass was clamped with tissue forceps and the internal hemorrhoids were exposed by traction. A V-shaped incision was made on both sides of the skin at the base of the hemorrhoid mass and detached upward, stripping the subcutaneous varicose plexus or connective tissue 5–10 mm above the dentate line. After exposing the base of the hemorrhoid mass, a figure-of-eight suture with 2 − 0 absorbable thread was performed, and the ligated tissue was removed. The same procedure was conducted for other hemorrhoids. An exhaust pipe, Vaseline gauze, and gelatin sponge were placed inside the anus, wrapped with sterile gauze, externally pressurized with a gauze block, and secured using a T-band. ESHB ESHB was performed by an experienced endoscopist (XJ Huang). Preoperative colon preparation and complete colonoscopy were performed. During surgery, the patient received intravenous general anesthesia and was placed in the left lateral decubitus position. The prolapsed hemorrhoids were removed by hand and a 6-row ligation device (MBL-6-F; Cook Medical, Bloomington, IN, USA) was installed at the front end of the endoscope (EG29-i10; PENTAX Corp.). After attaching the multiple-band ligation device to the endoscope, the super-hemorrhoidal mucosa was completely suctioned into the ligating device, and an elastic band was released [5]. First, three positions, namely, right anterior, right posterior, and left median, were selected for mucosal ligation. Subsequently, three ligation positions were crossed on the oral side, and a total of six ligation positions were used. After withdrawing the endoscope from the anus, the residual external hemorrhoids and skin tags were treated with endoscopic ligation. Outcome assessments Efficacy evaluation Clinical efficacy was evaluated 6 months after surgery. The evaluation criteria were as follows: Cured: resolution of prolapse of the internal hemorrhoids, bleeding symptoms, and pain or mass in the anus; Effective: reduced bleeding symptoms and anal mass; and Ineffective: hematochezia and prolapse symptoms were not alleviated or were aggravated. The total effective rate was calculated as (cure + effective) cases/total cases × 100. Safety evaluation Anal pain was quantified using a 0- to 10-point visual analog scale (VAS), in which a score of 0 indicates no pain, 1–3 points indicates mild pain, 4–6 points indicates moderate pain, 7–9 indicates severe pain, and 10 indicates excruciating pain [6]. Patients with urinary retention were referred to those who could not discharge urine, thereby necessitating urgent catheterization. Postoperative bleeding was defined as a large amount of bleeding that required surgical sutures or endoscopic hemostasis. Operative time The operative time in the MMH group was defined as the time from satisfactory anesthesia to the end of the operation. The operative time in the ESHB group was defined as the time from endoscopic insertion into the anus to the end of endoscopic ligation. Length of hospital stay The length of hospital stay was defined as the number of days from the day of surgery until discharge. Statistical analysis Statistical analysis was performed using SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Kolmogorov–Smirnov normality test was conducted on continuous variables in each group, and measurement data that met normal distribution are expressed as “x ± s”. Normally distributed measurement data were reported as M (P25, 75), and the rank sum test was used for comparison between the two groups. Count data are presented as rates, and between-group comparisons were performed using the chi-square test. Statistical significance was set at P < 0.05. RESULTS General information Table 1 summarizes the baseline characteristics of the patients in the MMH and ESHB groups. No significant differences in the general data were observed between the two groups ( P > 0.05). Table 1 Baseline characteristics of the two groups Groups ESHB group ( n = 65) MMH group ( n = 65) t/z/x² P -value Sex, n Male 29 32 0.278 0.598 Female 36 33 Age, years (x ± s) 48.40 ± 11.35 44.66 ± 10.99 1.907 0.059 Duration of mixed hemorrhoids, years [M (P25, 75)] 5 (2–10) 7 (3–10) -1.231 0.218 Classification of internal hemorrhoids, n Grade III 52 54 0.205 0.651 Grade IV 13 11 Appearance of external hemorrhoids, n Varicose 21 22 0.035 0.852 Connective tissue 44 43 Comparison of the efficacy between the two intervention groups The total effective rate was 100% in both groups; however, the difference was not statistically significant ( P > 0.05) (Table 2 ). Table 2 Comparison of therapeutic effect between the two groups Groups Cure Effective Ineffective Total effective rate ESHB group ( n = 65) 43 (66.15%) 22 (33.85%) 0 (0.00) 65 (100%) MMH group ( n = 65) 47 (72.31%) 18 (27.69%) 0 (0.00) 65 (100%) x² 0.578 P 0.447 Comparison of the operative time and length of hospital stay Operative time and length of hospital stay were significantly shorter in the ESHB group than in the MMH group ( P < 0.01). The length of hospital stay for 36 patients (55.38%) in the ESHB group was 1 day. Postoperative VAS score and incidence of urinary retention were significantly lower in the ESHB group than in the MMH group ( P < 0.01). One case of massive postoperative bleeding occurred in each group, which stopped after surgical suturing or endoscopic clip closure (Table 3 ). Table 3 Comparison of treatment-related indicators between the two groups Groups Operative time, minutes [M (P25, 75)] Length of hospital stay, days [M (P25, 75)] Postoperative VAS score Postoperative bleeding Postoperative urine retention ESHB group ( n = 65) 6 (6.0–8.0) 1 (1–3) 3 (2.0–4.0) 1 (1.54%) 0 (0%) MMH group ( n = 65) 30 (25–32) 7 (7–10) 5 (4.0–6.0) 1 (1.54%) 19 (29.23%) z/x² -9.913 -9.575 -7.640 0.000 22.252 P < 0.01 < 0.01 < 0.01 1.000 < 0.01 DISCUSSION The anal cushion is a normal anatomical structure composed of blood vessels, smooth muscles, and connective tissues, and is located in the submucosal tissue at the end of the anal canal and rectum. The “three lines and two zones” structure of the anal canal can be observed through endoscopy. The three lines are the anal, dentate, and anal verge lines, and the two zones are the columnae and anal pecten areas. A broadly defined anal cushion should include the overall structure of the end of the rectum (upper), columnae anales area (middle), and anal pecten area (lower) [7]. Nevertheless, no clear conclusion regarding the pathogenesis of hemorrhoids has been established. However, the two generally believed hypotheses are that (i) the anal cushion has weakened and (ii) varicose veins have weakened [8]. The “anal cushion weakening” theory emphasizes changes in anatomical structure, whereas the “varicose vein weakening” theory emphasizes changes in blood flow. Numerous studies have shown that the pathogenesis of hemorrhoids is the weakening of the lower anal cushion under the influence of various factors [7, 9, 10]: the pressure of the three terminal branches of the inflow of the superior rectal artery increases, and the outflow of the superior, middle, and inferior rectal veins decreases, leading to the dilation of the vascular plexus of the anal-cushion arterial-venular anastomosis, eventually resulting in the formation of hemorrhoids. Based on these theories, effective reduction of anal cushion weakening and protection of the integrity of the anal cushion structure and function are of great importance in the treatment of hemorrhoids [11]. Furthermore, endoscopy plays an important role in the diagnosis and treatment of hemorrhoids. The anorectal and dentate lines can be accurately identified using the endoscope in a straight position with the assistance of the cap as well as in the retroflexed position. Varicose and connective tissue external hemorrhoids were observed below the dentate line. Different degrees of prolapse of internal and external hemorrhoids can be determined by the appearance of the anus [12]. Currently, MMH is the standard and commonly used treatment for mixed hemorrhoids, and can remove most internal and external hemorrhoids with a definite curative effect and low recurrence rate [13, 14]. However, if the surgical resection wound is large, postoperative pain is serious, and complications, such as bleeding, urinary retention, and anal stenosis, can occur. Rubber band ligation blocks the blood supply to hemorrhoids by ligating the base of the internal hemorrhoids with a band, causing atrophy and necrosis of the hemorrhoids [15, 16]. Although this method is effective, safe, and simple, band ligation at the base of internal hemorrhoids may destroy the structure and function of the anal pad. After surgery, patients experience an obvious feeling of anal heaving, and complications, such as bleeding, pain, and prolapse, may occur. There are a few points for internal hemorrhoid ligation, generally 1–3 points, that have a limited effect on anal pad lifting and a high recurrence rate. The general treatment principle for hemorrhoids is to protect the anal pad, restore function, and improve symptoms; usually, no treatment is required for asymptomatic hemorrhoids [8]. Since June 2021, we have been conducting ESHB procedures to address mixed hemorrhoids with prolapse. Prolapse with hemorrhoid mucosal banding was more effective in reducing the anal pad and blocking the blood supply to the three terminal branches of the superior rectal artery. Anal pad reduction improved the reflux of the superior, middle, and inferior rectal veins, further reducing the dilation of the vascular plexus of the anal-pad arterial-venular anastomosis, and effectively improving the related symptoms of mixed hemorrhoids with prolapse. Regarding ESHB, we have accumulated some valuable insights. First, superior hemorrhoidal mucosa ligation proves more effective in realigning the anal pad, safeguarding its structural and functional integrity, and reducing postoperative anal pain and complications. Second, strategically performing ESHB at specific locations along the rectum—namely, the right anterior, right posterior, and left middle ends—can partially block blood supply to internal hemorrhoids via the upper rectal artery. For cases of mixed hemorrhoids with prolapse (degrees III and IV), targeting the oral side of the prior ligation point can further augment the effect of anal pad lifting. Third, conducting endoscopic observation in the retroflexed position aids in precise identification of the anorectal and dentate lines, thereby mitigating postoperative anal discomfort and complications. Direct endoscopic ligation of the superior hemorrhoidal mucosa ensures accurate targeting, without inadvertently engaging internal hemorrhoids and dentate line tissue. Lastly, external mixed hemorrhoids also benefit from the elevation following superior hemorrhoidal mucosa ligation. Any remaining external hemorrhoids and skin tags external to the anus can be either excised or ligated using an endoscopic high-frequency electric coil. While this research offers valuable insights into efficacy and safety of ESHB, some of its limitations are important to acknowledge. This was a single-center study that included a small number of cases and involved a short observation time. Further multicenter, long-term clinical research with big data, as well as follow-up observations, should be conducted to provide more evidence-based medical evidence for the clinical promotion and application of endoscopic mucosal ligation in hemorrhoids. In conclusion, ESHB for hemorrhoids can help effectively restore the downward displacement of the anal pad, protect the integrity of the structure and function of the anal pad, improve the symptoms of mixed hemorrhoids with prolapse, significantly shorten operative and hospitalization times, reduce the postoperative anal pain score, and decrease the incidence of postoperative urinary retention. ESHB is an effective, safe, simple, and minimally invasive treatment. Declarations Acknowledgments: We thank Elsevier Language Editing Services for editing a draft of this manuscript. Funding information: None. Conflict of interest: Authors declare no conflict of interests for this article. Ethics statement Approval of the research protocol by an Institutional Review Board: This retrospective cohort study was approved by the Medical Ethics Committee of People’s Hospital of Qiandongnan Miao and Dong Autonomous Prefecture (approval no.: QDNYYEC2021006; approval date: March 15, 2021) and has been performed in accordance with 1964 Declaration of Helsinki. Informed consent: All patients signed informed consent. Registry and the registration no. of the study/trial: The clinical trial registration was completed (registration no.: NCT06250140; registration date: January 31, 2024). Data sharing and data accessibility: The deidentified participant data and their postoperative feedback details can be provided if other researchers contact our corresponding author through email any time after the article be published. Author contributions: Xiu-jiang Huang and Wen Xu drafted the manuscript; Hao Lin, Ping Jiang, and Hong-jing Yang collected the data; Li-juan Chen, Kai-xi Yang, and Yu-ji Huang analyzed the data; Ying Zhu and Shou-jiang Tang designed the study. All authors read and approved the final manuscript. References Aibuedefe B, Kling SM, Philp MM, Ross HM and Poggio JL (2021) An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int. J. Colorectal Dis. 36 (9): 2041–2049. https://doi.org/10.1007/s00384-021-03953-3 Lohsiriwat V, Sheikh P, Bandolon R, Ren DL, Roslani AC, Schaible K, Freitag A, Martin M, Yaltirik P and Godeberge P (2023) Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review. Adv. Ther. 40 (1): 117–132. https://doi.org/10.1007/s12325-022-02351-7 Long Q, Wen Y and Li J (2023) Milligan-Morgan hemorrhoidectomy combined with non-doppler hemorrhoidal artery ligation for the treatment of grade III/IV hemorrhoids: a single centre retrospective study. BMC Gastroenterol. 23 (1): 293. https://doi.org/10.1186/s12876-023-02933-x Davis BR, Lee-Kong SA, Migaly J, Feingold DL and Steele SR (2018) The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 61 (3): 284–292. https://doi.org/10.1097/dcr.0000000000001030 Xu W, Xia G, Li L, Cao G, Yan X, Dong L and Zhu Y (2024) Evaluation of a novel disposable endoscope for retroflexed endoscopic rubber band ligation of internal hemorrhoids: a randomized pilot study. Postgrad. Med. J. https://doi.org/10.1093/postmj/qgae013 Xu W, Xia G, Dong L and Zhu Y (2024) Effect of lidocaine on postoperative analgesia of endoscopic rubber band ligation combined with injection sclerotherapy for treatment of internal hemorrhoids: A retrospective study (with video). Arab J Gastroenterol. https://doi.org/10.1016/j.ajg.2024.01.007 Gibbons CP, Read NW and Trowbridge EA (1986) Anal cushions. Lancet 2 (8497): 42. https://doi.org/10.1016/s0140-6736(86)92586-9 Lohsiriwat V (2012) Hemorrhoids: from basic pathophysiology to clinical management. World J. Gastroenterol. 18 (17): 2009-17. https://doi.org/10.3748/wjg.v18.i17.2009 T Yamana (2017) Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids. J Anus Rectum Colon 1 (3): 89–99. https://doi.org/10.23922/jarc.2017-018 Brown S, Girling C, Thapa Magar H, Chaudry A, Bhatti B, Sayers A and Hind D (2022) Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff. Colorectal Dis 24 (6): 764–772. https://doi.org/10.1111/codi.16078 Hulme-Moir M and Bartolo DC (2001) Hemorrhoids. Gastroenterol. Clin. North Am. 30 (1): 183 − 97. https://doi.org/10.1016/s0889-8553(05)70173-4 Fukuda A, Kajiyama T, Kishimoto H, Arakawa H, Someda H, Sakai M, Seno H and Chiba T (2005) Colonoscopic classification of internal hemorrhoids: usefulness in endoscopic band ligation. J Gastroenterol Hepatol 20 (1): 46–50. https://doi.org/10.1111/j.1440-1746.2004.03536.x NA Medina-Gallardo, X De Castro, E De Caralt-Mestres, Y Curbelo-Peña, A Dardano-Berriel, J Serrat Puyol, P Roura-Poch and H Vallverdu-Cartie (2022) Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial. Dis Colon Rectum 65 (8): 1034–1041. https://doi.org/10.1097/dcr.0000000000002250 KI Khan, M Akmal, A Waqas and S Mahmood (2014) Role of prophylactic antibiotics in Milligan Morgan hemorrhoidectomy - a randomized control trial. Int J Surg 12 (8): 868 − 71. https://doi.org/10.1016/j.ijsu.2014.06.005 FH Lew and LD Ailabouni (2023) Rubber Band Ligation of Internal Hemorrhoids. Dis Colon Rectum 66 (9): e950. https://doi.org/10.1097/dcr.0000000000002578 P Pastor Peinado, J Ocaña, P Abadía Barno, A Ballestero Pérez, JD Pina Hernández, G Rodríguez Velasco, I Moreno Montes, E Mendía Conde, E Tobaruela de Blas, JM Fernández Cebrián, J Die Trill and JC García Pérez (2023) Quality of life and outcomes after rubber band ligation for haemorrhoidal disease. Langenbecks Arch Surg 408 (1): 243. https://doi.org/10.1007/s00423-023-02990-6 Additional Declarations No competing interests reported. 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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-4534422","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317970048,"identity":"2ae7d2b9-2fe1-4a64-b27c-cdd239915504","order_by":0,"name":"Xiu-jiang Huang","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Xiu-jiang","middleName":"","lastName":"Huang","suffix":""},{"id":317970049,"identity":"2eeae3b0-8a44-4ea9-8b10-49ee29144069","order_by":1,"name":"Wen Xu","email":"","orcid":"","institution":"Southern Medical University Shenzhen Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Xu","suffix":""},{"id":317970050,"identity":"9c3dc066-aeb7-4e25-8c3e-6bcebc60ed39","order_by":2,"name":"Hao Lin","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Lin","suffix":""},{"id":317970051,"identity":"20556f21-de77-420c-a2a4-4c9cdafd9c2d","order_by":3,"name":"Ping Jiang","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Ping","middleName":"","lastName":"Jiang","suffix":""},{"id":317970052,"identity":"591f0e20-158b-41a1-8599-5eeb9e8f8d31","order_by":4,"name":"Hong-jing Yang","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Hong-jing","middleName":"","lastName":"Yang","suffix":""},{"id":317970053,"identity":"8656b892-107b-4865-a2d1-91bc75375fb4","order_by":5,"name":"Li-juan Chen","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Li-juan","middleName":"","lastName":"Chen","suffix":""},{"id":317970054,"identity":"92de90e9-11d2-40ec-a2a5-a63ce77fe813","order_by":6,"name":"Kai-xi Yang","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Kai-xi","middleName":"","lastName":"Yang","suffix":""},{"id":317970055,"identity":"db4e5ae6-6037-4e90-87d3-f1e581fa42da","order_by":7,"name":"Yu-ji Huang","email":"","orcid":"","institution":"People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Yu-ji","middleName":"","lastName":"Huang","suffix":""},{"id":317970056,"identity":"a485bcbf-8246-4e13-844d-b3c3a337cb56","order_by":8,"name":"Ying Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCSBOYGDg4YdwmYnXIiPZQJIWILAxOECsFvnZPWYSD3fU8hifP50mwVBhndjAfvYAXi2Mc86YSSSeOc5jdiN3mwTDmfTEBp68BLxamCVygFrajgG18G6TYGw7nNggwWOAVwsbTItx/1mgln9EaOGBaKkBKgM6jLGBCC0SEmnFFoltB3gkbuRutkg4lm7cxpODX4v8jOSNN3+21dnz95/deONDjbVsP/sZ/FqAgAUYNYchzASQ7wipBwLmDwwMdUSoGwWjYBSMghELAGZDQDvTw3QcAAAAAElFTkSuQmCC","orcid":"","institution":"Southern Medical University Shenzhen Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhu","suffix":""},{"id":317970057,"identity":"58c84a8d-3c25-4fa0-bdbc-2f7fb70ba1f0","order_by":9,"name":"Shou-jiang Tang","email":"","orcid":"","institution":"University of Mississippi Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Shou-jiang","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2024-06-05 13:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4534422/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4534422/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59283351,"identity":"4cf5259d-400f-467b-90fc-af926b0c7903","added_by":"auto","created_at":"2024-06-28 16:00:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1829701,"visible":true,"origin":"","legend":"\u003cp\u003eEndoscopic findings of internal hemorrhoids\u003c/p\u003e\n\u003cp\u003e(A) The anorectal line is indicated by arrows. (B) The dentate line is indicated by arrows. (C) Localization of the internal hemorrhoids using a retroflexed endoscope. ▲: Right posterior position; ★: right anterior position; ◆: left side position\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4534422/v1/94511698aba4d9b5627afa03.jpg"},{"id":59283349,"identity":"a9089c28-2bff-49f4-84ad-25cdb8154e30","added_by":"auto","created_at":"2024-06-28 16:00:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1702369,"visible":true,"origin":"","legend":"\u003cp\u003eEndoscopic manifestations of hemorrhoids\u003c/p\u003e\n\u003cp\u003e(A) Swollen internal hemorrhoids with hematocystic spots were observed using a retroflexed endoscope. (B) Internal hemorrhoids with partial prolapse. (C) Mixed hemorrhoids with circumferential prolapse\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4534422/v1/2e6cbc12374d4bca15bf0f3e.jpg"},{"id":59283350,"identity":"a9c9d41d-cd82-48b8-9089-2389a97bb2df","added_by":"auto","created_at":"2024-06-28 16:00:05","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2504470,"visible":true,"origin":"","legend":"\u003cp\u003eESHB for mixed hemorrhoids with prolapse\u003c/p\u003e\n\u003cp\u003e(A) Anal appearance of mixed hemorrhoids with varicose and connective tissue external hemorrhoids. (B) Swollen internal hemorrhoids with hematocystic spots were observed using an endoscope. (C) An endoscopic cap was used to observe the internal hemorrhoids and the dentate line. (D) The mucosa of hemorrhoids was ligated at six points in the direct position. (E) Appearance of the anal canal was observed using a retroflexed endoscope. (F) Appearance of the anus after ESHB with prolapse relief.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4534422/v1/5549734f9fa6d6667f78fd48.jpg"},{"id":66434504,"identity":"afcb49c7-5f26-4667-a9e4-444ec51aec0b","added_by":"auto","created_at":"2024-10-11 22:46:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":32058374,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4534422/v1/a7093ddb-d0e6-470c-8cd2-8bd9ea9b56e9.pdf"},{"id":59283352,"identity":"bd6530f2-dc72-4fb3-8e34-2f7f9b842cd5","added_by":"auto","created_at":"2024-06-28 16:00:07","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":106880655,"visible":true,"origin":"","legend":"","description":"","filename":"videowithnarration.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4534422/v1/6110caca99175438b4cba77b.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy and Safety of Endoscopic Super-Hemorrhoidal Banding for Mixed Hemorrhoids with Prolapse","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHemorrhoids can be classified as internal, external, or mixed. Mixed hemorrhoids form as a result of the fusion of internal and external hemorrhoids through the vascular plexus [1]. Mixed hemorrhoids with prolapse are often accompanied by symptoms such as bleeding, pain, swelling, and itching [2], which adversely affect patients\u0026rsquo; quality of life and are difficult to relieve with conservative treatment. Most symptomatic mixed hemorrhoids require surgical treatment, with Milligan\u0026ndash;Morgan hemorrhoidectomy (MMH) being the most common procedure. However, MMH has disadvantages and is associated with difficulties in achieving satisfactory clinical outcomes [3]. Strategies to further improve the therapeutic effect, reduce postoperative anal pain, and decrease the incidence of complications are urgent issues that need to be addressed. Among the minimally invasive treatments being developed, endoscopic diagnosis and treatment of hemorrhoids has become prevalent; this treatment is considered effective, safe, and simple.\u003c/p\u003e \u003cp\u003eThis study aimed to explore the effectiveness and safety of endoscopic super-hemorrhoidal banding (ESHB) by retrospectively analyzing patients with mixed hemorrhoids and prolapse who underwent ESHB or MMH between June 2021 and June 2023 at our center.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eThe clinical data of 142 patients with mixed hemorrhoids and prolapse treated at the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture from June 2021 to June 2023 were collected. The inclusion criteria were as follows: (i) a diagnosis of mixed hemorrhoids that met the relevant criteria of the American Society of Colorectal Surgeons\u0026rsquo; 2018 Clinical Practice Guidelines for the Management of Hemorrhoids (the grade of internal hemorrhoids in patients with mixed hemorrhoids and prolapse was grade III or IV) [4]; (ii) external hemorrhoids manifesting as either connective-tissue external hemorrhoids or varicose external hemorrhoids; and (iii) age between 18 and 75 years. The exclusion criteria were as follows: (i) thrombotic external hemorrhoids, anal fissure, perianal abscess, anal fistula, and malignant anal tumor; (ii) previous history of lower rectal or anal surgery; (iii) immunodeficiency or inflammatory bowel disease; (iv) severe diseases in other organs or systems and coagulopathy; and (v) puerperal women. Following the inclusion and exclusion criteria, initially, 140 patients were enrolled, with 10 subsequently excluded due to loss to follow-up. Among them, 65 patients were allocated to the MMH treatment group, while 65 were assigned to the ESHB treatment group based on their chosen treatment modality. This retrospective cohort study was approved by the Medical Ethics Committee of the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture (Approval No. : QDNYYEC2021006; approval date: March 15, 2021), conducted in accordance with the 1964 Declaration of Helsinki. Furthermore, clinical trial registration was completed (registration no. : NCT06250140; registration date: January 31, 2024), and written informed consent was obtained from all patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTherapeutic methods\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eMMH\u003c/h2\u003e \u003cp\u003eThe MMH was performed by an anorectal surgeon. Intestinal cleansing and complete colonoscopy (EG29-i10, PENTAX Corp., Tokyo, Japan) were performed preoperatively. During surgery, the patient received epidural anesthesia and was placed in the lithotomy position. Routine disinfection and draping were performed. The skin of the hemorrhoid mass was clamped with tissue forceps and the internal hemorrhoids were exposed by traction. A V-shaped incision was made on both sides of the skin at the base of the hemorrhoid mass and detached upward, stripping the subcutaneous varicose plexus or connective tissue 5\u0026ndash;10 mm above the dentate line. After exposing the base of the hemorrhoid mass, a figure-of-eight suture with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable thread was performed, and the ligated tissue was removed. The same procedure was conducted for other hemorrhoids. An exhaust pipe, Vaseline gauze, and gelatin sponge were placed inside the anus, wrapped with sterile gauze, externally pressurized with a gauze block, and secured using a T-band.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eESHB\u003c/h3\u003e\n\u003cp\u003eESHB was performed by an experienced endoscopist (XJ Huang). Preoperative colon preparation and complete colonoscopy were performed. During surgery, the patient received intravenous general anesthesia and was placed in the left lateral decubitus position. The prolapsed hemorrhoids were removed by hand and a 6-row ligation device (MBL-6-F; Cook Medical, Bloomington, IN, USA) was installed at the front end of the endoscope (EG29-i10; PENTAX Corp.). After attaching the multiple-band ligation device to the endoscope, the super-hemorrhoidal mucosa was completely suctioned into the ligating device, and an elastic band was released [5]. First, three positions, namely, right anterior, right posterior, and left median, were selected for mucosal ligation. Subsequently, three ligation positions were crossed on the oral side, and a total of six ligation positions were used. After withdrawing the endoscope from the anus, the residual external hemorrhoids and skin tags were treated with endoscopic ligation.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcome assessments\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eEfficacy evaluation\u003c/h2\u003e \u003cp\u003eClinical efficacy was evaluated 6 months after surgery. The evaluation criteria were as follows:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCured: resolution of prolapse of the internal hemorrhoids, bleeding symptoms, and pain or mass in the anus;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEffective: reduced bleeding symptoms and anal mass; and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIneffective: hematochezia and prolapse symptoms were not alleviated or were aggravated.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe total effective rate was calculated as (cure\u0026thinsp;+\u0026thinsp;effective) cases/total cases \u0026times; 100.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSafety evaluation\u003c/h2\u003e \u003cp\u003eAnal pain was quantified using a 0- to 10-point visual analog scale (VAS), in which a score of 0 indicates no pain, 1\u0026ndash;3 points indicates mild pain, 4\u0026ndash;6 points indicates moderate pain, 7\u0026ndash;9 indicates severe pain, and 10 indicates excruciating pain [6]. Patients with urinary retention were referred to those who could not discharge urine, thereby necessitating urgent catheterization. Postoperative bleeding was defined as a large amount of bleeding that required surgical sutures or endoscopic hemostasis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOperative time\u003c/h2\u003e \u003cp\u003eThe operative time in the MMH group was defined as the time from satisfactory anesthesia to the end of the operation. The operative time in the ESHB group was defined as the time from endoscopic insertion into the anus to the end of endoscopic ligation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLength of hospital stay\u003c/h2\u003e \u003cp\u003eThe length of hospital stay was defined as the number of days from the day of surgery until discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Kolmogorov\u0026ndash;Smirnov normality test was conducted on continuous variables in each group, and measurement data that met normal distribution are expressed as \u0026ldquo;x\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u0026rdquo;. Normally distributed measurement data were reported as M (P25, 75), and the rank sum test was used for comparison between the two groups. Count data are presented as rates, and between-group comparisons were performed using the chi-square test. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the baseline characteristics of the patients in the MMH and ESHB groups. No significant differences in the general data were observed between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eBaseline characteristics of the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eESHB group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMMH group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et/z/x\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge, years (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.40\u0026thinsp;\u0026plusmn;\u0026thinsp;11.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.907\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDuration of mixed hemorrhoids, years [M (P25, 75)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (3\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClassification of internal hemorrhoids, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.651\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAppearance of external hemorrhoids, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaricose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.852\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConnective tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the efficacy between the two intervention groups\u003c/h2\u003e \u003cp\u003eThe total effective rate was 100% in both groups; however, the difference was not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eComparison of therapeutic effect between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIneffective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eTotal effective rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESHB group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (66.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (33.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e65 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMH group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (72.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (27.69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e65 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ex\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the operative time and length of hospital stay\u003c/h2\u003e \u003cp\u003eOperative time and length of hospital stay were significantly shorter in the ESHB group than in the MMH group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The length of hospital stay for 36 patients (55.38%) in the ESHB group was 1 day. Postoperative VAS score and incidence of urinary retention were significantly lower in the ESHB group than in the MMH group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). One case of massive postoperative bleeding occurred in each group, which stopped after surgical suturing or endoscopic clip closure (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of treatment-related indicators between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperative time, minutes [M (P25, 75)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLength of hospital stay, days [M (P25, 75)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostoperative VAS score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostoperative bleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperative urine retention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESHB group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.0\u0026ndash;4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMH group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (25\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4.0\u0026ndash;6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (29.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ez/x\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-9.913\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9.575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe anal cushion is a normal anatomical structure composed of blood vessels, smooth muscles, and connective tissues, and is located in the submucosal tissue at the end of the anal canal and rectum. The \u0026ldquo;three lines and two zones\u0026rdquo; structure of the anal canal can be observed through endoscopy. The three lines are the anal, dentate, and anal verge lines, and the two zones are the columnae and anal pecten areas. A broadly defined anal cushion should include the overall structure of the end of the rectum (upper), columnae anales area (middle), and anal pecten area (lower) [7]. Nevertheless, no clear conclusion regarding the pathogenesis of hemorrhoids has been established. However, the two generally believed hypotheses are that (i) the anal cushion has weakened and (ii) varicose veins have weakened [8]. The \u0026ldquo;anal cushion weakening\u0026rdquo; theory emphasizes changes in anatomical structure, whereas the \u0026ldquo;varicose vein weakening\u0026rdquo; theory emphasizes changes in blood flow. Numerous studies have shown that the pathogenesis of hemorrhoids is the weakening of the lower anal cushion under the influence of various factors [7, 9, 10]: the pressure of the three terminal branches of the inflow of the superior rectal artery increases, and the outflow of the superior, middle, and inferior rectal veins decreases, leading to the dilation of the vascular plexus of the anal-cushion arterial-venular anastomosis, eventually resulting in the formation of hemorrhoids. Based on these theories, effective reduction of anal cushion weakening and protection of the integrity of the anal cushion structure and function are of great importance in the treatment of hemorrhoids [11]. Furthermore, endoscopy plays an important role in the diagnosis and treatment of hemorrhoids. The anorectal and dentate lines can be accurately identified using the endoscope in a straight position with the assistance of the cap as well as in the retroflexed position. Varicose and connective tissue external hemorrhoids were observed below the dentate line. Different degrees of prolapse of internal and external hemorrhoids can be determined by the appearance of the anus [12].\u003c/p\u003e \u003cp\u003eCurrently, MMH is the standard and commonly used treatment for mixed hemorrhoids, and can remove most internal and external hemorrhoids with a definite curative effect and low recurrence rate [13, 14]. However, if the surgical resection wound is large, postoperative pain is serious, and complications, such as bleeding, urinary retention, and anal stenosis, can occur. Rubber band ligation blocks the blood supply to hemorrhoids by ligating the base of the internal hemorrhoids with a band, causing atrophy and necrosis of the hemorrhoids [15, 16]. Although this method is effective, safe, and simple, band ligation at the base of internal hemorrhoids may destroy the structure and function of the anal pad. After surgery, patients experience an obvious feeling of anal heaving, and complications, such as bleeding, pain, and prolapse, may occur. There are a few points for internal hemorrhoid ligation, generally 1\u0026ndash;3 points, that have a limited effect on anal pad lifting and a high recurrence rate.\u003c/p\u003e \u003cp\u003eThe general treatment principle for hemorrhoids is to protect the anal pad, restore function, and improve symptoms; usually, no treatment is required for asymptomatic hemorrhoids [8]. Since June 2021, we have been conducting ESHB procedures to address mixed hemorrhoids with prolapse. Prolapse with hemorrhoid mucosal banding was more effective in reducing the anal pad and blocking the blood supply to the three terminal branches of the superior rectal artery. Anal pad reduction improved the reflux of the superior, middle, and inferior rectal veins, further reducing the dilation of the vascular plexus of the anal-pad arterial-venular anastomosis, and effectively improving the related symptoms of mixed hemorrhoids with prolapse. Regarding ESHB, we have accumulated some valuable insights. First, superior hemorrhoidal mucosa ligation proves more effective in realigning the anal pad, safeguarding its structural and functional integrity, and reducing postoperative anal pain and complications. Second, strategically performing ESHB at specific locations along the rectum\u0026mdash;namely, the right anterior, right posterior, and left middle ends\u0026mdash;can partially block blood supply to internal hemorrhoids via the upper rectal artery. For cases of mixed hemorrhoids with prolapse (degrees III and IV), targeting the oral side of the prior ligation point can further augment the effect of anal pad lifting. Third, conducting endoscopic observation in the retroflexed position aids in precise identification of the anorectal and dentate lines, thereby mitigating postoperative anal discomfort and complications. Direct endoscopic ligation of the superior hemorrhoidal mucosa ensures accurate targeting, without inadvertently engaging internal hemorrhoids and dentate line tissue. Lastly, external mixed hemorrhoids also benefit from the elevation following superior hemorrhoidal mucosa ligation. Any remaining external hemorrhoids and skin tags external to the anus can be either excised or ligated using an endoscopic high-frequency electric coil.\u003c/p\u003e \u003cp\u003eWhile this research offers valuable insights into efficacy and safety of ESHB, some of its limitations are important to acknowledge. This was a single-center study that included a small number of cases and involved a short observation time. Further multicenter, long-term clinical research with big data, as well as follow-up observations, should be conducted to provide more evidence-based medical evidence for the clinical promotion and application of endoscopic mucosal ligation in hemorrhoids.\u003c/p\u003e \u003cp\u003eIn conclusion, ESHB for hemorrhoids can help effectively restore the downward displacement of the anal pad, protect the integrity of the structure and function of the anal pad, improve the symptoms of mixed hemorrhoids with prolapse, significantly shorten operative and hospitalization times, reduce the postoperative anal pain score, and decrease the incidence of postoperative urinary retention. ESHB is an effective, safe, simple, and minimally invasive treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe thank Elsevier Language Editing Services for editing a draft of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAuthors declare no conflict of interests for this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eApproval of the research protocol by an Institutional Review Board:\u0026nbsp;\u003c/strong\u003eThis retrospective cohort study was approved by the Medical Ethics Committee of People\u0026rsquo;s Hospital of Qiandongnan Miao and Dong Autonomous Prefecture (approval no.: QDNYYEC2021006; approval date: March 15, 2021) and has been performed in accordance with 1964 Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e All patients signed informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistry and the registration no. of the study/trial:\u0026nbsp;\u003c/strong\u003eThe clinical trial registration was completed (registration no.: NCT06250140; registration date: January 31, 2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing and data accessibility:\u003c/strong\u003e The deidentified participant data and their postoperative feedback details can be provided if other researchers contact our corresponding author through email any time after the article be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eXiu-jiang Huang and Wen Xu drafted the manuscript; Hao Lin, Ping Jiang, and Hong-jing Yang collected the data; Li-juan Chen, Kai-xi Yang, and Yu-ji Huang analyzed the data; Ying Zhu and Shou-jiang Tang designed the study. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eAibuedefe B, Kling SM, Philp MM, Ross HM and Poggio JL (2021) An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int. J. Colorectal Dis. 36 (9): 2041\u0026ndash;2049. https://doi.org/10.1007/s00384-021-03953-3\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLohsiriwat V, Sheikh P, Bandolon R, Ren DL, Roslani AC, Schaible K, Freitag A, Martin M, Yaltirik P and Godeberge P (2023) Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review. Adv. Ther. 40 (1): 117\u0026ndash;132. https://doi.org/10.1007/s12325-022-02351-7\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLong Q, Wen Y and Li J (2023) Milligan-Morgan hemorrhoidectomy combined with non-doppler hemorrhoidal artery ligation for the treatment of grade III/IV hemorrhoids: a single centre retrospective study. BMC Gastroenterol. 23 (1): 293. https://doi.org/10.1186/s12876-023-02933-x\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDavis BR, Lee-Kong SA, Migaly J, Feingold DL and Steele SR (2018) The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 61 (3): 284\u0026ndash;292. https://doi.org/10.1097/dcr.0000000000001030\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXu W, Xia G, Li L, Cao G, Yan X, Dong L and Zhu Y (2024) Evaluation of a novel disposable endoscope for retroflexed endoscopic rubber band ligation of internal hemorrhoids: a randomized pilot study. Postgrad. Med. J. https://doi.org/10.1093/postmj/qgae013\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXu W, Xia G, Dong L and Zhu Y (2024) Effect of lidocaine on postoperative analgesia of endoscopic rubber band ligation combined with injection sclerotherapy for treatment of internal hemorrhoids: A retrospective study (with video). Arab J Gastroenterol. https://doi.org/10.1016/j.ajg.2024.01.007\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGibbons CP, Read NW and Trowbridge EA (1986) Anal cushions. Lancet 2 (8497): 42. https://doi.org/10.1016/s0140-6736(86)92586-9\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLohsiriwat V (2012) Hemorrhoids: from basic pathophysiology to clinical management. World J. Gastroenterol. 18 (17): 2009-17. https://doi.org/10.3748/wjg.v18.i17.2009\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eT Yamana (2017) Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids. J Anus Rectum Colon 1 (3): 89\u0026ndash;99. https://doi.org/10.23922/jarc.2017-018\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBrown S, Girling C, Thapa Magar H, Chaudry A, Bhatti B, Sayers A and Hind D (2022) Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff. Colorectal Dis 24 (6): 764\u0026ndash;772. https://doi.org/10.1111/codi.16078\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHulme-Moir M and Bartolo DC (2001) Hemorrhoids. Gastroenterol. Clin. North Am. 30 (1): 183\u0026thinsp;\u0026minus;\u0026thinsp;97. https://doi.org/10.1016/s0889-8553(05)70173-4\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFukuda A, Kajiyama T, Kishimoto H, Arakawa H, Someda H, Sakai M, Seno H and Chiba T (2005) Colonoscopic classification of internal hemorrhoids: usefulness in endoscopic band ligation. J Gastroenterol Hepatol 20 (1): 46\u0026ndash;50. https://doi.org/10.1111/j.1440-1746.2004.03536.x\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNA Medina-Gallardo, X De Castro, E De Caralt-Mestres, Y Curbelo-Pe\u0026ntilde;a, A Dardano-Berriel, J Serrat Puyol, P Roura-Poch and H Vallverdu-Cartie (2022) Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial. Dis Colon Rectum 65 (8): 1034\u0026ndash;1041. https://doi.org/10.1097/dcr.0000000000002250\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKI Khan, M Akmal, A Waqas and S Mahmood (2014) Role of prophylactic antibiotics in Milligan Morgan hemorrhoidectomy - a randomized control trial. Int J Surg 12 (8): 868\u0026thinsp;\u0026minus;\u0026thinsp;71. https://doi.org/10.1016/j.ijsu.2014.06.005\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFH Lew and LD Ailabouni (2023) Rubber Band Ligation of Internal Hemorrhoids. Dis Colon Rectum 66 (9): e950. https://doi.org/10.1097/dcr.0000000000002578\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eP Pastor Peinado, J Oca\u0026ntilde;a, P Abad\u0026iacute;a Barno, A Ballestero P\u0026eacute;rez, JD Pina Hern\u0026aacute;ndez, G Rodr\u0026iacute;guez Velasco, I Moreno Montes, E Mend\u0026iacute;a Conde, E Tobaruela de Blas, JM Fern\u0026aacute;ndez Cebri\u0026aacute;n, J Die Trill and JC Garc\u0026iacute;a P\u0026eacute;rez (2023) Quality of life and outcomes after rubber band ligation for haemorrhoidal disease. Langenbecks Arch Surg 408 (1): 243. https://doi.org/10.1007/s00423-023-02990-6\u003c/span\u003e\u003c/li\u003e\n\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":"Endoscopic super-hemorrhoidal banding, Endoscopy, Milligan-Morgan hemorrhoidectomy, Mixed hemorrhoids, Prolapse","lastPublishedDoi":"10.21203/rs.3.rs-4534422/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4534422/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTraditional miligan-organ hemorrhoidectomy (MMH) has disadvantages for mixed hemorrhoids with prolapse. Strategies to further improve the therapeutic effect, reduce postoperative anal pain, and decrease the complication rate are urgently required. We investigated the efficacy and safety of endoscopic superhemorrhoidal banding (ESHB) for mixed hemorrhoids with prolapse.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe clinical data of 130 consecutive patients with mixed hemorrhoids and prolapse at the People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture from June 2021 to June 2023 were retrospectively collected and analyzed. Sixty-five patients who underwent MMH and 65 who underwent ESHB were categorized into MMH and ESHB groups, respectively. The outcomes, length of the procedure, hospitalization time, postoperative pain (evaluated using the visual analog scale [VAS]), and incidence of urinary retention were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe efficacy was 100% in both groups, with no statistically significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Operation length and hospitalization time were significantly shorter in the ESHB group than in the MMH group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The VAS scores for postoperative pain and incidence of urinary pain were significantly lower in the ESHB group than in the MMH group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eESHB can effectively restore the weakened anal cushion and protect its structural and functional integrity, improve symptoms related to mixed hemorrhoids with prolapse, shorten operative time and hospital stay, and reduce the incidence of postoperative complications. It is a safe and simple minimally invasive endoscopic treatment with an efficacy similar to that of MMH.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003e: The clinical trial registration was completed (registration no.: NCT06250140; registration date: January 31, 2024).\u003c/p\u003e","manuscriptTitle":"Efficacy and Safety of Endoscopic Super-Hemorrhoidal Banding for Mixed Hemorrhoids with Prolapse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-28 16:00:00","doi":"10.21203/rs.3.rs-4534422/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":"56dce0d7-c294-47f9-bc8a-25cc93f884fc","owner":[],"postedDate":"June 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-11T22:38:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-28 16:00:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4534422","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4534422","identity":"rs-4534422","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}