Evaluation of short-term outcomes of Endoscopic Super-Hemorrhoidal Banding for mixed hemorrhoids with prolapsed internal hemorrhoids: a retrospective study

Abstract

Background

To evaluate the clinical efficacy and safety of Endoscopic Super-hemorrhoidal Banding (ESHB) in treating mixed hemorrhoids with Grade II-IV internal hemorrhoid prolapse as the main symptom.

Methods

A retrospective analysis was conducted on clinical data of patients with mixed hemorrhoids treated in our hospital from June 2021 to June 2024. They were divided into two groups: patients underwent Milligan-Morgan hemorrhoidectomy (MMH) as the control group, and patients underwent ESHB as the observation group. Treatment outcomes included efficacy measurement, operative time, hospital stay, postoperative anal pain scores, and incidence of complications like bleeding and urinary retention were compared.

Results

245 patients underwent Milligan-Morgan hemorrhoidectomy (MMH) and 235 patients underwent ESHB. The cure rates were 69.36% in the ESHB group and 72.65% in the MMH group, with no statistically significant difference between the two groups (P > 0.05). The observation group had significantly shorter operative time and hospital stay (P < 0.01), lower postoperative anal pain scores and incidence of urinary retention (P < 0.01). One patient in each group had severe postoperative bleeding, which stopped after surgical suture or endoscopic titanium clip closure.

Conclusion

Short-term follow-up indicates that ESHB can effectively reposition the prolapsed anal cushions, preserve the anatomical structure and functional integrity of the anal cushions, alleviate symptoms associated with mixed hemorrhoids primarily characterized by internal hemorrhoid prolapse, shorten both the operative time and hospital stay, and reduce patients’ postoperative anal pain scores as well as the incidence of postoperative complications. It is an effective, safe, and simple minimally invasive treatment method; however, its long-term efficacy still requires further validation.

Trial registration

This was a retrospective observational study. Trial registration was performed retrospectively (registration no.: NCT06250140; registration date: January 31, 2024).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-026-03744-z.

Introduction

Hemorrhoids can be classified into internal, external, and mixed types based on their location. Mixed hemorrhoids result from the fusion of internal hemorrhoids and corresponding external hemorrhoids through dense vascular plexuses, with those presenting internal hemorrhoid prolapse as the main symptom being relatively common clinically [1]. The anal cushion, a normal anatomical structure at the rectum’s terminal end beneath the anal canal mucosa, comprises vascular plexuses, smooth muscle, and connective tissue, aiding anal sphincter function and defecation regulation [2]. Using a retroflexed endoscope with a transparent cap, the “three lines and two zones” of the anal canal can be clearly seen. Theories of anal cushion prolapse and varicose veins are widely accepted as pathogenic mechanisms of hemorrhoidal disease [3]. We posit that overall pathological prolapse of the anal cushion is central, causing increased pressure in rectal artery branches, impaired venous return, and abnormal dilation, leading to hemorrhoids. The dentate line differentiates internal (above, with mucosal elevation) and external hemorrhoids (below, with varicose masses) [4]. Mixed hemorrhoids span both, often requiring surgical intervention as conservative treatments are often ineffective.

Patients often suffer from bleeding, pain, anal moisture, and pruritus [5], significantly affecting their quality of life. Conservative treatments are often ineffective, necessitating surgical intervention in most cases. Current common treatment methods include Milligan-Morgan hemorrhoidectomy (MMH), Procedure for Prolapse and Hemorrhoids (PPH), and Rubber Band Ligation (RBL), but these methods have varying degrees of limitations and are difficult to achieve satisfactory clinical outcomes [6]. Therefore, improving therapeutic efficacy, effectively alleviating postoperative anal pain, and reducing the incidence of complications have become urgent clinical issues. In recent years, with the expanded application of digestive endoscopy techniques in the diagnosis and treatment of hemorrhoids and the development of minimally invasive concepts, endoscopic treatment of hemorrhoids has emerged as a novel approach, gaining attention for its minimally invasive, effective, safe, and simple operation. This study aims to explore the efficacy and safety of a new endoscopic treatment technique, Endoscopic Super-Hemorrhoidal Banding (ESHB), in treating mixed hemorrhoids with internal hemorrhoid prolapse as the main symptom. To this end, we retrospectively analyzed clinical data of patients who underwent ESHB at our endoscopy center and MMH at our proctology department from June 2021 to June 2024, aiming to provide a more scientific and rational basis for clinical decision-making.

Patients and methods

Clinical data

This study collected case data of patients with mixed hemorrhoids presenting internal hemorrhoid prolapse as the main symptom who were treated at our hospital from June 2021 to June 2024. The patients received either ESHB or MMH treatment. The study protocol was approved by the Ethics Committee of Qiandongnan Miao and Dong Autonomous Prefecture People’s Hospital (Ethics Approval Number: 202106), and all patients signed informed consent forms. Additionally, the clinical trial registration was completed (registration no.: NCT06250140; registration date: January 31, 2024).

Inclusion criteria

Meeting the diagnostic criteria for mixed hemorrhoids outlined in the “Clinical Practice Guidelines for Hemorrhoid Management (2024)” by the American Society of Colorectal Surgeons (ASCRS) [7];

(2) The primary internal hemorrhoid component of the mixed hemorrhoids being grade II-IV, and the external hemorrhoid component primarily being varicose external hemorrhoids or skin tags at the anal verge; (3) Aged between 18 and 75 years old.

Exclusion criteria

(1) Grade I internal hemorrhoids; (2) The external hemorrhoid component of the mixed hemorrhoids being connective tissue external hemorrhoids or thrombotic external hemorrhoids; (3) Patients with concomitant anorectal diseases such as rectal prolapse, anal fissure, perianal abscess, anal fistula, or anal malignancies; (4) Patients with a history of previous low rectal or anal surgery; (5) Patients with concomitant immune or inflammatory diseases such as immunodeficiency disorders or inflammatory bowel disease; (6) Patients with severe diseases in other organs or systems, or with coagulation disorders; (7) Women in the puerperium.

Research methods

Surgical methods

All patients underwent standard bowel preparation and total colonoscopy (using the PENTAX EG29-i10 endoscope, Japan) to exclude organic diseases such as colorectal malignancies and inflammatory bowel disease [3]. The classification of hemorrhoids was based on clinical examination and patients’ symptoms [8]. The hemorrhoids were observed during endoscopic examination (Figs. 1 and 2).

Fig. 1.

Endoscopic findings of internal hemorrhoids. 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

Fig. 2.

Endoscopic manifestations of hemorrhoids. 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

1. MMH Group [9]: Experienced proctology physicians performed the procedure: lithotomy position, epidural anesthesia, disinfection, V-shaped incision, blunt dissection, “8”-shaped ligation, excision, repeated for other masses, and postoperative dressing.

2. ESHB Group: Performed by experienced attending physicians in digestive endoscopy. Patients were placed in the left lateral position and received intravenous general anesthesia. The surgeon first manually reduced the prolapsed internal hemorrhoids. A 6-shot ligation device (using the COOK MBL-6-F ligation device, USA) was attached to the tip of the endoscope, and the endoscope was adjusted to the forward-viewing mode. The cup of the ligation device was aligned with the rectal mucosa at the upper edge of the anorectal line. Suction was initiated to fully aspirate the mucosa into the cup until the endoscopic view showed a full-screen “red sign” (mucosa completely filling the cup). The ligation ring was released by rotating the handle of the ligation device, completing one ligation [10]. For grade II internal hemorrhoids, three basal ligation points were performed on the rectal mucosa above the hemorrhoids at the right anterior, right posterior, and left mid positions. For grade III and IV internal hemorrhoids, three additional cross-ligation points were added above the three basal points to enhance the effect of anal pad reduction (Fig. 3, Supplementary Material Video 1). After the surgery, the gas in the rectum was aspirated through the endoscope to alleviate discomfort such as abdominal distension. Patients were administered diclofenac sodium suppositories for anal analgesia.

Fig. 3.

ESHB for mixed hemorrhoids with prolapse. 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

Observation indicators and evaluation criteria

1. Efficacy Evaluation:

Clinical efficacy was assessed for all patients six months after the surgery. Based on the degree of symptom improvement, the therapeutic effects were categorized into three grades:

“Cure” was defined as the complete or near-complete disappearance of internal hemorrhoid prolapse symptoms (with spontaneous retraction), significant alleviation of hematochezia (a reduction of ≥ 80% compared to pre-surgery levels), and marked reduction in anal pain with minimal impact on daily life; “Effective” indicated an improvement of at least one grade in the degree of internal hemorrhoid prolapse, some relief of hematochezia (a reduction of 50–79% compared to pre-surgery levels), and a reduction in anal pain; “Ineffective” was characterized by no significant improvement (improvement < 50%) or worsening of internal hemorrhoid prolapse and hematochezia symptoms, as well as no relief or worsening of anal pain. The formula for calculating the total effective rate is as follows: Total Effective Rate (%) = (Number of Cure Cases + Number of Effective Cases) / Total Number of Cases × 100%. Recurrence was defined as the reoccurrence or worsening of original symptoms during the six-month follow-up period after surgery, the re-prolapse of hemorrhoidal masses detected through digital rectal examination or endoscopy, or the need for pharmacological treatment or additional medical intervention due to symptom recurrence. Treatment failure was defined as the absence of any improvement in the main symptoms one month after surgery, the occurrence of severe complications after surgery requiring urgent medical intervention or a change in the treatment plan, or the patient’s proactive request to switch treatment methods due to dissatisfaction with the therapeutic effect. The efficacy assessment was independently conducted by two anorectal surgeons with the title of attending physician who did not participate in the surgeries, based on the patients’ symptoms, physical signs, and examination results. In cases of disagreement, a consensus was reached through discussion. The assessment included symptom questionnaires, digital rectal examinations, and, when necessary, anoscopy or endoscopy.

• (2)Safety Evaluation:

Postoperative Anal Pain: The degree of postoperative anal pain was assessed using the Visual Analogue Scale (VAS). Trained nurses conducted the evaluations at 24 h, 48 h, 72 h, and 1 week postoperatively. The VAS scoring system employed a 0–10 scale, where 0 indicated no pain and 10 represented severe pain [11]. During the assessment, nurses explained the scoring criteria to the patients, who then marked their subjective pain perception on the scale. To minimize bias, the assessing nurses were not fully blinded but were unaware of the study hypothesis during data collection.

Postoperative Urinary Retention: The incidence of postoperative urinary retention was evaluated by recording the number of urinary retention cases occurring within 72 h after surgery. Urinary retention was defined as bladder distension with an inability to voluntarily void 6–8 h postoperatively, necessitating intervention such as induction or indwelling catheterization.

Postoperative Bleeding: The incidence of postoperative bleeding was assessed by documenting the number of significant bleeding cases occurring within 14 days after surgery. Significant postoperative bleeding was defined as the presence of active bleeding or accumulation of large blood clots, requiring clinical interventions such as surgical ligation for hemostasis or endoscopic hemostasis.

• (3)Surgical Indicators Evaluation:

Surgical Time: For the MMH group, timing started after satisfactory anesthesia until the end of surgery. For the ESHB group, timing started from the insertion of the endoscope into the anus until the completion of endoscopic ligation.

Hospital Stay: Defined as the number of days from the day of surgery to discharge. For day surgery patients, the hospital stay was recorded as 1 day.

Statistical methods

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 were expressed as “x ± s”. Non normal distribution data were reported as M (P25, 75), and the rank sum test was used for comparison between the two groups. Count data were presented as rates, and between-group comparisons were performed using the chi-square test. Statistical significance was set at P < 0.05. For binary outcomes, absolute risk reduction (ARR), number needed to treat (NNT), and 95% confidence intervals (CI) for proportions were calculated using the Wilson score method to supplement P-values and provide clinically meaningful effect estimates.

Results

General information

This study collected case data of 480 patients. Among them, 235 patients received ESHB, and 245 patients underwent MMH. There were no statistically significant differences in baseline data between the two groups (P > 0.05) (see Table 1).

Table 1.

Baseline characteristics of the two groups

Groups		ESHB group (n = 235)	MMH group (n = 245)		P-value
Sex, n (%)	Male	119 (50.64%)	141 (57.55%)	0.14
	Female	116 (49.36%)	104 (42.45%)
Age, years [M (P25, P75)]		47 (38, 54)	47 (37, 55)	0.83
Duration of mixed hemorrhoids, years [M (P25, P75)]		4 (2, 8)	3 (2, 5)	0.83
Classification of internal hemorrhoids, n	Grade II	161	170	0.90
	Grade III	67	64
	Grade IV	7	11

Comparison of cure rates and clinical outcomes between the two treatment groups

At the 6-month postoperative follow-up, the cure rate in the ESHB group was 69.36% (163/235) and in the MMH group was 72.65% (178/245), with no statistically significant difference between the two groups (P > 0.05). The proportion of patients with partial improvement (“effective”) was 30.64% (72/235) in the ESHB group and 27.35% (67/245) in the MMH group. No patient in either group was classified as “ineffective.” During the follow-up period, a small number of patients experienced symptom recurrence (3 cases in the ESHB group and 5 cases in the MMH group), with no statistically significant difference in recurrence rates between the two groups. No treatment failure cases were observed in either group. (Table 2)

Table 2.

Comparison of therapeutic effect between the two groups

Groups	Cure	Effective	Ineffective	Recurrence, n (%) [6-month]
ESHB group (n = 235)	163(69.36%)	72(30.64%)	0(0.00)	3 (1.28%)
MMH group (n = 245)	178(72.65%)	67(27.35%)	0(0.00)	5 (2.04%)

No statistically significant difference was observed in cure rates between the two groups (P > 0.05). Recurrence was defined as reoccurrence or worsening of symptoms, re-prolapse on examination, or need for additional intervention during the 6-month follow-up period. P-value for recurrence comparison: P = 0.72 (chi-square test)

Comparison of surgical treatment-related indicators between the two patient groups

The duration of surgery and hospital stay in the ESHB group were shorter than those in the MMH group, with a statistically significant difference (P < 0.01). In the ESHB group, 152 patients (64.68%) were scheduled for day surgery to complete their treatment. The postoperative anal pain severity score and the incidence of urinary retention in the ESHB group were significantly lower than those in the MMH group, with a statistically significant difference (P < 0.01). The urinary retention rate was 3.40% (8/235; 95% CI: 1.5%–6.6%) in the ESHB group versus 20.41% (50/245; 95% CI: 15.5%–26.0%) in the MMH group, yielding an absolute risk reduction (ARR) of 17.01% (95% CI: 11.8%–22.2%) and a number needed to treat (NNT) of 6 (95% CI: 5–9). There was one case of severe postoperative bleeding in each group, and the bleeding ceased after surgical suture ligation or endoscopic titanium clip closure, respectively (Table 3).

Table 3.

Comparison of treatment-related indicators between the two groups

	ESHB group (n = 235)	MMH group (n = 245)	z/x²	P
‌Operative time, minutes [M (P25, 75)]‌	6(5.0, 8.0)	25(22, 30)	245	<0.001
‌Length of hospital stay, days [M (P25, 75)]‌	1(1, 3)	7(5, 8)	733.5	<0.001
‌Postoperative VAS score‌	2(2.0, 3.0)	4(3.0, 5.0)	5540	<0.001
‌Postoperative bleeding‌	1(0.43%)	1(0.41%)	1.347	0.999
‌Postoperative urine retention‌	8(3.40%)	50(20.41%)	72.833	<0.001

Discussion

Mixed hemorrhoids, often involving prolapsed internal hemorrhoids, are commonly treated with surgical methods like MMH, Procedure for Prolapse and Hemorrhoids (PPH), and rubber band ligation (RBL). MMH provides definitive efficacy but causes significant trauma, pain, and complications. PPH excels in prolapse correction but risks serious complications such as rectal perforation. RBL is minimally invasive with rapid recovery, but its efficacy is limited for grade III-IV hemorrhoids, and recurrence rates are high [12]. ESHB offers a novel alternative. Based on the anal cushion prolapse theory, ESHB ligates the superior rectal mucosa and partially blocks the blood supply of the superior rectal artery, improving venous return and reducing vascular dilation. This alleviates prolapse, bleeding, and external hemorrhoids while preserving anal cushion integrity [13]. ESHB advantages include minimal invasiveness, reduced pain and complications, effective prolapse correction, faster recovery, and lower recurrence rates than RBL, making it ideal for grade III-IV hemorrhoids. Since its adoption in June 2021, ESHB has shown favorable outcomes, aligning with treatment principles of symptom relief, anal cushion preservation, and functional restoration [14].

This study confirmed the safety and efficacy of ESHB. In this study, no patient in either group was classified as “ineffective,” which reflects the clinical effectiveness of both procedures within this patient population. Rather than reporting a combined total effective rate, we focus on the cure rate (complete or near-complete symptom resolution) as the primary efficacy metric: 69.36% (95% CI: 63.1%–75.2%) in the ESHB group and 72.65% (95% CI: 66.7%–78.0%) in the MMH group, with no statistically significant difference between groups. We acknowledge that a substantial proportion of patients achieved only partial improvement, and that symptom recurrence occurred in a small number of patients during follow-up (3 cases [1.28%] in the ESHB group and 5 cases [2.04%] in the MMH group), underscoring the importance of long-term monitoring. Regarding Kaplan–Meier recurrence analysis, time-to-event data were not systematically recorded in this retrospective study; future prospective studies will incorporate this analysis.

Based on our experience: Firstly, precise ligation site of ESHB involves ligation of the superior rectal mucosa above the hemorrhoids (rather than the base of the hemorrhoids as in traditional RBL), preserving the anal cushion and reducing postoperative complications. Secondly, basic ligation is performed at three points (corresponding to the arterial branches). For severe prolapse, an additional three points (totaling six) are ligated. Thirdly, antegrade ligation (suctioning from top to bottom) allows for precise positioning, avoiding accidental suctioning of the sensitive dentate line area and reducing pain. Last, prolapse often decreases by at least one grade after the initial ligation; for cases with insufficient efficacy, staged ligations can be performed at intervals of 4–6 weeks.

In recent years, multiple systematic reviews and meta-analyses have provided higher-quality evidence-based medical evidence for hemorrhoid treatment. Studies have demonstrated that lifestyle factors play a significant role in the pathogenesis of hemorrhoids, underscoring the importance of conservative management [15]. The latest international guidelines recommend a stepwise treatment strategy. For patients with Grade III internal hemorrhoids, minimally invasive techniques such as hemorrhoidal artery ligation (HAL) and transanal hemorrhoidal dearterialization (THD) have emerged as important therapeutic options [16, 17]. Another study comparing HAL with rubber band ligation revealed comparable short-term efficacy between the two techniques, but HAL demonstrated superior postoperative pain control [18]. This finding is similar to our observation of milder postoperative pain following ESHB, suggesting that endoscopically assisted precise ligation may offer comparable advantages. However, it should be noted that these studies predominantly employed standardized efficacy evaluation systems and longer follow-up periods, areas where our study has limitations. A recent meta-analysis comparing the long-term outcomes of different minimally invasive hemorrhoid treatment techniques found that while short-term efficacy was comparable, significant differences in 2-year recurrence rates emerged, highlighting the importance of long-term follow-up [19]. This further corroborates the issue of insufficient short-term follow-up mentioned in our study’s limitations. Compared to these high-quality studies, this study, as a single-center retrospective exploration, primarily offers preliminary feasibility evidence for the ESHB technique. Nevertheless, prospective studies adhering to international standards are still required to validate its long-term efficacy.

This single-center retrospective study has limitations: This single-center retrospective study has notable inherent biases. It used non-randomized grouping, failing to balance baseline confounders. Severe selection bias exists: patient allocation to ESHB or MMH depended on clinical and patient choices, possibly creating unmeasured baseline differences in factors like physical status and treatment compliance. Surgeon-based allocation bias is evident, with ESHB and MMH performed by distinct specialist teams, whose varying skills may affect outcomes. No statistical adjustment was made for confounders (e.g., BMI, constipation history) despite balanced basic baseline data. Performance bias may occur due to non-blinded outcome assessment and surgeons’ awareness of research aims, potentially causing subjective outcome recording. Subjective efficacy criteria lack standardization, and omitting PROs and quality-of-life scores hinders comprehensive assessment. Complication reporting may overlook mild or delayed issues. Single-center findings have limited generalizability due to surgeon and patient variability. Lack of standardized procedures and blinding may cause technical variations and measurement bias, while the short 6-month follow-up underestimates recurrence. Future research should use validated tools and long-term monitoring for objective assessment.

Conclusion

ESHB is a safe, effective, minimally invasive, and convenient treatment for mixed hemorrhoids primarily characterized by prolapsed internal hemorrhoids. Its core advantages lie in precisely repositioning the anal cushion and preserving its function, significantly improving symptoms, while also shortening surgery and hospital stay durations, reducing postoperative pain, and lowering the incidence of urinary retention. This study is a single-center exploratory effort, and future multi-center, large-sample, long-term follow-up RCTs are needed to further validate the long-term efficacy and safety of ESHB and promote its standardized application.

Authors’ contributions

XJ. H. and W. X. drafted the manuscript; H. L., P. J., and HJ. Y. collected the data; LJ. C., KX. Y., and YJ. H. analyzed the data; Y. Z. and J. L. designed the study. All authors read and approved the final manuscript.

Funding

None.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This retrospective study was conducted in accordance with the Declaration of Helsinki (2013 revision) and all relevant national and institutional ethical guidelines and regulations. The study protocol was approved by the Ethics Committee of Qiandongnan Miao and Dong Autonomous Prefecture People's Hospital (Ethics Approval Number: 202106), and all patients signed informed consent forms. Given the retrospective nature of the study using anonymized clinical data and/or human tissue samples, the requirement for written informed consent was waived by the ethics committee. All patient identifiers were removed or anonymized to protect confidentiality, and the data were analyzed in compliance with relevant privacy and ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.