Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid

Shifting Paradigms in Hemorrhoid Management: The Emergence and Impact of Cap-Assisted Endoscopic Sclerotherapy

Hemorrhoidal disease (HD) is a prevalent proctological condition that has puzzled people since ancient times, and the most common symptom is painless bleeding. Traditional treatments include conservative treatment, nonsurgical office-based treatments, and surgery. Sclerotherapy is one of the oldest forms of nonoperative intervention and is widely used to treat internal hemorrhoids with the development of endoscopy technology. However, sclerotherapy is always accompanied by complications such as bleeding, pain, abscess, etc., when the sclerosant is injected into the wrong site. Cap-assisted endoscopic sclerotherapy (CAES), a new minimally invasive technology, was first time coined in 2015 for the treatment of hemorrhoidal disease. The left-posterior-right-anterior (LPRA) anus positioning method under endoscopy provides reliable methodological support for advancing hemorrhoidal treatment via endoscopy. The current trend is that treatment for HD has shifted from being performed predominantly by the Department of Proctology Surgery to being managed mostly by the Department of Gastroenterology. This review reviewed the shifting paradigms of sclerotherapy for HD and discussed the emerging development of CAES.

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review to assess the safety and efficacy of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for the treatment of hemorrhoidal disease.

METHODS

Our study was conducted in accordance with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020. Primary endpoints included overall recurrence and type of recurrence while secondary endpoints included postoperative complications, reintervention, presence of rectal ulcer, rectal stricture, defecation abnormalities and perianal abscess. Α regression analysis, where the percentage of patients with grade II, III and IV hemorrhoidal disease was used as a covariate, was also performed.

RESULTS

Twelve studies with 4249 patients met all the inclusion criteria and were eventually included. The crude and pooled estimates of the overall recurrence and complications by the end of follow-up were 10% (95% CI, 6.52%-14.08%) and 5.20% (95% CI, 2.59%-8.52%), respectively. Regression analysis displayed no correlation between recurrence and the grade of hemorrhoid disease II, β= -0.0012 (95% CI, -0.0074 to 0.0049) (p = .64), grade III β= -0.0006 (95% CI, -0.0056 to 0.0045) (p = .79) and grade IV β = 0.0025 (95% CI, -0.0075 to 0.0124). However, a trend suggestive of increased recurrence was observed in patient populations with a higher proportion of grade IV disease.

CONCLUSION

ALTA sclerotherapy may be a safe and viable alternative for patients with hemorrhoidal disease. Long-term follow-up and high-quality randomized controlled trials will help define the place of ALTA sclerotherapy in the armamentarium of treatment of hemorrhoids.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Sclerotherapy for hemorrhoidal disease: systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the safety and efficacy of sclerotherapy methods for hemorrhoidal disease (HD) over the past 40 years.

METHODS

The review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A comprehensive literature search was conducted, including studies reporting the use of sclerotherapy in patients with HD. Study eligibility criteria were defined, and data were extracted independently by the authors. Random-effects meta-analyses were performed to assess outcomes of interest.

RESULTS

Out of 1965 records identified, 44 studies met the inclusion criteria, involving 9729 patients. The majority of studies were conducted in Japan, followed by the UK, Italy, and Portugal. The median age of participants was 52 years, and the majority were male. The Goligher grade distribution indicated varying degrees of HD severity. Sclerotherapy was predominantly administered through anoscopy, with polidocanol being the most commonly used agent. The procedure was generally performed without pre-injection analgesia. The meta-analysis of 14 randomized controlled trials (RCTs) revealed that sclerotherapy was not inferior to control interventions in terms of success rate (risk ratio [RR] 1.00, 95% CI 0.71-1.41) and recurrence rate (RR 1.11, 95% CI 0.69-1.77), while resulting in fewer complications (RR 0.46, 95% CI 0.23-0.92).

CONCLUSIONS

This systematic review highlights the safety and efficacy of sclerotherapy for HD, which yields similar success rates and fewer complications compared to other conservative or surgical approaches. Further research is warranted to optimize sclerotherapy techniques and evaluate long-term outcomes.

REGISTRATION

PROSPERO 2023 CRD42023396910.

Sclerotherapy in Hemorrhoids

Injection sclerotherapy for all grades of interhemorrhoids in various situations and co-morbidities has become popular method of treatment. Several types of surgical operations both conventional and stapled hemorrhoidectomy has many and serious described side effects. On the contrary, proctoscopic injection sclerotherapy using some of the modern sclerosants and thin bore needle injections is an office-based ambulatory method of treatment of internal hemorrhoids; it is low in cost, devoid of any major complications besides it is quite successful as reported. Its safety and efficacy has been published in recent years. This manuscript is a result of thorough systemic review using PRISMA guidelines on various sclerosing agents, their merits and demerits, methods of administration, and outcome in internal hemorrhoids.

Biomedical applications of tannic acid

Tannic Acid (TA) is a naturally occurring antioxidant polyphenol that has gained popularity over the past decade in the field of biomedical research for its unique biochemical properties. Tannic acid, typically extracted from oak tree galls, has been used in many important historical applications. TA is a key component in vegetable tanning of leather, iron gall ink, red wines, and as a traditional medicine to treat a variety of maladies. The basis of TA utility is derived from its many hydroxyl groups and its affinity for forming hydrogen bonds with proteins and other biomolecules. Today, the study of TA has led to the development of many new pharmaceutical and biomedical applications. TA has been shown to reduce inflammation as an antioxidant, act as an antibiotic in common pathogenic bacterium, and induce apoptosis in several cancer types. TA has also displayed antiviral and antifungal activity. At certain concentrations, TA can be used to treat gastrointestinal disorders such as hemorrhoids and diarrhea, severe burns, and protect against neurodegenerative diseases. TA has also been utilized in biomaterials research as a natural crosslinking agent to improve mechanical properties of natural and synthetic hydrogels and polymers, while also imparting anti-inflammatory, antibacterial, and anticancer activity to the materials. TA has also been used to develop thin film coatings and nanoparticles for drug delivery. In all, TA is fascinating molecule with a wide variety of potential uses in pharmaceuticals, biomaterials applications, and drug delivery strategies.

Laparoscopic anterior resection for rectal stenosis caused by ALTA injection for internal hemorrhoids: A case report

We herein report the first case of rectal stenosis that developed after internal hemorrhoid treatment with aluminum potassium sulfate and tannic acid (ALTA) therapy that was successfully treated by laparoscopic surgery. A 72-year-old man suffered from a fever and rectal stenosis after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA at a previous clinic. Three months after ALTA therapy, he developed frequent mucous and bloody stools. Lower intestinal tract endoscopy revealed circumferential severe rectal stenosis. He was therefore referred to our hospital. The patient suffered from frequent stool build-up and difficulty defecating. We performed balloon-dilatation intervention. The stenosis was not improved at all. Five months after ALTA therapy, we performed laparoscopic low anterior resection with diverting ileostomy. Three months after the operation, ileostomy takedown was performed. The patient has experienced no rectal stenosis in the 2 years since his radical operation.

Progress in Endoscopic Treatment of Hemorrhoids

Hemorrhoids are one of the most common diseases of the anorectal region. Previously, treatment for hemorrhoids included conservative treatment, outpatient treatment, and surgical treatment. The development of flexible reversible endoscopes has provided precise controllability and imaging, enabling further improvement and development of various endoscopic techniques to treat hemorrhoids. This article discusses several of these endoscopic techniques: rubber band ligation, sclerotherapy, and electrocoagulation. The development, efficacy, and advantages of these treatments are summarized and evaluated. It is expected that going forward, endoscopic technology will be further applied in clinical practice and may become the first-line method for the treatment of hemorrhoids.

Gluteal-fold flap repair of rectovaginal fistula caused by aluminum potassium sulfate hydrate-tannic acid injection for internal hemorrhoids: a case report

BACKGROUND

Rectovaginal fistula (RVF) following aluminum potassium sulfate hydrate-tannic acid (ALTA) injection therapy for hemorrhoids is a rare complication. We report the first case of RVF after ALTA injection therapy successfully treated by gluteal-fold flap.

CASE PRESENTATION

A 49-year-old female suffered from a fever and rectal ulcer after undergoing internal hemorrhoid treatment with a submucosal ALTA injection at a previous clinic. One week after ALTA therapy, she noted obvious passage of flatus and stool through the vagina, and was diagnosed with RVF by anoscope at another clinic. She was referred to our hospital 3 weeks after ALTA therapy. Sigmoid colostomy was performed for fecal diversion as a preliminary step for fistula repair. However, the fistula was scarred and the defect between the rectum and vagina did not improve at all. Ten months after ALTA therapy, we performed fistula repair by gluteal-fold flap. Seven months later, sigmoid-colostomy reversal was performed. The patient has experienced no RVF in the 3 years since sigmoid-colostomy reversal.

CONCLUSIONS

The gluteal-fold flap strategy is a useful option for severe RVF management.

Cap-assisted endoscopic sclerotherapy for internal hemorrhoids: technique protocol and study design for a multi-center randomized controlled trial

BACKGROUND

Cap-assisted endoscopic sclerotherapy is a new interventional therapy for internal hemorrhoids and rectal prolapse under colonoscopy. The proper length of the endoscopic injection needle is the core for performing cap-assisted endoscopic sclerotherapy well with more benefits and less complications. However, no data are currently available to guide endoscopists to consider the length of injection needle before cap-assisted endoscopic sclerotherapy. This study is designed to evaluate the efficacy and safety of cap-assisted endoscopic sclerotherapy with long or short injection needle in the treatment of internal hemorrhoids.

METHODS

This is a nationwide multi-center, prospective, single-blind and randomized controlled trial. Patients with grade I-II internal hemorrhoids who have failed to conservative treatments and grade III internal hemorrhoids who are not suitable for surgery or refuse surgery will be included. Participants will be randomized 1:1 into either long or short injection needle group. The primary outcome is the recurrence rate of internal hemorrhoids 24 weeks after cap-assisted endoscopic sclerotherapy. The secondary outcomes are as follows: (1) symptom severity score, (2) three-level EuroQoL five dimensions health scale scores, (3) occurrence of adverse events and severe adverse events, and (4) patients' attitudes toward cap-assisted endoscopic sclerotherapy. Data collection will be conducted before and during operation, the 1st day, 1st week, 2nd week, and 24th week after cap-assisted endoscopic sclerotherapy.

DISCUSSION

The outcome of this study is expected to provide a practical clinical protocol of cap-assisted endoscopic sclerotherapy for patients with internal hemorrhoids and promote the use of this new endoscopic technique.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03917056. Registered on 12 April 2019.

Rectosigmoidal manifestations of venous malformations: MR imaging findings and interdisciplinary therapeutic modalities

The aim of this study was to identify the frequency of rectosigmoidal involvement in patients with venous malformations (VM) of the lower extremities and to demonstrate multidisciplinary therapeutic options. The medical records and magnetic resonance images (MRI) of patients with VM of the lower extremities, over a six-year period, were reviewed retrospectively in order to determine the occurrence of rectosigmoidal involvement. Vascular interventions, surgical treatments, percutaneous and hybrid (endoscopy-guided angiography) sclerotherapy and procedural complications (according to Clavien-Dindo classification) were also noted. Of the 378 patients with vascular malformation of the lower limbs, 19 patients (5%) had documented venous rectosigmoidal malformation. All of these 19 patients reported episodes of rectal bleeding, while seven patients (36.8%) also had anemia. All patients underwent endoscopy. By endoscopy, seven patients (36.8%) showed discreet changes, and 12 patients (63.2%) showed pronounced signs of submucosal VM with active (47.3%) or previous (15.7%) bleeding. Treatment was performed in all patients with pronounced findings. Six patients underwent endoscopy-guided hybrid sclerotherapy, one patient underwent endoscopic tissue removal, one patient received percutaneous sclerotherapy and one patient received a combination of transvenous embolization and hybrid sclerotherapy. Three patients required open surgery. No complications occurred after conservative treatments; however, one complication was reported after open surgery. None of the treated patients reported further bleeding and anemia at the end of the follow-up period. In this cohort, rectosigmoidal VM occurred in 5% of patients presenting with a high incidence of rectal bleeding. Percutaneous or endoscopy-guided hybrid sclerotherapy appeared to be a safe and effective alternative to surgery.

Robot-assisted low anterior resection after aluminum potassium sulfate and tannic acid sclerosing therapy for internal hemorrhoids

Background

Internal hemorrhoids are the most common anal diseases. Aluminum potassium sulfate and tannic acid (ALTA) injection is a new sclerosing therapy for the treatment of internal hemorrhoids. Although ALTA injection has been widely used, there are no previous reports of rectal cancer patients who underwent robot-assisted low anterior resection (Rob-LAR) after ALTA injection to treat internal hemorrhoids.

Case presentation

A 70-year-old man with rectal cancer was presented to our hospital. He had an ALTA injection 2 months before presentation at a clinic due to hematochezia with internal hemorrhoids. The rectal tumor was located 7 cm above the anal verge, and Rob-LAR with the da Vinci Xi system was performed. The patient had sclerosis on the stump of the anal side, which made it difficult to transect the rectum with linear staplers. This required multiple repeats of compression through the SmartClamp feedback. After anastomosis with the double-stapling technique, we constructed a diverting ileostomy.

Conclusion

Although ALTA injection is a promising strategy for internal hemorrhoids, rectal cancer should be excluded before the sclerosing therapy.

Effectiveness of Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid as a Non-Surgical Treatment for Internal Hemorrhoids

BACKGROUND/AIMS

Sclerotherapy with aluminum potassium sulfate and tannic acid (ALTA) has a potent effect on internal hemorrhoids. In this retrospective study, we compared the effects of endoscopic ALTA therapy and standard ALTA therapy.

METHODS

We investigated patients who underwent treatment for internal hemorrhoids at our institution between 2014 and 2016. They were divided into a standard ALTA group (n=33, treated using proctoscopy) and an endoscopic ALTA group (n=48). We compared the clinical findings between the 2 groups.

RESULTS

There were no intergroup differences in background factors. The mean ALTA dose was 21.9±7.2 mL and 17.8±3.4 mL in the standard and endoscopic ALTA groups, respectively (p<0.01). Adverse events occurred in 4 patients (12.1%) from the standard ALTA group and 6 patients (12.5%) from the endoscopic ALTA group. In both groups, the patients reported good satisfaction with the therapeutic effect at 1 month after the procedure. Hemorrhoids recurred in 2 patients (6.3%) from the standard ALTA group and 4 patients (8.3%) from the endoscopic ALTA group.

CONCLUSION

Endoscopic ALTA sclerotherapy is equivalent to standard ALTA therapy in terms of efficacy, adverse events, and recurrence. Therefore, it is a useful non-surgical option for patients with internal hemorrhoids who prefer a less invasive treatment.