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Differing perioperative care practices alter length of stay after laparoscopic surgery

Dear Sir, We write in response to the prospective study of outcome from rubber band ligation (RBL) of haemorrhoids published in the February 2006 issue [1]. We agree with the authors’ conclusions that the majority of patients with haemorrhoids can be successfully treated on an outpatient basis with rubber band ligation. The treatment of fourth-degree haemorrhoids by RBL in this study is however unusual. Whilst meta-analyses support RBL as a first-line treatment for grade 1–3 haemorrhoids [2], the evidence for the treatment of fourth-degree haemorrhoids by RBL is less definitive. Studies have suggested that thirdand small fourth-degree haemorrhoids may be treated by RBL [1,3]. However, a recent systematic review of randomized trials comparing RBL with excisional haemorrhoidectomy found a significantly reduced symptom recurrence and retreatment rate with excisional haemorrhoidectomy compared with RBL for grade 3–4 haemorrhoids [4]. These findings were supported by a trial of patients with large prolapsing haemorrhoids which found haemorrhoidectomy to be the most effective method in the long term [5]. In the study, 40 patients in total were referred with fourth-degree haemorrhoids. The decision was made to proceed directly to formal haemorrhoidectomy in 11, whereas 29 were included in the study [1]. It would be interesting to know whether this decision was based on haemorrhoid size or symptomology. At 2-month follow up, 85% of the patients with fourth-degree haemorrhoids were reportedly symptomfree [1]. However at long-term follow up, by postal questionnaire 56% of the total had symptoms attributable to haemorrhoids [1]. This high symptom recurrence rate questions the long-term success of RBL, even if only 14% had required retreatment. Again, data regarding the recurrence rate of different haemorrhoid grades after RBL would be meaningful as would the proctoscopic appearances of the haemorrhoids at long-term follow up. There is significant evidence that the nonoperative treatment of fourth-degree haemorrhoids leads to recurrence and the need for retreatment. Given the large size of this study, it is therefore unfortunate that the group did not address this issue with long-term follow-up data on RBL in fourth-degree haemorrhoids. E. Barrow and A. J. M. Watson Colorectal Unit, Department of Surgery, Manchester Royal Infirmary, Manchester, UK E-mail: angus.watson@cmmc.nhs.uk