Comparison of Rubber Band Ligation and Haemorrhoidectomy in Patients With Symptomatic Haemorrhoids Grade III (HollAND)

Comparison of Rubber Band Ligation and Haemorrhoidectomy in Patients With Symptomatic Haemorrhoids Grade III: a Multicentre, Randomized Controlled Trial and Cost-utility Analysis.

Rationale: Haemorrhoidal disease is one of the most common anorectal disorders which affects nearly half of the general population1. Given the current numerous modalities the obvious question which needs to be answered is which treatment is the best. An interesting conclusion from a recent systematic review regarding operative procedures for haemorrhoidal disease is that all procedures have their own advantages and disadvantages. There is a need for evaluating treatment from the patient's point of view and transparency in surgical and non-surgical treatment outcome. So far there is no sufficiently large trial that meets that demand.

Objective: To establish the best treatment of patients with symptomatic haemorrhoids grade III: haemorrhoidectomy versus rubber band ligation (RBL). Patient bound effectiveness, clinical effectiveness and cost-utility of both treatments is compared; primary outcome is quality of life at 24 months measured with the EQ-5D-5L with Dutch rating and recurrence at one year post procedure. The assumption is that treatment with rubber band ligation is equally effective in comparison with haemorrhoidectomy in terms of quality of life.

Study design:Multicentre randomized controlled non-inferiority trial with cost-utility analysis. Two treatment protocols are compared: haemorrhoidectomy and rubber band ligation.

Study population: Patients aged ≥ 18 years with symptomatic haemorrhoids gr III. Patients are recruited in multiple clinics during 18-24 months.

Intervention: Participants are allocated to either rubber band ligation or haemorrhoidectomy.

Main study parameters/endpoints: Primary outcome measure is quality of life at 24 months measured with the EQ-5D-5L with Dutch rating and recurrence at one year post procedure. Secondary outcomes are: complaint reduction with proctology specific patient-related outcome measure (HSS, PROM, PROMHISS), vaizey score, resumption of work, pain (VAS), complications and recurrence at two years.

Study Overview

• Status: Recruiting
• Conditions: Rectal Diseases; Hemorrhoids; PROM; Hemorrhoids, Internal
• Intervention / Treatment: Procedure: RBL; Procedure: Hemorrhoidectomy

• Study Type: Interventional
• Enrollment (Anticipated): 360
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Lisette Dekker, MD; Phone Number: +31612204316; Email: l.dekker@proctoskliniek.nl

Study Locations

• Netherlands
  • Almere, Netherlands
    • Recruiting
    • Flevoziekenhuis
    • Contact: Schouten, dr.
  • Amersfoort, Netherlands
    • Recruiting
    • Meander MC
    • Contact: Verheijen, dr.
  • Amsterdam, Netherlands
    • Recruiting
    • OLVG
    • Contact: de Castro, dr.
  • Amsterdam, Netherlands
    • Recruiting
    • University Medical Center location AMC
    • Contact: Bemelman, prof. dr.
  • Capelle Aan Den IJssel, Netherlands
    • Recruiting
    • IJsselland ziekenhuis
    • Contact: van Ruler, dr.
  • Gouda, Netherlands
    • Recruiting
    • Groene Hart Ziekenhuis
    • Contact: Baeten, dr.
  • Maastricht, Netherlands
    • Recruiting
    • MUMC+
    • Contact: Breukink, dr.
  • Utrecht, Netherlands
    • Recruiting
    • Diakonessenhuis
    • Contact: Schiphorst, dr.
  • Utrecht, Netherlands
    • Recruiting
    • Centraal Militair Hospitaal
    • Contact: Meij, dr.

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Haemorrhoids grade III (Goligher classification)
• Age 18 years and older
• Sufficient understanding of the Dutch written language (reading and writing)

Exclusion Criteria:

• Previous rectal or anal surgery with the exception of rubber band ligation
• Previous surgery for haemorrhoids (at any time)
• More than one injection treatment for haemorrhoids in the past 3 years
• More than one rubber band ligation procedure in the past 3 years
• Previous rectal radiation
• Pre-existing sphincter injury
• Inflammatory bowel disease
• Medically unfit for surgery or for completion of the trial (ASA>III)
• Pregnancy
• Hyper-coagulability disorders
• Patients previously randomised to this trial
• Not able or willing to provide written informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
OTHER: Rubber band ligation; Rubber band ligation is performed by a suction device that allows a rubber band to be applied at the base of the haemorrhoid via a proctoscope. Maximal suction force used is 40 mmHg. A maximum of 3-4 bands are used per session. This rubber band constricts the blood supply causing it to become ischaemic before being sloughed approximately 1-2 weeks later. The resultant fibrosis reduces any element of haemorrhoidal prolapse that may have been present. No sedation is required for this day-care procedure. Patients are asked to administer an enema 2 hours prior to the procedure.	Procedure: RBL; Both arms are standard care procedures in the Netherlands
OTHER: Hemorrhoidectomy; There are two main excisional procedures currently carried out: open (Milligan and Morgan) and closed (Ferguson). Both have the intention of excising the haemorrhoidal cushions. The procedure is performed under either general or spinal anaesthesia in a day-care setting. Patients were asked to administer an enema 2 hours prior to the procedure.	Procedure: Hemorrhoidectomy; Both arms are standard care procedures in the Netherlands

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health related quality of life	The EQ-5D-5L is a generic Health Related Quality of Life (HRQoL) measure, which is broadly used in economic evaluation. The instrument examines a patient's HRQoL on the day of the interview. It consists of the EQ-5D-5L descriptive system and the EQ-Visual Analogue Scale. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has five levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. Responses to the 5 items result in a patient's health state that can be transformed into an index score representing health-related quality of life, ranging between 0 (death) and 1 (full health). These index scores are combined with length of life to calculate the QALY. The EQ-VAS records the patient's self-rated health with endpoints labelled 'the best health you can imagine' at the top and 'the worst health you can imagine' at the bottom.	24 months
Recurrence	Patient self reported assessment with a dichotomous question: "At the moment, do you feel your symptoms from your haemorrhoids are: (1) cured or improved compared with before treatment; or (2) unchanged or worse compared with before treatment?" Any patient who answers '1' but has required further treatment since the initial procedure will be reclassified as '2', identified via hospital records, their consultant and patient questioning	at 12 months
In-hospital direct costs	with EQ-5D-5L and cost incremental analysis (iMCQ and iPCQ): The impact of disease on the ability of a person to perform work should be part of an economic evaluation when a societal perspective is applied. iMTA is highly experienced in methods for measuring and valuing productivity losses.The Productivity Costs Questionnaire (iPCQ) may be combined with the iMTA Medical Consumption Questionnaire (iMCQ), a generic instrument for measuring medical costs. The iMCQ includes questions related to frequently occurring contacts with health care providers and can be complemented with extra questions that are relevant for specific study populations.	this will be asked at 6 weeks, 6, 12 and 24 months
In-hospital indirect costs	with EQ-5D-5L and cost incremental analysis (iMCQ and iPCQ): The impact of disease on the ability of a person to perform work should be part of an economic evaluation when a societal perspective is applied. iMTA is highly experienced in methods for measuring and valuing productivity losses.The Productivity Costs Questionnaire (iPCQ) may be combined with the iMTA Medical Consumption Questionnaire (iMCQ), a generic instrument for measuring medical costs. The iMCQ includes questions related to frequently occurring contacts with health care providers and can be complemented with extra questions that are relevant for specific study populations.	this will be asked at 6 weeks, 6, 12 and 24 months
Out-of-hospital postoperative costs	with EQ-5D-5L and cost incremental analysis (iMCQ and iPCQ): The impact of disease on the ability of a person to perform work should be part of an economic evaluation when a societal perspective is applied. iMTA is highly experienced in methods for measuring and valuing productivity losses.The Productivity Costs Questionnaire (iPCQ) may be combined with the iMTA Medical Consumption Questionnaire (iMCQ), a generic instrument for measuring medical costs. The iMCQ includes questions related to frequently occurring contacts with health care providers and can be complemented with extra questions that are relevant for specific study populations.	this will be asked at 6 weeks, 6, 12 and 24 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health related quality of life	The EQ-5D-5L is a generic Health Related Quality of Life (HRQoL) measure, which is broadly used in economic evaluation. The instrument examines a patient's HRQoL on the day of the interview. It consists of the EQ-5D-5L descriptive system and the EQ-Visual Analogue Scale. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has five levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. Responses to the 5 items result in a patient's health state that can be transformed into an index score representing health-related quality of life, ranging between 0 (death) and 1 (full health). These index scores are combined with length of life to calculate the QALY. The EQ-VAS records the patient's self-rated health with endpoints labelled 'the best health you can imagine' at the top and 'the worst health you can imagine' at the bottom.	12 months
Patient reported outcome measures concerning symptoms in daily life; Vaizey score	Vaizey faecal continence score consists of 7 questions with a maximum of score of 24. The higher the score, the higher the worse the outcome.	12 months
Patient reported outcome measures concerning symptoms in daily life; proctoPROM	The proctoPROM is a validated questionnaire consisting of five questions concerning patients well-being, wich are each scored on a numeric rating scale from 0 to 10. Regarding impact of symptoms, 0 correlates with 'no impact at all' and 10 with 'highly impacted on daily life'. Than the mean of the 5 question is taken.	12 months
Patient reported outcome measures concerning symptoms in daily life; PROM-HISS	Patient-Reported Outcome Measure-Haemorrhoidal Impact and Satisfaction Score which are each scored on a numeric rating scale from 0 to 10. Regarding impact of symptoms, 0 correlates with 'no impact at all' and 10 with 'highly impacted on daily life'. For patient satisfaction with treatment, this ranges between 0 'not satisfied' and 10 'very satisfied'.	12 months
Patient reported outcome measures concerning symptoms in daily life; HHS	Hemorrhoid severity score consists of five questions concerning the frequency of symptoms of hemorrhoids. The higher the score the more frequent the symptoms occur.	12 months
Patient reported outcome measures concerning symptoms in daily life, VAS pain score	The pain visual analogue scale has a numeric rating scale from 0 to 10 with 0 being 'no pain' and 10 'worse pain you ever felt'.	this will be asked 1 day post procedure, 1 week and 6 weeks post procedure.
Return to work	Number of days patients are able to return to work	this will be asked at 1 week and 6 weeks post procedure.
Need for further treatment		12 months
Complications	Adverse events as: peroperative bleeding, postoperative bleeding, urinary retention requiring catheterisation, pelvic sepsis, anal fissure, anal fistula, wound discharge, residual anal skintages, anal stenosis, fecal incontinence, death	12 months

Collaborators and Investigators

• Sponsor: Proctos Kliniek
• Investigators: Principal Investigator: Ingrid Han-Geurts, MD PhD, Proctos Kliniek; Study Chair: Willem Bemelman, Prof., Amsterdam University Medical Center, location AMC

Publications and helpful links

Helpful Links

• Study website
• Dutch Workgroup Coloproctology

Study record dates

Study Major Dates

• Study Start (ACTUAL): November 25, 2019
• Primary Completion (ANTICIPATED): November 25, 2023
• Study Completion (ANTICIPATED): November 25, 2023

Study Registration Dates

• First Submitted: October 23, 2020
• First Submitted That Met QC Criteria: November 3, 2020
• First Posted (ACTUAL): November 9, 2020

Study Record Updates

• Last Update Posted (ACTUAL): March 16, 2021
• Last Update Submitted That Met QC Criteria: March 12, 2021
• Last Verified: March 1, 2021

More Information

Terms related to this study

• Keywords: Hemorrhoidal disease; PROM; Hemorrhoids; Hemorrhoidectomy; Rubber band ligation
• Additional Relevant MeSH Terms: Digestive System Diseases; Cardiovascular Diseases; Vascular Diseases; Gastrointestinal Diseases; Intestinal Diseases; Hemorrhoids; Rectal Diseases
• Other Study ID Numbers: NL69227.018.19

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: (Several versions of) processed data, documentation of the research process, including deindentified participant data, raw data, syntaxes
• IPD Sharing Time Frame: 3 months embargo due to publishing.
• IPD Sharing Access Criteria: There will be access restrictions to my data collection. A request must be made at Data Access Committee (DAC).
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No