Helping haemorrhoids patients avoid painful and expensive surgery

Piles (also known as haemorrhoids) are a common condition, affecting up to a third of the population, with approximately 23,000 operations carried out in England per year. There are many different treatment options for piles, ranging from dietary advice to surgical options.

Photo of a surgeon talking to a patient in a hospital bed


One of the most common surgical options for haemorrhoids includes rubber band ligation (RBL), which involves placing a small band around the base of the pile to cut off the blood supply. It is relatively cheap but involves a long recovery time and a higher risk of the pile returning.

A second surgical option is a haemorrhoidal artery ligation (HAL), which uses a device to locate the arteries feeding the piles, which are then stitched. This procedure is more painful and expensive than rubber band ligation, has a longer waiting time, but may involve a shorter recovery.

At the time of undertaking this research, there was a lack of evidence to suggest which of the two procedures were of most benefit to patients and were most likely to prevent piles from returning.


Between 2012 and 2014, we undertook the HuBBLe trial to determine which of the two treatments (rubber band ligation and haemorrhoidal artery ligation) were of the most benefit to patients. Led by Professor Steven Brown and coordinated by the Sheffield Clinical Trials Research Unit, the trial recruited 372 individuals with piles from across the UK and provided them with either rubber band ligation or haemorrhoidal artery ligation.

The results of the trial found that one year after surgery, 49% of the patients had a recurrence of symptoms after RBL compared with 30% of patients undergoing HAL.

About one-third of RBL whose symptoms persisted underwent at least one further treatment; in these patients, there was a minimal difference compared to HAL in terms of if or when the symptoms returned.

Symptom scores, quality of life, continence and complications were similar across the two treatments. Those undergoing HAL tended to have more pain than those undergoing RBL, and HAL was found to be much more expensive than RBL.


Following the publication of the results in The Lancet, the results of the trial have influenced health policy in the UK, the US and across Europe, and have prevented patients from receiving the more painful and expensive procedure.

Professor Steven Brown, who led the study, commented that "HuBBLe has influenced the management of haemorrhoids through greater awareness of cost efficacy. Some surgeons and centres have moved to recommending a course of rubber band ligation rather than surgical intervention for certain patients and current NHS guidance stresses the need for this group to have failed rubber band ligation before undergoing intervention."

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