Internal hemorrhoids are one of the most commonly diagnosed benign anorectal disorders worldwide. They are treated, in part, using suppositories or ointment application in conjunction with preventing straining while defecating. However, additional intervention is required when symptoms become aggravated. In Japan, conventional hemorrhoidectomy has been widely applied for correcting prolapsed internal hemorrhoids. Unfortunately, it is accompanied by postoperative pain and hospitalization, requiring absence from the work place for 2–3 weeks. Recently, several alternative treatment options have become available for patients who do not respond to conservative medical management. Rubber band ligation and sclerotherapy have been shown to be simple and safe treatments for hemorrhoids. The most common sclerosing agent, 5% phenol almond oil, has been considered ineffective, so an aluminum potassium sulfate and tannic acid (ALTA) combination has been developed in Japan by adjusting certain constituents of the Xiaozhiling, a sclerosing agent developed by Shi in the 1970s [1,2]. This agent induces an inflammatory reaction resulting in fibrosis, which increases support to tissues while preventing recurrence of prolapse and hemorrhage [3]. An early clinical study conducted in Japan indicated that the rate of resolution for prolapsing hemorrhoids after an ALTA injection exceeded 90%, similar to the prognosis after surgery [4]. Follow-up studies showed shorter durations of procedure time and hospital stay, a lower frequency of postoperative pain, and a higher rate of prolapse disappearance with ALTA therapy than with ligation, excision, or other procedures [2,5,6]. The cumulative success rate of ALTA sclerotherapy in a 5-year follow-up study was also satisfactory (78.2%–89.3%).

In this issue of Clinical Endoscopy, Tomiki et al. reported that endoscopic ALTA sclerotherapy was equivalent to standard ALTA therapy in terms of efficacy, adverse events, and recurrence of hemorrhoids [7]. In this retrospective study, they compared two groups with regard to therapeutic effects, patient satisfaction, adverse events such as fever and anal pain, and the recurrence rate during a 1-year follow-up period. One month after the procedures, 97.0% of patients in the standard ALTA group experienced therapeutic effects ranging from improvement to cure, and 95.8% of patients in the endoscopic ALTA group experienced therapeutic effects. The patients reported good satisfaction (very satisfied or satisfied) at all the same time-points in the standard (93.9%) and endoscopic (95.8%) ALTA groups. Hemorrhoids recurred in two patients (6.3%) from the standard ALTA group and in four (8.3%) from the endoscopic ALTA group. Adverse events occurred in four patients (12.1%) in the standard ALTA group and in six (12.5%) in the endoscopic ALTA group. Among these measures, there were no statistically significant differences between the two groups. The injection dose was 21.9±7.2 mL in the standard ALTA group and 17.8±3.4 mL in the endoscopic ALTA group, which was significantly different (p<0.01).

In the present study, the authors performed a careful, thorough standard vs. endoscopic procedure using a lower ALTA dose as a precaution, yet the therapeutic effect was overall satisfactory. It is expected that the ALTA dose can be increased in future while monitoring patients for adverse events. Endoscopic ALTA may be less embarrassing, especially for women, when comparing the left lateral decubitus position with Sim’s position. Using a flexible endoscope is also beneficial when performing a standardized 4-step injection procedure because the visual field is clearly displayed as a high definition image and a precise injection can be accomplished by fine positioning of the scope. Along with further development of endoscopic ALTA, additional research including a multi-center, prospective randomized study with a large number of cases must be conducted. Currently, it is reasonable to conclude that endoscopic ALTA is a less invasive and comparably efficacious therapeutic strategy for hemorrhoids, which should make a large market diffusion for this option.