One-stop colonoscopy-based management of colorectal polyps and internal hemorrhoids in older adults: A real-world cohort study

Abstract

BACKGROUND

Older adults frequently present with coexisting colorectal neoplasia and internal hemorrhoids requiring endoscopic management. Managing these conditions across separate endoscopic sessions may increase procedural burden, particularly in older patients with multiple comorbidities.

AIM

To evaluate clinical outcomes and safety associated with one-stop colonoscopy-based endoscopic management for elderly patients in a real-world setting.

METHODS

This retrospective real-world cohort study enrolled consecutive adults (≥ 18 years) with Goligher grade I-III internal hemorrhoids receiving one-stop colonoscopy-based endoscopic management at a tertiary endoscopy center from July 2022 to September 2025. Colonoscopy and polypectomy (when indicated) were performed before hemorrhoid intervention during the same session. Patients were followed after treatment, with a median follow-up duration of 12 months. Clinical outcomes, safety and patient-reported indicators were compared between elderly (≥ 65 years) and non-elderly (< 65 years) groups.

RESULTS

A total of 661 patients were included (≥ 65 years, n = 100; < 65 years, n = 561). Elderly patients had higher prevalences of comorbidities, adenoma, advanced adenoma, and high-grade dysplasia. Symptom improvement was reported by 82.0% of elderly and 82.4% of non-elderly patients [risk difference: -0.4%; 95% confidence interval (CI): -9.5 to 6.8]. The overall rate of any adverse event was 12.0% in elderly patients and 11.6% in non-elderly patients (risk difference: 0.4%; 95%CI: -6.4 to 7.5). No serious adverse events were recorded in either group. Postprocedural discomfort, patient satisfaction, cost acceptance, and the need for more than one treatment session did not differ significantly. In multivariable analysis, age was not significantly associated with symptom improvement (adjusted odds ratio = 1.01, 95%CI: 0.99-1.02; P = 0.365). Exploratory subgroup analyses did not identify statistically significant age-related differences in the measured clinical outcomes, although subgroup sizes were limited.

CONCLUSION

One-stop colonoscopy-based endoscopic management was associated with high rates of symptom improvement and a low frequency of observed procedure-related adverse events in appropriately selected elderly patients. Observed clinical outcomes were generally similar between elderly and non-elderly patients. These findings support the clinical feasibility of this consolidated endoscopic strategy in selected older adults, while prospective comparative studies are needed to further establish its safety and potential advantages over staged management.

Key Words: Hemorrhoids; Older adults; Colonoscopy; Colorectal polyps; One-stop management; Endoscopic therapy

Core Tip: This retrospective real-world cohort study evaluated a one-stop colonoscopy-based strategy integrating diagnostic colonoscopy, polypectomy when indicated, and hemorrhoid treatment during a single session in older adults. Despite a higher comorbidity burden, elderly patients achieved > 80% symptom improvement, with a low frequency of observed adverse events, and age was not independently associated with symptom improvement. These findings support the clinical feasibility of a consolidated endoscopic strategy in appropriately selected older adults, while its potential advantages over staged management require prospective evaluation.

INTRODUCTION

With population ageing, the prevalence of colorectal polyps and colorectal cancer rises markedly in older adults, with polyp detection rates increasing substantially beyond 50 years of age[1,2]. Colonoscopic screening followed by polypectomy represents a cornerstone strategy for early detection and colorectal cancer prevention within this age group. Nevertheless, elderly patients frequently face unique clinical challenges during endoscopic procedures, including multiple comorbidities, diminished physiological reserve, and difficulties related to bowel preparation and sedation-associated postprocedural recovery[2,3].

Symptomatic internal hemorrhoids also become more prevalent with advancing age, as degenerative changes in the supporting tissues of the anal cushions increase the risk of anorectal bleeding, prolapse, and impaired health-related quality of life[4,5]. For symptomatic grade I-III internal hemorrhoids refractory to conservative measures, international clinical guidelines from the American Society of Colon and Rectal Surgeons and the European Society of ColoProctology recommend minimally invasive office-based therapies, including rubber band ligation (RBL) and sclerotherapy[6,7]. Existing head-to-head comparative studies of these two modalities have reported inconsistent results concerning symptom relief, postprocedural pain and recurrence risk[8]. However, comparative evidence specifically focused on elderly patient populations remains limited.

Older adults undergoing colonoscopic evaluation for colorectal neoplasia may also have concomitant symptomatic hemorrhoidal disease, requiring both colonic lesion management and anorectal intervention. These conditions may be managed across separate endoscopic sessions, potentially requiring repeated bowel preparation and additional endoscopic procedures, which may be particularly burdensome for older adults with multiple comorbidities or limited physiological reserve[2,9,10]. A one-stop colonoscopy-based strategy integrating diagnostic colonoscopy, polypectomy when indicated, and endoscopic treatment of internal hemorrhoids within a single session may therefore offer a more consolidated endoscopic care pathway[9,11].

However, the real-world safety and clinical applicability of this integrated approach in elderly patients remain insufficiently defined. Although several studies have demonstrated the feasibility of performing hemorrhoidal ligation during colonoscopy, these investigations were primarily conducted in mixed-age populations and focused on hemorrhoidal outcomes rather than comprehensive endoscopic management of coexisting colorectal neoplasia and hemorrhoidal disease[9,10]. We therefore conducted a retrospective cohort study to evaluate the clinical outcomes and safety associated with one-stop colonoscopy-based endoscopic management in elderly patients.

MATERIALS AND METHODS

Study design and patients

This retrospective cohort study was conducted at the Endoscopy Center of the First Affiliated Hospital of Chongqing Medical University, a tertiary referral center in China. Consecutive adult patients who underwent one-stop colonoscopy-based endoscopic management for internal hemorrhoids from July 2022 to September 2025 were screened for eligibility. Patients aged ≥ 18 years with Goligher grade I-III internal hemorrhoids who completed full colonoscopy during the same session were included. Exclusion criteria were incomplete colonoscopy, severe coagulopathy, inflammatory bowel disease, anorectal malignancy, other significant anorectal disorders, including anal fistula, anal fissure, or external hemorrhoidal thrombosis, prior anorectal surgery, a history of colorectal cancer, receipt of non-standard sclerotherapy, and incomplete key study data required for the analysis. Patients who otherwise met the eligibility criteria but could not be reached for follow-up were classified as lost to follow-up and were not included in the final analytic cohort.

The study protocol was approved by the Institutional Ethics Committee of the First Affiliated Hospital of Chongqing Medical University (approval No. 2025-553-01), which waived the requirement for written informed consent because of the retrospective use of de-identified data.

One-stop endoscopic management

All included patients underwent a standardized one-stop diagnostic and therapeutic pathway. Preprocedural evaluation included routine laboratory testing, coagulation profile, and anesthetic assessment when indicated; electrocardiography was additionally performed in patients aged ≥ 65 years.

A complete colonoscopic examination was first performed to evaluate the colorectum and identify synchronous lesions. When polyps were detected, resection was performed during the same session according to lesion size, location, and morphology, together with endoscopist judgment, using biopsy forceps, cold snare polypectomy, hot snare polypectomy, or endoscopic mucosal resection, as appropriate. Thorough hemostasis and wound inspection were conducted for all polypectomy sites before proceeding to anorectal intervention. Endoscopic hemorrhoid treatment was then performed at the end of the same session.

Endoscopic treatment of internal hemorrhoids was subsequently performed during the same session under flexible endoscopic visualization. The choice between endoscopic polidocanol foam sclerotherapy (EPFS) and RBL was individualized according to symptom characteristics, endoscopic findings, endoscopist judgment, and patient preference within routine clinical practice. For EPFS, polidocanol foam (Aethoxysklerol^®) at a 3% concentration was selected according to hemorrhoidal grade and endoscopic characteristics. Injection depth and volume were carefully controlled to ensure submucosal delivery and to avoid deep mural or transmural injection. The number of injection sites and total injected volume were determined at the discretion of the endoscopist based on the size and extent of the hemorrhoidal cushions. For RBL, the number of rubber bands applied was also individually determined by the endoscopist according to the range and severity of hemorrhoid cushions. All hemorrhoidrelated procedures were performed by experienced endoscopists in accordance with established safety principles for endoscopic sclerotherapy and band ligation. Because full colonic evaluation and any indicated polypectomy were completed before hemorrhoid treatment, potential procedural interference with the evaluation of colonic lesions was minimized. Intravenous anesthesia was administered according to routine clinical practice and patient preference following preprocedural assessment.

Pathological assessment

All resected polyp specimens were assessed under standardized institutional pathological review protocols. Histological slides were interpreted by experienced gastrointestinal pathologists, and ambiguous cases were adjudicated by consensus review. Advanced adenoma was defined as an adenoma with at least one of the following features: Lesion size ≥ 10 mm, tubulovillous or villous histology, or high-grade dysplasia. High-grade dysplasia was defined according to the two-tier World Health Organization classification, representing marked cytological and architectural atypia limited to the mucosal epithelium[11,12].

Outcome measures and subgroup analyses

The primary outcome was patient-reported improvement in hemorrhoid-related symptoms during follow-up. Trained nurses conducted standardized telephone follow-up using a uniform question asking whether the patient’s predominant hemorrhoid-related symptoms had improved compared with baseline. Responses were categorized as improved or not improved. Secondary outcomes included postprocedural discomfort, patient-reported satisfaction, cost acceptance, and the requirement for more than one treatment session. Patient satisfaction and cost acceptance were also assessed by patient report during follow-up.

Safety outcomes included adverse events occurring within 30 days after endoscopic treatment. Adverse events and their severity were classified according to the American Society for Gastrointestinal Endoscopy lexicon for endoscopic adverse events[13]. Safety information was obtained from available follow-up records, including telephone follow-up and subsequent clinical or endoscopic records when available. Postprocedural discomfort was defined as anorectal pain, anal distention, and bleeding. Postprocedural bleeding was defined as overt hematochezia requiring clinical evaluation after the procedure. Serious adverse events included events resulting in death, hospitalization or prolongation of hospitalization, substantial disability, or other serious clinical consequences, in accordance with the American Society for Gastrointestinal Endoscopy lexicon[13].

Patients were categorized as elderly (≥ 65 years) and non-elderly (< 65 years). A prespecified subgroup analysis was performed within the elderly cohort, comparing patients aged ≥ 70 years with those aged 65-69 years. Additional exploratory subgroup analyses were performed according to anesthesia status within the elderly cohort and according to hemorrhoid treatment modality (RBL or EPFS).

Statistical analysis

Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, United States). Continuous variables were expressed as mean ± SD or median [interquartile range (IQR)], as appropriate, and were compared using the independent-samples t test or Mann-Whitney U test according to data distribution. Categorical variables were presented as n (%) and were compared using the Pearson χ² test, Fisher’s exact test, or the Fisher-Freeman-Halton exact test, as appropriate. For contingency tables larger than 2 × 2 with sparse expected cell counts, the Fisher-Freeman-Halton exact test was used. Standardized mean differences (SMDs) were calculated for selected baseline characteristics to describe the magnitude of between-group differences. To assess potential attrition bias, available baseline characteristics were compared between patients included in the final analytic cohort and those lost to follow-up. No imputation of missing data was performed.

Multivariable logistic regression analysis was performed to identify factors associated with post-treatment symptom improvement. Covariates included age, sex, body mass index, hemorrhoid grade, treatment modality, anesthesia use, and total operation duration. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. For the primary outcome and selected clinically relevant secondary outcomes, absolute risk differences with 95%CIs were calculated using the Newcombe score method to quantify between-group differences. All tests were two-sided, and P < 0.05 was considered statistically significant.

RESULTS

Study population and baseline characteristics

A total of 958 patients were screened for eligibility, of whom 661 were included in the final analytic cohort after exclusion of those with a history of colorectal cancer, receipt of non-standard sclerotherapy, or incomplete key study data, and after accounting for patients lost to follow-up (Figure 1). The cohort comprised 100 elderly patients aged ≥ 65 years (15.1%) and 561 non-elderly patients aged < 65 years (84.9%).

Figure 1 Flow diagram of patient selection and cohort formation. The flow diagram shows the screening, exclusion, loss to follow-up, and final inclusion of patients in the analytic cohort.

Baseline characteristics are summarized in Table 1. Sex distribution and follow-up duration showed little between-group difference, whereas body mass index showed a modest difference (|SMD| = 0.175). Hemorrhoid grade and presenting symptoms did not differ significantly between groups. The overall distribution of comorbidity status differed significantly (P < 0.001), with elderly patients having a higher comorbidity burden. Hypertension, diabetes mellitus, cardiovascular disease, and multiple comorbidities showed notable imbalance (|SMD| ≥ 0.1), whereas malignancy history showed little between-group difference.

Table 1 Baseline characteristics by age group, n (%)/median (interquartile range).

Variable	≥ 65 years (n = 100)	< 65 years (n = 561)	P value	SMD
Age, years	69.0 (67.0-72.0)	48.0 (39.0-56.0)	< 0.001	-
Male sex	51 (51.0)	310 (55.3)	0.431	-0.085
BMI	23.9 (21.1-25.5)	23.9 (21.6-26.1)	0.375	-0.175
Hemorrhoid grade			0.482	-
Grade I	5 (5.0)	24 (4.3)
Grade II	74 (74.0)	445 (79.3)
Grade III	21 (21.0)	92 (16.4)
Presenting symptoms			0.109	-
Bleeding	54 (54.0)	268 (47.8)
Prolapse	11 (11.0)	34 (6.1)
Bleeding and prolapse	4 (4.0)	36 (6.4)
Other symptoms	31 (31.0)	223 (39.8)
Comorbidity status			< 0.001
Hypertension	21 (21.0)	81 (14.4)		0.172
Diabetes mellitus	10 (10.0)	19 (3.4)		0.267
Cardiovascular disease	4 (4.0)	5 (0.9)		0.202
Malignancy history	0 (0.0)	2 (0.4)		-0.085
Multiple comorbidities	23 (23.0)	28 (5.0)		0.537
Follow-up time, months	12.0 (10.0-12.0)	12.0 (9.0-12.0)	0.977	0.037

P values were calculated using the Mann-Whitney U test for continuous variables and the Pearson χ² test, Fisher’s exact test, or the Fisher-Freeman-Halton exact test for categorical variables, as appropriate. Standardized mean differences were calculated for binary variables and selected continuous variables to describe the magnitude of between-group differences. Comorbidity categories were mutually exclusive. Patients with a single comorbid condition were classified according to that condition, whereas patients with two or more comorbid conditions were classified as having multiple comorbidities. Standardized mean differences were not calculated for multicategorical variables (hemorrhoid grade and presenting symptoms). SMD: Standardized mean difference; BMI: Body mass index.

To evaluate potential selection bias related to loss to follow-up, we further compared baseline characteristics between patients retained in the final analytic cohort and those lost to follow-up, stratified by age (Supplementary Table 1). Complete baseline data required for a valid comparative analysis were unavailable for patients excluded because of incomplete key study data; therefore, these patients were not included in this comparison. Baseline features were largely balanced between retained and lost to follow-up patients in the elderly subgroup. Among patients younger than 65 years, imbalances in hemorrhoid grade and presenting symptoms were observed between retained patients and those lost to follow-up.

Colonoscopic findings

Colonoscopic findings differed by age group (Figure 2). Elderly patients had higher prevalences of adenoma (59.0% vs 36.5%), advanced adenoma (35.0% vs 15.2%), and high-grade dysplasia (5.0% vs 0.5%) than non-elderly patients. Whereas Figure 2 presents patient-level prevalence using all patients within each age group as the denominator, Supplementary Figure 1 shows the histopathological distribution among patients with colorectal polyps, excluding patients without polyps. As detailed in Supplementary Figure 1, tubular adenoma was the most common histotype in the elderly (61.6% vs 47.8% in non-elderly), while hyperplastic polyps were more frequent in younger patients (50.2% vs 31.4%). In addition to pathological features, macroscopic colonoscopic parameters including polyp size and anatomical position also exhibited significant age-related disparities, as summarized in Table 2. Specifically, elderly patients had a larger median maximum polyp diameter and more frequently had polyps involving multiple colonic locations.

Figure 2 Prevalence of colorectal lesions according to age group. Prevalence was calculated using all patients within each age group as the denominator. Adenoma, advanced adenoma, and high-grade dysplasia are shown for elderly (≥ 65 years) and non-elderly (< 65 years) patients. HGD: High-grade dysplasia.

Table 2 Treatment and procedural characteristics by age group, n (%)/median (interquartile range).

Variable	≥ 65 years (n = 100)	< 65 years (n = 561)	P value
Concomitant polypectomy	88 (88.0)	412 (73.4)	0.002
Polyp location1			0.055
Ascending colon	4 (4.5)	22 (5.3)
Transverse colon	2 (2.3)	18 (4.4)
Descending colon	1 (1.2)	13 (3.2)
Sigmoid colon	13 (14.8)	93 (22.6)
Rectum	2 (2.3)	32 (7.8)
Multiple locations	66 (75.0)	234 (56.8)
Maximum polyp diameter1, mm	6 (5.0-10.0)	6 (5.0-7.0)	< 0.001
Hemorrhoid treatment modality			0.106
RBL	43 (43.0)	194 (34.6)
EPFS	57 (57.0)	367 (65.4)
Intravenous anesthesia	88 (88.0)	531 (94.7)	0.012
Hemorrhoid procedure time, minutes	10.4 (8.5-13.6)	10.2 (8.1-13.1)	0.618
Total operation duration, minutes	32.1 (22.9-40.1)	25.2 (20.3-32.0)	< 0.001

¹Analyses were limited to patients who underwent concomitant polypectomy (≥ 65 years, n = 88; < 65 years, n = 412).

P values were calculated using the Pearson χ² test, Fisher’s exact test, the Fisher-Freeman-Halton exact test, or the Mann-Whitney U test, as appropriate. RBL: Rubber band ligation; EPFS: Endoscopic polidocanol foam sclerotherapy.

Intraprocedural oozing or bleeding commonly occurred during polypectomy; all bleeding episodes were managed promptly with endoscopic hemostasis before subsequent internal hemorrhoid treatment. Thirty-day postprocedural adverse event data stratified by age are summarized in Supplementary Table 2. The overall rate of any adverse event was similar between elderly and non-elderly patients [12.0% (95%CI: 6.4-20.0) vs 11.6% (95%CI: 9.1-14.5); risk difference: 0.4%; 95%CI: -6.4 to 7.5; P = 0.867]. No serious adverse events were recorded in either group. Individual eventspecific rates including pain, anal distention, and postprocedural bleeding were low in both age groups. The wide CIs for rare adverse events, however, limited the precision of between-group comparisons.

Treatment and procedural characteristics

Treatment and procedural characteristics are summarized in Table 2. Concomitant polypectomy was more frequent in elderly patients (88.0% vs 73.4%, P = 0.002). The distribution of polyp location was similar between the two groups (P = 0.055), whereas maximum polyp diameter differed significantly (P < 0.001). The distribution of hemorrhoid treatment modalities was similar between groups (RBL: 43.0% vs 34.6%; EPFS: 57.0% vs 65.4%; P = 0.106). Intravenous anesthesia was used less frequently in elderly patients (88.0% vs 94.7%, P = 0.012). Hemorrhoid procedure time was comparable between groups (10.4 minutes vs 10.2 minutes, P = 0.618), whereas total operation duration was longer in elderly patients [32.1 (IQR: 22.9-40.1) minutes vs 25.2 (IQR: 20.3-32.0) minutes; P < 0.001].

Clinical outcomes according to age group

Clinical outcomes are presented in Table 3. Symptom improvement rates were similar between elderly and non-elderly patients (82.0% vs 82.4%, P = 0.932); the corresponding absolute risk difference and 95%CI are shown in Table 3. The proportion of patients requiring more than one treatment session was low in both groups (2.0% vs 3.7%, P = 0.557).

Table 3 Clinical outcomes of endoscopic treatment by age group, n (%).

Variable	≥ 65 years (n = 100)	< 65 years (n = 561)	P value	RD, %	95%CI
Symptom improvement	82 (82.0)	462 (82.4)	0.932	-0.4	-9.5 to 6.8
Postprocedural discomfort			0.263	-	-
Pain	6 (6.0)	16 (2.9)		-	-
Anal distention	2 (2.0)	24 (4.3)		-	-
Bleeding	2 (2.0)	10 (1.8)		-	-
Cost acceptance	85 (85.0)	470 (83.8)	0.759	1.2	-7.5 to 7.8
Patient satisfaction			0.335	-	-
Satisfied	94 (94.0)	511 (91.1)		2.9	-3.9 to 7.1
Unsatisfied	6 (6.0)	50 (8.9)		-	-
> 1 treatment session	2 (2.0)	21 (3.7)	0.557	-1.7	-4.1 to 3.4

P values were calculated using the Pearson χ² test, Fisher’s exact test, or the Fisher-Freeman-Halton exact test, as appropriate. All tests were two-sided. Risk differences and corresponding 95% confidence intervals for the primary outcome and selected clinically relevant secondary outcomes were calculated from raw 2 × 2 contingency tables using the Newcombe score method, without multivariable adjustment. Risk differences were calculated as the proportion in the ≥ 65-year group minus that in the < 65-year group. RD: Risk difference; CI: Confidence interval.

Postprocedural discomfort was uncommon and did not differ between groups. Rates of pain, anal distention, and minor bleeding were low in both elderly and non-elderly patients. Patient-reported satisfaction remained high (94.0% vs 91.1%, P = 0.335), and cost acceptance was similar between groups (85.0% vs 83.8%, P = 0.759).

Subgroup analyses within elderly patients

Among elderly patients, no statistically significant differences in symptom improvement, postprocedural discomfort, patient satisfaction, cost acceptance, or the proportion requiring more than one treatment session were observed between those aged ≥ 70 years (n = 45) and those aged 65-69 years (n = 55) (Table 4).

Table 4 Clinical outcomes within elderly patients by age subgroups, n (%).

Variable	≥ 70 years (n = 45)	65-69 years (n = 55)	P value
Symptom improvement	38 (84.4)	44 (80.0)	0.565
Postprocedural discomfort			0.593
Pain	3 (6.7)	3 (5.5)
Anal distention	2 (4.4)	0 (0.0)
Bleeding	1 (2.2)	1 (1.8)
Cost acceptance	35 (77.8)	50 (90.9)	0.067
Patient satisfaction			1.000
Satisfied	42 (93.3)	52 (94.5)
Unsatisfied	3 (6.7)	3 (5.5)
> 1 treatment session	1 (2.2)	1 (1.8)	1.000

P values were calculated using the Pearson χ² test, Fisher’s exact test, or the Fisher-Freeman-Halton exact test, as appropriate. All tests were two-sided.

An exploratory analysis according to anesthesia status within the elderly cohort is shown in Supplementary Table 3. Symptom improvement was reported in 83.0% of patients receiving intravenous anesthesia and 75.0% of those without intravenous anesthesia (P = 0.501). No statistically significant differences were observed in the other measured clinical outcomes, including postprocedural discomfort, patient satisfaction, cost acceptance, and the proportion requiring more than one treatment session.

Subgroup analyses stratified by hemorrhoid treatment modality

Age-stratified clinical outcomes of RBL and EPFS are presented in Supplementary Tables 4 and 5. The RBL subgroup contained 43 elderly and 194 non-elderly patients, while the EPFS subgroup included 57 elderly and 367 non-elderly patients. No statistically significant age-group differences were observed in symptom improvement, postprocedural discomfort, individual adverse events, cost acceptance, patient satisfaction, or the proportion requiring more than one treatment session within either treatment subgroup (all P > 0.05).

Factors associated with symptom improvement

Univariable and multivariable logistic regression analyses were performed to identify factors associated with posttreatment symptom improvement (Figure 3). Univariable crude results are presented in Figure 3A, and multivariableadjusted results are shown in Figure 3B.

Figure 3 Factors associated with symptom improvement following endoscopic treatment of internal hemorrhoids. A: Odds ratios and 95% confidence intervals from univariable logistic regression analysis; B: Adjusted odds ratios and 95% confidence intervals derived from multivariable logistic regression analysis. Covariates included age, sex, body mass index, hemorrhoid grade, treatment modality, anesthesia use, and total operation duration. OR: Odds ratio; CI: Confidence interval; BMI: Body mass index; RBL: Rubber band ligation; EPFS: Endoscopic polidocanol foam sclerotherapy.

In univariable analysis, male sex (OR = 1.71, 95%CI: 1.1-2.57, P = 0.009) and body mass index (OR = 1.06, 95%CI: 1.01-1.13, P = 0.038) were associated with symptom improvement. After multivariable adjustment, only male sex remained independently associated with higher odds of symptom improvement (adjusted OR = 1.66; 95%CI: 1.09-2.54, P = 0.019). Age (adjusted OR = 1.01; 95%CI: 0.99-1.02, P = 0.365), body mass index, hemorrhoid grade, treatment modality, anesthesia use, and total operation duration were not significantly associated with symptom improvement (all P > 0.05). The multivariable model showed no evidence of poor calibration (Hosmer-Lemeshow χ² = 7.36, df = 8, P = 0.498).

DISCUSSION

In this real-world cohort, observed clinical outcomes following one-stop colonoscopy-based simultaneous management of colorectal polyps and internal hemorrhoids were generally similar between elderly and non-elderly patients. Elderly participants carried more comorbidities and a higher rate of advanced adenomas and high-grade dysplasia, yet both age groups achieved over 80% hemorrhoid symptom improvement with low rates of procedure-related adverse events. In multivariable analysis adjusting for relevant clinical and procedural factors, age was not significantly associated with post-treatment symptom improvement. These findings suggest that chronological age alone may not necessarily preclude consideration of this combined minimally invasive endoscopic regimen in appropriately selected older adults.

The low frequency of observed adverse events in elderly patients may partly reflect the minimally invasive nature of modern endoscopic interventions[14,15]. RBL and polidocanol foam sclerotherapy primarily target the submucosal vascular cushions, resulting in limited tissue injury and minimal disruption to surrounding structures[16,17]. Consistent with current international hemorrhoid-management guidelines[6,7], both modalities are established first-line office-based therapies for grade I-III symptomatic internal hemorrhoids, although head-to-head comparative studies have reported inconsistent outcomes regarding postprocedural pain and recurrence risk[8].

Our standardized workflow prioritizes full colonoscopy and polypectomy prior to retroflexed hemorrhoid therapy, which minimizes potential procedural interference and facilitates differentiation of bleeding sources. In our cohort, intraprocedural oozing or bleeding commonly occurred during polypectomy; all bleeding episodes were promptly controlled by endoscopic hemostasis before initiating hemorrhoid treatment, and no delayed post-polypectomy bleeding or colonic perforation events were documented.

In addition, consolidating polypectomy and hemorrhoid therapy into a single session may offer the practical advantage of completing both interventions during one episode of endoscopic care, potentially avoiding repeated bowel preparation and additional endoscopic sessions[2,18]. Nevertheless, these presumed practical benefits including reduced procedural burden, repeated bowel preparation, and anesthesia exposure cannot be definitively validated in our nonrandomized retrospective design because no staged-management comparator cohort was enrolled, and causal relationships cannot be inferred. Notably, elderly patients had a longer total operation duration than non-elderly patients, although the duration of the hemorrhoid intervention itself was similar between groups. Individualized anesthetic management and careful intraoperative monitoring therefore remain important in elderly patients undergoing combined endoscopic procedures.

Beyond procedural safety, the one-stop approach may offer clinical advantages in selected patients. Elderly patients in this cohort had a markedly higher prevalence of adenoma, advanced adenoma, and high-grade dysplasia, underscoring the importance of complete colonoscopic evaluation even in patients presenting with anorectal symptoms[1,19,20]. Integrating colorectal evaluation with hemorrhoid treatment allows diagnostic and therapeutic procedures to be completed within the same session and may simplify the overall endoscopic care pathway[21]. This strategy may be particularly beneficial in older adults with multiple comorbidities or increased vulnerability to repeated interventions[22].

Subgroup analyses were generally consistent with the overall findings. No statistically significant differences in the measured clinical outcomes were observed between patients aged ≥ 70 years and those aged 65-69 years. However, the relatively small number of patients in these age subgroups limits the precision of these comparisons and the ability to detect uncommon adverse events. Similarly, no statistically significant age-group differences in the measured clinical outcomes were observed within either the RBL or EPFS subgroup, although the relatively small number of elderly patients within each treatment subgroup warrants cautious interpretation. No statistically significant differences were identified according to anesthesia status within the elderly cohort, but the small number of patients who underwent treatment without anesthesia further limits definitive conclusions.

Our findings are consistent with prior studies showing that elderly patients undergoing hemorrhoid treatment often have higher comorbidity burdens but do not necessarily experience worse outcomes or higher complication rates[23-25]. Several prior investigations have demonstrated the technical feasibility of performing endoscopic hemorrhoid therapy during diagnostic colonoscopy; nevertheless, most published reports enrolled mixed-age populations and did not specifically evaluate older adults with synchronous colorectal polyps, a frequently-encountered real-world clinical scenario[16]. Taken together, these findings, alongside existing evidence on minimally invasive hemorrhoid interventions, suggest that an integrated one-stop endoscopic strategy may be feasible in appropriately selected elderly patients, although larger prospective studies are needed to more precisely establish its safety and long-term effectiveness.

Limitations

This study has several limitations. First, this is a single-center, uncontrolled retrospective cohort without a staged-management comparator. Thus, causal inferences that one-stop care reduces procedural burden, resource consumption, anesthesia exposure or costs cannot be drawn, and only observational safety profiles can be reported. Second, selection bias may stem from loss to followup and incomplete key outcome data. Baseline imbalances in hemorrhoid grade and presenting symptoms were observed among patients < 65 years who were lost to follow-up; patients excluded because of heterogeneous missing key study data could not be reliably included in the baseline comparison, leaving residual selection bias that could not be fully evaluated. In addition, symptom improvement and other patient-reported outcomes were assessed retrospectively by telephone follow-up without a validated symptom instrument, which may have introduced recall or misclassification bias. Third, the small sample size of elderly patients limits statistical power, particularly for detecting rare severe adverse events in subgroups. Fourth, important comorbidity and procedural factors were imbalanced between age groups. Although we applied a unified prespecified covariate set for multivariable adjustment in Figure 3 and assessed model calibration using the Hosmer-Lemeshow goodness-of-fit test, additional sensitivity analyses were not performed, and residual confounding cannot be fully excluded. Fifth, median follow-up was 12 months; long-term recurrence and sustained symptom control remain to be determined. Prospective multicenter studies with larger elderly cohorts and longer follow-up are needed to further evaluate this one-stop strategy.

CONCLUSION

In this real-world cohort, one-stop colonoscopy-based endoscopic management was associated with high rates of symptom improvement and a low frequency of observed procedure-related adverse events in appropriately selected elderly patients. Concomitant polypectomy was frequently performed during the same session, with no delayed post-polypectomy bleeding or colonic perforation documented in this cohort. Despite a higher burden of comorbidities and a greater prevalence of advanced adenomas and high-grade dysplasia, observed clinical outcomes were generally similar between elderly and non-elderly patients. These findings support the clinical feasibility of a consolidated one-stop endoscopic strategy in appropriately selected older patients. Its practical advantages relative to conventional staged management remain unproven and warrant prospective comparative studies.