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An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis

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Abstract

Background

Pathologic hemorrhoids are common among adults age 45–65. Hemorrhoids are characterized as internal or external, and grades 1–4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments.

Methods

A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS.

Results

A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01–6.51), infrared photocoagulation (OR 0.38, CI 0.02–5.61), and stapling (OR 0.48, CI 0.19–1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00–0.46) and harmonic scalpel (OR 0.00, CI 0.00–0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00–2.54) and LigaSure (OR 0.16, CI 0.03–0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05–1.51) and stapled (OR 0.36, CI 0.15–0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser.

Conclusion

There are multiple favorable techniques without a clear “gold standard” based on current literature. Open discussion should be had between patients and physicians to guide individualized care.

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References

  1. Mott T, Latimer K, Edwards C (2018) Hemorrhoids: diagnosis and treatment options. Am Fam Physician. Published online February 1, 2018.

  2. Lawrence A, McLaren ER (2020) External hemorrhoid. StatPearls. Published online November 19, 2020.

  3. Holzheimer RG (2001) Surgical treatment of haemorrhoids. Surg Treat Evid-Based Probl-Oriented. Published online 2001.

  4. Simillis C, Thoukididou SN, Slesser AAP, Rasheed S, Tan E, Tekkis PP (2015) Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. Published online December 2015. https://doi.org/10.1002/bjs.9913

  5. Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L, Pratschke J, Peer S, Gruber H (2016) Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial. Colorectal Dis. Published online July 2016. https://doi.org/10.1111/codi.13280

  6. Genova P, Damiano G, Lo Monte AI, Genova G (2019) Transanal hemorrhoidal dearterialization versus Milligan-Morgan hemorrhoidectomy in grade III/IV hemorrhoids. Ann Ital Chir. Published online 2019.

  7. Mahmood K, Asif KH, Ashraf MN, Imran M (2016) Comparison of open vs closed haemorrhoidectomy in the management of haemorrhoids. Pak J Med Sci 1;10:1132-4.

  8. Abid KJ, Gul M, Amin MN, Saleem MT, Ishaque S (2015) Comparison between open and stapled haemorrhoidectomy in the treatment of 3rd and 4th degree haemorrhoids at surgical unit II Shalamar Hospital Lahore. Pakistan J Med H Sci 1;9(4):1144-7.

  9. Zhai M, Zhang YA, Wang ZY, Sun JH, Wen J, Zhang Q, Li JD, Wu YZ, Zhou F, Xu HL (2016) A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids. Gourcerol G, ed. Gastroenterol Res Pract. 2016;2016:8143703. https://doi.org/10.1155/2016/8143703

  10. Giarratano G, Toscana E, Toscana C, Petrella G, Shalaby M, Sileri P (2018) Transanal Hemorrhoidal Dearterialization Versus Stapled Hemorrhoidopexy: Long-Term Follow-up of a Prospective Randomized Study. Surg Innov. Published online June 2018. https://doi.org/10.1177/1553350618761757

  11. Tsunoda A, Takahashi T, Kusanagi H (2017) A prospective randomized trial of transanal hemorrhoidal dearterialization with mucopexy versus ultrasonic scalpel hemorrhoidectomy for grade III hemorrhoids. Tech Coloproctology 21(8):657-665. https://doi.org/10.1007/s10151-017-1673-1

  12. Bilgin Y, Hot S, Barlas İS, Akan A, Eryavuz Y (2015) Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease. Asian J Surg 38(4):214-219. https://doi.org/10.1016/j.asjsur.2014.09.004

  13. Mengal MA, Qasim KF, Baloch FA, Elahi SA (2017) Early Outcomes of Stapled Vs Conventional Hemorrhoidectomy. Pak J Med Health Sci 1;11(1):180-3.

  14. Samee MU, Qammar SM, Saifullah W, et al. (2018) Stapled Hemorrhoidopexy versus Traditional Hemorrhoidectomy: A Comparative Study of two Procedures in Advanced Hemorrhoids. Pak J Med Health Sci 12(4).

  15. Bakhtiar N, Moosa FA, Jaleel F, Qureshi NA, Jawaid M (2016) Comparison of hemorrhoidectomy by LigaSure with conventional Milligan Morgan’s hemorrhoidectomy. Pak J Med Sci. Published online 2016. https://doi.org/10.12669/pjms.323.9976

  16. Alhomoud H, Mohsen M, Termos S, Abdelmohsen M (2018) Hemorrhoidectomy with Harmonic Scalpel vs Conventional Hemorrhoidectomy. World J Laparosc Surg 11:121. https://doi.org/10.5005/jp-journals-10033-1352

  17. Megahed H (2019) Harmonic scalpel versus conventional hemorrhoidectomy. Al-Azhar Assiut Med J 17(1):24. https://doi.org/10.4103/AZMJ.AZMJ_104_18

  18. Lin H-C, He Q-L, Shao W-J, et al. (2019) Partial Stapled Hemorrhoidopexy Versus Circumferential Stapled Hemorrhoidopexy for Grade III to IV Prolapsing Hemorrhoids: A Randomized, Noninferiority Trial. Vol 62. https://doi.org/10.1097/DCR.0000000000001261

  19. Aljabery RM, Jaber AA (2020) Comparison of Hemorrhoidectomy by Ligasure with Conventional Milligan Morgan’s Hemorrhoidectomy. Medico Leg Update. 2020;20(1):1324-1328. https://doi.org/10.37506/mlu.v20i1.558

  20. Shoukat H, Iqbal M, Ullah S, Mirza A, Dar UF, Dar UF (2016) Comparison of Hemorrhoidectomy Using Bipolar Diathermy Vs Harmonic Scalpel. Pak J Med Health Sci 1;10(2):489-91.

  21. Nikshoar MR, Maleki Z, Nemati Honar B (2017) The Clinical Efficacy of Infrared Photocoagulation Versus Closed Hemorrhoidectomy in Treatment of Hemorrhoid. J Lasers Med Sci 9(1):23-26.

  22. Trenti L, Biondo S, Galvez A, Bravo A, Cabrera J, Kreisler E (2017) Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes. Tech Coloproctology 21(5):337-344. https://doi.org/10.1007/s10151-017-1620-1

  23. Carvajal López F, Hoyuela Alonso C, Juvany Gómez M, Troyano Escribano D, Trias Bisbal MA, Martrat Macià A, Ardid Brito J (2019) Prospective Randomized Trial Comparing HAL-RAR Versus Excisional Hemorrhoidectomy: Postoperative Pain, Clinical Outcomes, and Quality of Life. Surg Innov 26(3):328-336. https://doi.org/10.1177/1553350618822644

  24. Titov AI, Abritsova MV, Mudrov AA (2016) Comparison of Doppler-assisted dearterialization with mucopexy and hemorrhoidectomy. Khirurgiya Zhurnal Im NI Pirogova (2):24. https://doi.org/10.17116/hirurgia2016224-28

  25. Kendirci M, Şahiner İT, Şahiner Y, Güney G (2018) Comparison of Effects of Vessel-Sealing Devices and Conventional Hemorrhoidectomy on Postoperative Pain and Quality of Life. Med Sci Monit Int Med J Exp Clin Res. 2018;24:2173-2179. https://doi.org/10.12659/msm.909750

  26. Ripetti V, La Vaccara V, Greco S, Arullani A (2015) A randomized trial comparing stapled rectal mucosectomy versus open and semiclosed hemorrhoidectomy. Diseases of the Colon & Rectum 1;58(11):1083-90. https://doi.org/10.1097/DCR.0000000000000454

  27. Trenti L, Biondo S, Moreno EK, Sanchez-Garcia JL, Espin-Basany E, Landaluce-Olavarria A, Bermejo-Marcos E, Garcia-Martinez MT, Jiménez DA, Jimenez F, Alonso A (2019) Short-term outcomes of transanal hemorrhoidal dearterialization with mucopexy versus vessel-sealing device hemorrhoidectomy for grade III to IV hemorrhoids: a prospective randomized multicenter trial. Diseases of the Colon & Rectum 1;62(8):988-96. https://doi.org/10.1097/DCR.0000000000001362

  28. Maloku H, Lazović R, Terziqi H (2019) Laser hemorrhoidoplasty versus Milligan-Morgan hemorrhoidectomy: Short-term outcome. Vojnosanitetski pregled 76(1):8-12. https://doi.org/10.2298/VSP170125070M

  29. Kim JH, Kim DH, Lee YP, Suh KW. Long-term follow-up of StarionTM versus Harmonic ScalpelTM hemorrhoidectomy for grade III and IV hemorrhoids. Asian J Surg. 2019;42(1):367-372. https://doi.org/10.1016/j.asjsur.2018.05.002

  30. Agbo SP (2011) Surgical management of hemorrhoids. J Surg Tech Case Rep 3(2):68. https://doi.org/10.4103/2006-8808.92797

  31. Cerato MM, Cerato NL, Passos P, Treigue A, Damin DC (2014) Surgical treatment of hemorrhoids: a critical appraisal of the current options. Arq Bras Cir Dig 27(1):66-70. https://doi.org/10.1590/s0102-67202014000100016

  32. Correa-Rovelo JM, Tellez O, Obregón L, Miranda-Gomez A, Moran S. Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial. Dis Colon Rectum. 2002;45(10):1367-1374; discussion 1374-1375. https://doi.org/10.1007/s10350-004-6426-3

  33. Ortiz H, Marzo J, Armendariz P (2002) Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg 89(11):1376-1381. https://doi.org/10.1046/j.1365-2168.2002.02237.x

  34. Senagore AJ, Singer M, Abcarian H et al (2004) A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum 47(11):1824–1836. https://doi.org/10.1007/s10350-004-0694-9

    Article  CAS  PubMed  Google Scholar 

  35. Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S (2001) Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg 88(5):669–674. https://doi.org/10.1046/j.0007-1323.2001.01772.x

    Article  CAS  PubMed  Google Scholar 

  36. Mehigan BJ, Monson JR, Hartley JE (2000) Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet Lond Engl 355(9206):782–785. https://doi.org/10.1016/S0140-6736(99)08362-2

    Article  CAS  Google Scholar 

  37. Racalbuto A, Aliotta I, Corsaro G, Lanteri R, Di Cataldo A, Licata A (2004) Hemorrhoidal stapler prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial. Int J Colorectal Dis. 19(3):239–244. https://doi.org/10.1007/s00384-003-0547-3

  38. Boccasanta P, Capretti PG, Venturi M et al (2001) Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am J Surg 182(1):64–68. https://doi.org/10.1016/s0002-9610(01)00654-7

    Article  CAS  PubMed  Google Scholar 

  39. Kairaluoma M, Nuorva K, Kellokumpu I (2003) Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome. Dis Colon Rectum. 46(1):93–99. https://doi.org/10.1007/s10350-004-6502-8

  40. Rowsell M, Bello M, Hemingway DM (2000) Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial. Lancet Lond Engl 355(9206):779–781. https://doi.org/10.1016/s0140-6736(99)06122-x

    Article  CAS  Google Scholar 

  41. Picchio M, Greco E, Filippo AD, Marino G, Stipa F, Spaziani E (2015) Clinical outcome following hemorrhoid surgery: a narrative review. Indian J Surg. Published online December 2015. https://doi.org/10.1007/s12262-014-1087-5

  42. Khanna R, Khanna S, Bhadani S, Singh S, Khanna AK (2010) Comparison of LigaSure hemorrhoidectomy with conventional Ferguson’s hemorrhoidectomy. Indian J Surg. Published online August 2010. https://doi.org/10.1007/s12262-010-0192-3

  43. Wang J-Y, Lu C-Y, Tsai H-L et al (2006) Randomized controlled trial of LigaSure with submucosal dissection versus Ferguson hemorrhoidectomy for prolapsed hemorrhoids. World J Surg 30(3):462–466. https://doi.org/10.1007/s00268-005-0297-1

    Article  PubMed  Google Scholar 

  44. Haksal MC, Çiftci A, Tiryaki Ç, Yazıcıoğlu MB, Özyıldız M, Yıldız SY (2017) Comparison of the reliability and efficacy of LigaSure hemorrhoidectomy and a conventional Milligan-Morgan hemorrhoidectomy in the surgical treatment of grade 3 and 4 hemorrhoids. Turk J Surg 33(4):233–236. https://doi.org/10.5152/turkjsurg.2017.3493

    Article  PubMed  PubMed Central  Google Scholar 

  45. de Freitas MOS, Santos JAD, Figueiredo MFS, Sampaio CA (2016) Analysis of the main surgical techniques for hemorrhoids. J Coloproctolgy. Published online June 2016. https://doi.org/10.1016/j.jcol.2015.12.008

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Authors and Affiliations

  1. Temple University Lewis Katz School of Medicine, 3500 N Broad St, Philadelphia, PA, 19140, USA

    Bianca Aibuedefe

  2. Department of General Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th floor, Philadelphia, PA, 19140, USA

    Sarah M. Kling

  3. Department of General Surgery, Department of Colon and Rectal Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th Floor, Philadelphia, PA, 19140, USA

    Matthew M. Philp, Howard M. Ross & Juan Lucas Poggio

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  2. Sarah M. Kling
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Correspondence to Bianca Aibuedefe.

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Aibuedefe, B., Kling, S.M., Philp, M.M. et al. An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int J Colorectal Dis 36, 2041–2049 (2021). https://doi.org/10.1007/s00384-021-03953-3

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