systematic review of doppler guided haemorrhoidal artery ligation

7/25/2019 Systematic Review of Doppler Guided Haemorrhoidal Artery Ligation

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Clinical outcome following Doppler-guided haemorrhoidalartery ligation: a systematic review

P. H. Pucher*, M. H. Sodergren*, A. C. Lord, A. Darzi* and P. Ziprin*

*Department of Surgery and Cancer, Imperial College London, London, UK and Department of Surgery, Croydon Health Services NHS Trust,

Croydon, UK

Received 25 June 2012; accepted 13 January 2013; Accepted Article online 12 March 2013

Abstract

AimDoppler-guided haemorrhoidal artery ligation

(DGHL) has experienced wider uptake and has recently

received National Institute for Health and Clinical

Excellence (NICE) approval in the UK. A systematic

review of the literature was conducted to assess its safety

and efficacy.

MethodThis review was conducted in keeping with

PRISMA guidelines. MEDLINE, EMBASE, Google

Scholar and Cochrane Library databases were searched.

Studies describing DGHL as a primary procedure and

reporting clinical outcome were considered. Primary

end-points were recurrence and postoperative pain. Sec-

ondary end-points included operation time, complica-

tions and reintervention rates. Studies were scored for

quality with either Jadad score or NICE scoring guide-

lines.

ResultsTwenty-eight studies including 2904 patients

were included in the final analysis. They were of poor

overall quality. Recurrence ranged between 3% and 60%

(pooled recurrence rate 17.5%), with the highest rates

for grade IV haemorrhoids. Postoperative analgesia was

required in 0

38% of patients. Overall postoperativecomplication rates were low, with an overall bleeding

rate of 5% and an overall reintervention rate of 6.4%.

The operation time ranged from 19 to 35 min.

Conclusion DGHL is safe and efficacious with a low

level of postoperative pain. It can be safely considered

for primary treatment of grade II and III haemorrhoids.

Keywords Haemorrhoid, hemorrhoid, Doppler-guided,

dearterialization, artery ligation, surgery

Introduction

Several treatment options are currently in use for the

surgical treatment of haemorrhoids when conservative

treatment is inappropriate or unsuccessful. Whilst Milli-

ganMorgan haemorrhoidectomy (MMH) [1] is con-

sidered the gold standard therapy, it is not without

complications and can be associated with considerable

postoperative pain [2]. Advances in technology and sur-

gical technique include the procedure for prolapse and

haemorrhoids (PPH) [3]. However, a 2006 review of

23 randomized trials found that PPH was inferior toMMH for recurrence and complications [2]. An alterna-

tive is Doppler-guided transanal haemorrhoidal ligation

(DGHL).

Doppler-guided haemorrhoidal artery ligation

(DGHL) utilizes a specialized anoscope incorporating a

Doppler ultrasound probe to allow identification and

targeted ligation of haemorrhoidal arteries [4]. Its mini-

mally invasive nature is intended to provide effective

treatment whilst minimizing postoperative pain. DGHL

can be performed under local anaesthesia and is suitable

as a day case procedure. As this technology has

improved, it has experienced wider uptake as an alterna-

tive to PPH or traditional MMH, despite a previous

systematic review concluding there was a lack of good

evidence or clinical trials to support the efficacy of

DGHL [5]. However, the recent endorsement of

DGHL by the UK National Institute for Health andClinical Excellence (NICE) for the management of

haemorrhoids [6] suggests that this has changed. In the

last 3 years, 20 studies entailing the use of DGHL in

approximately 1000 patients have been published. It

may therefore now be time to re-evaluate the evidence

available for DGHL. The aim of this review was to

assess the current evidence for DGHL to establish its

safety and efficacy with regard to treatment success and

complications.

Correspondence to: Mikael Sodergren, Imperial College London, St Marys

Hospital, Department of Surgery and Cancer, Praed Street, London W2 1NY,

UK.

E-mail: [email protected]

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2013 The Association of Coloproctology of Great Britain and Ireland. 15, e284e294e284

Systematic review doi:10.1111/codi.12205


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Method

Search strategy

The review was conducted in keeping with PRISMA

guidelines [7]. MEDLINE, EMBASE, Google Scholar

and Cochrane Library databases (from 1950 to 1 March

2012) were searched using MeSH headings and the fol-

lowing search strings: Doppler, dearterialization, artery

ligation. These were combined with the term hemor-

rhoid using the AND boolean operator.

Selection criteria

Titles and abstracts of search results were screened for

articles relevant to DGHL. Studies which assessed

DGHL as the primary procedure and reported clinical

outcomes as primary end-points were included. Rele-

vant articles were retrieved for full text analysis.Reviews, commentaries, letters and editorials as well as

articles not translated into English were excluded. In

cases where multiple publications referred to the same

dataset or patient group, such as where short- and

long-term follow-ups were published separately, only

the longer-term follow-up was considered for inclusion

in this review.

Primary end-points were recurrence and postopera-

tive pain [8]. Secondary end-points were operation

time, postoperative complications, long-term symptom

recurrence (prolapse, bleeding or pain) and reoperation

rate.

A literature search and study selection were per-

formed by two independent reviewers, with any dis-

crepancy revolved by consensus. The same reviewers

then conducted data extraction from the selected stud-

ies using a standard pro forma. For randomized trials

and comparative cohort studies only data relating to

the outcome were extracted as the randomized trials

had already been recently subject to a limited review

[8]. Studies were critically appraised and assigned a

quality score based on the Jadad scoring system for

comparative trials [9] or a score of , + or ++ based

on NICE guidelines for assessment of cohort studies

[10].

Results

The selection process for the included articles is summa-

rized in Fig. 1. Initial database searches returned 100

references, and applying the selection criteria resulted in

39 publications being retrieved for further consideration.

Twenty-eight articles were included in the final analysis,

comprising five randomized trials, two comparative

cohort studies and 21 cohort studies (Tables 1 and 2).

These included 2904 patients having DGHL. Most

studies were from European centres, the exceptions

Online database search with exclusion of

duplicate search results

n= 100

Records screened by title and

abstract

n= 100

Excluded as not relating to

DGHAL or not in English

n= 61

Full-text articles assessed

Excluded as not DGHAL (n= 3),

subset of other published data

(n= 3), not clinical endpoint

(n= 1), DGHAL as secondary

procedure (n= 1), unable to

retrieve (n= 3)Studies included in final

analysis

n= 28

Figure 1 Flow chart of the study literature search and results (DGHL, Doppler-guided haemorrhoidal artery ligation).

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2013 The Association of Coloproctology of Great Britain and Ireland. 15, e284e294 e285

P. H. Pucher et al. Clinical outcome following DGHL: systematic review


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Table

1

Comparativetrials.

Author,year,country,

studytype

DG

HLpatients

(n),grade

Ageat

DGHL(years)*

Compared

procedure

Patients(n),grade

ofhaemorrhoid

Agenon-

DGHL(years)

Priortreatment

Criticalappraisal

Quality

score

Shuurman,2012,

Netherlands,

randomizedtrial[29]

38,II/III

50

13.0

HLwith

out

Dopple

r

guidance

35,II/III

51

13.7

Singlesurgeon,not

blinded.

Poweredtoassume

25%

poorersuccessrate

fornon-

DopplerHL

3

Infantino,2012,Italy,

10-centrerandomized

trial[28]

85,III

47.6

11

PPH

84,III

46.2

11.5

Assumes10%inferio

rityof

DGHLinpoweringstudy.

Relativelysmallsam

plefor

numberofcentres

3

Gupta,2011,India,

randomizedtrial[15]

24,III

44

11.2

HLwith

out

Dopple

r

guidance

24,III

47.4

10.4

Homogeneousgrou

ps.Single

surgeon,moderate

length

offollow-up

5

Giordano,2011,UK,

comparative

cohorttrial[27]

28,II(16),

I

II(12)

54(2373)

PPH

24,II(15),

III(9)

48(3578)

1patientin

DGHLgroup

priorMMH

Nonrandomized,group

allocationdecided

intraoperativelyby

surgeon

0

Festen,2009,Netherlands,

randomizedtrial[26]

23,III(19),

IV

(4)

Mean39

PPH

18,III(17),

IV(1)

35

Allhadprevious

RBL

Homogeneousgrou

p.

Smallsample

2

Bursics,2004,Hungary,

randomizedtrial[29]

30,I(1),

II

(6),III

(1

0),IV(13)

47.4

15

MMH

30,II(7),III

(9),IV(14)

46.4

13

Homogeneousgrou

p.

Smallsample

0

Avital,2011.Israel,

comparativecohort[11]

51

(III)

50

7.3

PPH

63,III

52

3.2

14patientsin

DGHLgroup

and13inPPH

grouphad

RBLor

sclerotherapy

Nonrandomized,patient

choiceofprocedure.

Singlesurgeon

0

PPH,procedureforprolapseand

haemorrhoids;HL,haemorrhoidalarteryligation;DGHL,Doppler-guidedhaemorrh

oidalarteryligation;MMH,MilliganMorganhaemorrhoidec-

tomy;RBL,rubberbandligation

.

*Agereportedasmean

SD(ra

nge).Patientsreportedbypreoperativelygradedseverityofhaemorrhoids.

Qualityscore:Jadadscoreforcomparativetrials,orNICEguidancerating

forcohorttrials.

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Table

2

Cohortstudies.


studytype

Pat

ients

(n)

Grade(no.

ofpatients)

Age(years)*

Procedure

Priortreatment

Criticalappraisal

Quality

score

Avital,2012,Israel,cohort

study[12]

100

II(19),III(81)

Mean42

DGHL

Singlesurgeon,report

ofinitialcases

Szmulowicz,2011,USA,

cohortstudy[13]

96

IIorIIIrecordedfor

40%ofpatients

63.5(2181)

DGHL+

RAR(9.4%only

DGHL)

15RBL

,4MMH,3PPH,4

multipleprocedures

Initialcaseswith

significantlyhigher

recurrenceratein

earlieroperations.

Gradenotrecord

ed,

heterogeneousgr

oup

Spyridakis,2011,Greece,

cohortstudy[18]

90

II(43),III(39),

IV(8)

46

12.6

DGHL

9MMH

,4RBL

Heterogeneousgroup

Ratto,2011,Italy,

cohortstudy[32]

35

IV

50.4

13.

8

DGHL+

RAR

Homogenousgroup,

experiencedsurgeons.

Smallsamplesize

+

Jeong,2011,SKorea,

cohortstudy[16]

97

II(13),III(68),

IV(16)

51.7

13.

2

DGHL+

RAR

5previo

ustreatment

Smallsamplesizefor

gradeIIandIV

+

Faucheron,2011,France,

cohortstudy[33]

100

IV

50(2185)

DGHL+

RAR,23patients

additionallyhadskintag

excision,1procedure

forfissure

58RBL

orphotocoagulation,

3MMH,9PPH,7

previousDGHL

Severalpatientsha

d

previousDGHL

Walega,2010,Poland,

cohortstudy[34]

30

IIIandIV

53(2973)

DGHL+

RAR

Initialcases,withall

3symptomatic

recurrencespartoffirst

10patients.Smallsample

Theodoropoulos,2010,

Greece,four-centre

cohortstudy[35]

147

III(95),IV(52)

45

5

87DGHL,60also

excisionorrectopexy,

12alsosphincterotomy

Heterogeneousgroup.

Selectionbias,on

lythose

with>3monthfollow-up

recordedselected

forstudy

Ratto,2010,Italy,

cohortstudy[25]

170

II(13),III(141),

IV(16)

47.3

13

(2281)

DGHL,DGHL+

RARin

32.9%ofpatients

Allgrad

eIIhadprevious

failedtherapy,15patients

hadprevioussurgery

(typen

otstated)

Initialcases,different

equipmentused(model

upgrade)forlatte

rhalf

ofcases.Heterog

eneous

procedure

Pol,2010,Netherlands,

cohortstudy[36]

244

Allgrades

49(2681)

DGHL

Initialcases,procedure

alsoperformedongrade

Ihaemorrhoids

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Table

2

(Continued).


studytype

Patients

(n)

Grade(no.

ofpatients)

Age(years)

*

Procedure

Priortreatment

Criticalappraisal

Quality

score

Infantino,2010,Italy,

five-centrecohort

study[37]

112

II(39),III(73)

48

13

DGHL

Homogeneousgroup

+

Forrest,2010,UK,

cohortstudy[24]

77

II(12),III(65)

DGHL+

RAR

Homogeneousgroup,

singlesurgeon

+

Wilkerson,2009,UK,

cohortstudy[17]

113

Allgrades

52(2082)

DGHL

53RBL

orsclerotherapy,

1PPH

,1MMH

Heterogeneousgroup,

nostratificationb

y

grade,moderatelosses

tofollow-up

Walega,2009,Austria/

Poland,cohort

study[20,38]

507

II(144),III(319),

IV(44)

DGHL,45alsohad

procedurefor

fissureortag

Initial100procedures

bysinglesurgeon

Faucheron,2008,France,

cohortstudy[19]

100

II(1),III(78),

IV(21)

45

13.7

(2176)

DGHL,12excision

ofskintag,7

fissurectomy

12RBL

orsclerotherapy,

4PPH

,2MMH

Homogeneousgroup

+

WallisdeVries,2007,

Netherlands,cohort

study[39]

110

II(42),III(68)

46(2580)

DGHL

Limitedfollow-up,

homogeneousgroup

+

DalMonte,2007,Italy,

cohortstudy[21]

330

II(138),III(162),

IV(30)

52.4(248

5)

DGHL

96RBL

,64sclerotherapy,

13cryotherapy,

2PPH

,2MMH

Poorpercentagefollow-up

Abdeldaim,2007,Ireland,

cohortstudy,[22]

27

I(1),II(15),

III(11)

DGHL

Smallpilotstudy,

unclearreporting

ofoutcomes

Ramirez,2005,Spain,

cohortstudy[23]

32

III(27),IV(5)

43(2676)

DGHL

Smallsample

+

Felice,2005,Malta,

cohortstudy[40]

68

III

48(2174)

DGHL

7RBL,

1MMH

Homogeneousgroup

+

Sohn,2001,USA,

cohortstudy[14]

60

Notgiven

48(2287)

DGHL,1also

underwent

fistulotomy

7RBL,

1MMH

Gradeofhaemorrhoids

andlengthoffollow-up

notreported

DGHL,Doppler-guidedhaemor

rhoidalarteryligation;RAR,rectoanalrepair;RBL,rubberbandligation;PPH,proce

dureforprolapseandhaemorrhoids;MMH

,MilliganMorgan

haemorrhoidectomy.

*Agereportedasmean

SD(ra

nge).

Qualityscore:studyqualityscoreperNICEassessmentguidance.

Originalpostoperativeresultspublishedin2006byScheyeretal.[39].

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being two from Israel [11,12], two from the USA

[13,14], one from India [15] and one from South Korea

[16]. Twenty-four of 28 included articles (2430

patients, 85% of all reported patients) stated the preop-

erative haemorrhoidal grade. These included grades I in

2 (0.1%), grade II in 501 (21%), grade III in 1515

(63.3%) and grade IV in 374 cases (16%). Twenty stud-

ies assessed DGHL as the primary procedure and seven

studies performed DGHL with rectoanal repair, in which

a further mucopexy was placed to reduce and fix pro-

lapsed haemorrhoidal tissue. Numerous studies also

described additional procedures being performed simul-

taneously in some patients, most commonly skin tag

excision or procedures for treatment of anal fissure or

fistula.

Recurrence

Recurrence varied from 3% to 60%, at 6 weeks to5 years (Table 3). The pooled total recurrence rate was

17.5%. Wilkerson et al. [17] reported the highest recur-

rence, 60%, at 30 months follow-up of 113 patients

with haemorrhoids of unspecified preoperative grade.

Despite the high symptom recurrence rate, 86% of

patients reported a significant improvement in symp-

toms. The longest follow-up was reported in a 5-year

follow-up study of 100 patients with grade II and grade

III haemorrhoids who underwent DGHL [12]. These

authors found recurrence in 12% of patients treated for

grade II and 31% for grade III haemorrhoids. Recur-

rence rates were universally higher in patients who had

been diagnosed with higher-grade haemorrhoids. Spyri-

dakis et al. [18] reported recurrence of 0% in grade II,

5% in grade III and 50% in grade IV at 12 months,

whilst Faucheron et al. [19] reported recurrence rates

of 9% for grade III and 23.8% for grade IV at

36 months. Similar findings were reported by other

studies which stratified recurrence rates by preoperative

grading [12,20]. The most commonly reported symp-

toms of recurrence at follow-up were bleeding (2.6

26.9%, pooled results 13.8%), prolapse (428.6%,

pooled results 9.4%) and chronic pain (3.310%). Pain

at follow-up was not pooled, as this symptom was

inconsistently reported.

Postoperative complications

The incidence of postoperative pain was reported by 14

studies. Where the definition of pain was explicitly

given, most studies defined postoperative pain as the

requirement of any analgesia, with one study instead

defining pain as a visual analogue pain score >2 on a

scale of 110 [21]. The reported incidence of postoper-

ative pain ranged from 0% to 38% with a pooled value

of 15% (Table 3).

Eighteen studies reported postoperative bleeding

complications. Most studies reported bleeding rates

between 0% and 8%, but three studies reported espe-

cially high rates of postoperative bleeding, at 18 [22],

18.8 [23] and 29% [24], with an overall pooled inci-

dence of 5% (Table 3). Other reported postoperative

complications include thrombosis (1.56.7%) and anal

fissure formation (0.910.3%). Other less commonly

reported postoperative complications included tenesmus

in up to 24.1%, and pruritus in up to 15.9% of patients,

both of which were reported by Ratto et al. [25] in

their report of 170 patients undergoing DGHL. The

mean reported operation time ranged from 19 to

35 min, with a mean number of vessels ligated ranging

from 5 to 10.7 (Table 4). The most commonly

reported postoperative complications were bleeding,

postoperative pain requiring analgesia, thrombosis andacute anal fissure.

Recurrence requiring further operation ranged from

2% to 24%, with a pooled reoperation rate of 6.4%.

Reoperations included outpatient treatment such as

rubber-band ligation and injection sclerotherapy, stapled

haemorrhoidectomy (PPH), MMH and repeat DGHL.

None of the retrieved articles described the criteria

for the choice of secondary intervention after failed

DGHL.

DGHL compared with other techniques

Five randomized trials and two cohort comparisons

were identified, comparing DGHL with PPH (four

studies, 325 patients total), MMH (one study, 60

patients) and haemorrhoidal artery ligation without the

use of Doppler guidance (two studies, 86 patients)

(Table 4). All studies comparing DGHL with PPH

found no significant difference in rates of recurrence or

postoperative complications. Both the randomized trial

reported by Festen et al. [26] and the comparative

cohort study by Avital et al. [11] reported significantly

shorter operation times (23 vs 34 min, P < 0.001 and

38 vs 50 min, P = 0.005, respectively) and reduced

analgesia requirements for DGHL compared with PPH.Giordano et al. [27] described a reduction in the time

taken to return to normal activity by almost half for

DGHL vs PPH (3.2 vs 6.3 days, P < 0.001). Infantino

et al. [28] found no difference between DGHL and

PPH for pain, postoperative complications and recur-

rence rates at median follow-up of 17 months; however,

they did report significantly higher rates of late post-

operative complications such as pain persisting over

30 days and abscess formation after PPH. They also

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Table

3

Resultsofstudiesanalysed.

Study

Optime(min)

Ligated

vessels(n)

Postoperativecomplications

F/U(months)

Recurrence

rate(%)

SymptomsatF/U

Reop

rate(%)

Pain(%)

Bleed(%

)

Thrombosis

(%)

Fissure

(%)

Bleeding

(%)

Prolapse

(%)

Pain

(%)

Shuurman[29]

5.2

0.71

0

2.6

2.6

6

13.2

Infantino[28]

5.9

2.4

17

0.4

(1520)

14

11.3

Gupta[15]

31

4.2

12

12.5

Giordano[27]

30(2045)

0

0

38(3348)

14

4

11

Festen[26]

34

1.5

17

4.3

Bursics[30]

6

1.7

11.5

3.1

3.3

Avital[11]

19

18

24

Avital[12]

19

6(91pts),

7(6pts),

8(2pts),

10(1pt)

60

GII12,GIII31

11

4

GII:2,

GIII:24

Szmulowicz[13]

713

2

3

2.1

15(335)

21

8.3

5.2

13

Spyridakis[18]

26

4.1

7.3

1.8

(314)

2.2

1.1

12

Total6.6

GII0,GIII5,

GIV50

Ratto[33]

33

12

6

5.7

8.6

10(628)

25.7

28.6

8.6

5.7

Jeong[16]

34

7.3

5.9

0.5

8

12

14.4

4

10.3

Faucheron[34]

35(1760)

6

4

3.1

34(1442)

9

12

9

6

Walega[35]

5.45(49)

3.3

3

17

0

17

10

Theodoropoulos

[36]

GIII8.6

2.2;

GIV10.7

2.8

24

15

5.5(624)

26.9

19.2

2.7

Ratto[25]

20

5,30

10(withRAR

)

6

15.9

1.2

2.3

11.5

12(141)

6.5

10.5

4.1

Pol[37]

68

18.4(1.437.2)

33

22

Infantino[37]

33.9

8.8

7.2

1.5

28.6

0.9

2.7

15.6

6.5(63

2)

14.3

20

6.3

3.6

12.5

Forrest[24]

6(19)

29

10.3

13.21(621)

14.3

2.6

6.5

5.2

3

Wilkerson[17]

6

1.9

30

60

51.1

20

17.8

Walega[20,38]*

37

18.1

6.1

3.6

2.1

Total18.5

GII7.6,GIII

16.3,GIV59.1

21.25

Faucheron[19]

28

6.1

8.4

2.4

4

4

3

36

Total:12

GIII9.0,

GIV23.8

12

DeVries[40]

16(1223)

7.3(116)

6.4

0.9

0.9

1.5

58

0.9

9

9

DalMonte[21]

19

2

1.5

0.6

46(2279)

7.5

3

2.7

Abdeldaim[22]

35(2050)

4(36)

11

18

6

8

7

10

11

Ramirez[23]

27(1843)

5(47)

18.8

3.1

3

12

40.6

Felice[41]

38

2.9

11(318)

9

6

27

5.9

Sohn[14]

6.7

1.5

34

3.3

13.3

6.7

3.3

Pooled

15

5

17.5

13.8

9.4

6.4

Rangedvaluesreportedasmean

SD(range).

Optime,operatingtimeinminutes;F/U,follow-uptimeinmonths;Reoprate,reoperationorreinterventionrate;GII/GIII/GIV,respectivegradeofhaemorrhoid(p

reoperativestaging).

*OriginalpostoperativeresultspublishedbyScheyeretal.[39].

Painscore(outof10)>

2.

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consider the shorter length of stay and lower equipment

costs for DGHL.

Gupta et al. [15] described a randomized trial of 48

patients with grade III haemorrhoids randomized

equally to undergo DGHL or haemorrhoidal artery

ligation without Doppler guidance, with targeted haem-

orrhoidal artery ligation on the basis of visual identifica-

tion of haemorrhoids and normal anatomical location of

supplying vessels. They reported no difference in recur-

rence or complication rates at 12 months. The opera-

tion time was reduced from 31 to 9 min ( P < 0.003)

and pain scores were halved (scale 110, scores 4.4 vs

2.2, P < 0.002). A recent randomized trial by Shuur-

man et al. [29] compared similar procedures, utilizing

the patient-reported Likert scale at 6 months of follow-up. There was no significant difference between the

groups for bleeding, dyschezia or pain, but prolapse was

reported to improve more in the non-Doppler group

(P < 0.05). It should be noted, however, that though

this study essentially concluded that haemorrhoidal

artery ligation without Doppler guidance was not infe-

rior, it may have been underpowered.

Comparing DGHL to open haemorrhoidectomy,

Bursics et al. [30] described a randomized trial of 60

patients with grade IIIV haemorrhoids. There was no

significant difference in complications or recurrence.

Significantly less analgesia was required by patients who

underwent DGHL (2.9 7.7 vs 11.7 12.6 doses,

P < 0.005).

Discussion

In an era of invasive surgical procedures aimed to maxi-

mize convenience and comfort for the patient, it is sur-

prising that the most widely accepted form of

haemorrhoidal surgery remains the relatively painful

open haemorrhoidectomy developed over 75 years ago.

PPH offers a less painful alternative but at the expense

of increased recurrence and complications [8.] Withregard to DGHL, the overall recurrence rate of 17.5%

is similar to that quoted for PPH (18%) and open

haemorrhoidectomy (16%) [2]. A recent limited system-

atic review and meta-analysis of three randomized trials

comparing PPH with DGHL found no difference in

effectiveness or complications, but significantly less

postoperative pain for DGHL [8].

The current evidence base for the effectiveness of

DGHL is poor, with only six randomized trials, report-

Table 4 Summary of Doppler-guided haemorrhoidal artery ligation (DGHL) compared with other procedures.

Study Comparison Outcome

Shuurman [29] DGHLvsHL No significant difference for patient reported severity of (Likert scale) bleeding, pain,

dyschezia. Greater improvement of prolapse symptoms in non-Doppler group

(P =

0.047). Higher rate of complications for DGHL (P

systematic review of doppler guided haemorrhoidal artery ligation

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