Systematic review

Systematic review and network meta-analysis comparing

clinical outcomes and effectiveness of surgical treatments
for haemorrhoids
C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis
Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
Correspondence to: Mr C. Simillis (e-mail: csimillis@gmail.com)

Background: The aim was to compare the clinical outcomes and effectiveness of surgical treatments for
haemorrhoids.
Methods: Randomized clinical trials were identified by means of a systematic review. A Bayesian network
meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.
Results: Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade
III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly
more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™
and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open
and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed,
stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more
pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled,
LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than
after open and closed procedures. THD provided the earliest time to first bowel movement. The
stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed
and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled
haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified
between treatments for anal stenosis, incontinence and perianal skin tags.
Conclusion: Open and closed haemorrhoidectomies resulted in more postoperative complications and
slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were
associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The
advantages and disadvantages of each surgical treatment should be discussed with the patient before
surgery to allow an informed decision to be made.

Paper accepted 8 July 2015

Published online 30 September 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9913

Introduction cushions, or protruding mass, soiling and difficulties with

Haemorrhoids are cushions of specialized submucosal
vascular tissue located in the anal canal, and are one of the
most common anorectal disorders1 . The exact prevalence
of symptomatic haemorrhoids is difficult to establish owing
to under-reporting by patients. A prospective study2 of
patients undergoing screening colonoscopy revealed the
presence of haemorrhoids in 38⋅9 per cent, with 44⋅7 per
cent of these suffering from haemorrhoidal symptoms.
Haemorrhoidal symptoms may include bright red bleed-
ing from the rectum, mucous discharge, perianal irritation
or pruritus, perianal pain, prolapse of the haemorrhoidal
hygiene1 – 4 .
Treatment options for haemorrhoidal disease range
from conservative management with advice on diet,
lifestyle changes and application of topical ointments,
to interventions that can be performed on an outpatient
setting (such as rubber band ligation, infrared coagulation,
injection sclerotherapy), as well as surgical treatments3 .
Based on the degree of prolapse and the classification by
Banov and colleagues5 , grade III and IV haemorrhoids
(prolapsed haemorrhoids requiring manual reduction
and non-reducible prolapsed haemorrhoids respectively)
are amenable to surgical treatment. Approximately 9000

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1604 C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis
haemorrhoidectomies (including around 1300 stapled pro-
cedures) were performed in England during 2012–20136 .
Hundreds of studies have been published comparing
the surgical treatments available for grade III and IV
haemorrhoids, including: open haemorrhoidectomy7 – 10 ,
closed haemorrhoidectomy11 – 14 , submucosal haemorr-
hoidectomy15,16 , stapled haemorrhoidectomy17 – 20 , trans-
anal haemorrhoidal dearterialization (THD)21 – 24 ,
LigaSure™ (Valleylab, Boulder, Colorado, USA) haemorr-
hoidectomy25 – 28 , Harmonic® (Ethicon Endo-Surgery,
Cincinnati, Ohio, USA) haemorrhoidectomy29 – 32 , laser
haemorrhoidectomy33 – 36 , Starion™ (Starion Instru-
ments, Saratoga, California, USA) haemorrhoidectomy37 ,
radiofrequency haemorrhoidectomy38,39 and bipolar scis-
sors haemorrhoidectomy40 . The aim of this study was to
perform a systematic review of the literature to identify
the surgical treatments available for grade III and IV
haemorrhoids, and to carry out a network meta-analysis to
compare the clinical outcomes and effectiveness of these
treatments.
Methods
Search strategy
A comprehensive literature search using a combination of
free-text terms and controlled vocabulary when applicable
was undertaken in the following databases: MEDLINE,
Embase, Science Citation Index Expanded, and Cochrane
Central Register of Controlled Trials (CENTRAL) in the
Cochrane Library. The World Health Organization Inter-
national Clinical Trials Registry Platform search portal and
ClinicalTrials.gov were also searched to identify further tri-
als. Details of the search strategy are provided in Table S1
(supporting information). The related articles function in
PubMed was used to broaden the search, and all abstracts,
studies and citations identified were reviewed. The ref-
erences of the identified trials were also searched to find
additional trials for inclusion. No restrictions were made
based on language, publication year or publication status.
The latest date for this search was 21 June 2014.
Inclusion and exclusion criteria
Only randomized clinical trials (RCTs) were considered
for this network meta-analysis, and only studies that
recruited patients with haemorrhoids clearly defined as
grades III and IV were included in the review. Finally,
only studies reporting on elective surgical treatments were
included; studies reporting on emergency haemorrhoidec-
tomy for painful or thrombosed haemorrhoids were
excluded.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
Outcomes of interest
The various surgical interventions aiming to treat grade
III and IV haemorrhoids were assessed for the follow-
ing outcomes: postoperative complications, defined as any
deviation from the normal postoperative course41 – all
complications reported by the studies were added and
included within this outcome; some included complications
were analysed and individually – urinary retention, consti-
pation/faecal impaction, postoperative bleeding, anal fis-
sure, wound complications; emergency reoperation owing
to early postoperative complications requiring expedited
or urgent surgical treatment; duration of surgery in min-
utes; operative blood loss in millilitres; length of hospital
stay in days; postoperative pain measured with a visual ana-
logue scale on days 1, 7 and 14 after surgery; time to first
bowel movement in days; time to return to work or normal
activities in days; recurrence of haemorrhoids – number of
patients with recurrent internal or prolapsed haemorrhoids
seen on rectal examination at the clinic, or number of
patients complaining of recurrent prolapsed haemorrhoids
at follow-up; symptoms reported by patients at follow-up
consistent with recurrent haemorrhoidal symptoms – all
recurrent symptoms reported were added and included
within this outcome; some of the included symptoms
were also analysed individually – recurrent haemorrhoidal
bleeding, recurrent pruritus, recurrent pain or discom-
fort related to haemorrhoids; anal stenosis, determined as
the proportion of patients complaining of difficulty void-
ing owing to outlet obstruction or anal stenosis/stricture
at follow-up; incontinence, assessed as the proportion of
patients experiencing soiling or difficulty with hygiene or
incontinence (any grade of incontinence) at follow-up; and
perianal skin tag, considered as the proportion of patients
complaining of perianal skin tags at follow-up, or perianal
skin tags found on rectal examination at the clinic.
Data collection
The trials for inclusion were identified independently by
two review authors by screening the titles and abstracts.
The full text was sought for any references identified for
potential inclusion by at least one of the authors, and
further selection for inclusion was based on the full text.
The following data were extracted from each study inde-
pendently by two review authors: first author, year of
publication, language of publication, country, inclusion and
exclusion criteria, sample size, participant characteristics
(such as age, sex, proportion of participants with grade
IV haemorrhoids), study design, including details of the
surgical interventions aimed at treating the haemorrhoids,
outcomes described above, and risk of bias (see below).
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Clinical outcomes and effectiveness of surgical treatments for haemorrhoids
Any discrepancies were resolved by discussion; if there was
disagreement, the final decision was taken by the senior
author. The Cochrane Collaboration’s risk of bias tool was
used to assess the risk of bias of the included trials based
on the following domains: allocation sequence generation,
allocation concealment, blinding of participants and per-
sonnel, blinding of outcome assessors, incomplete outcome
data and selective outcome reporting42 . The other source
of bias assessed was vested interest bias: whether a trial was
conducted by a party with vested interests in the outcome of
the trial, such as a drug manufacturer. For each of these risk
domains, the studies were categorized as at low, uncertain
or high risk of bias.
Statistical analysis
The systematic review and meta-analysis was conducted
according to guidelines from the Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses
(PRISMA) Group43 . For binary data, based on the number
of patients developing the adverse event, a binomial model
was used for the analysis and the odds ratio (OR) was cal-
culated. For outcomes where some patients may develop
multiple adverse events, the total number of adverse events
rather than the number of patients was imputed in the
analysis, and a Poisson model was used. An arbitrary
constant of 1 was added to the denominator and 0⋅5 to
the numerator for trials with zero-event outcomes44 . For
continuous outcomes the mean difference (MD) was cal-
culated. If the data were likely to be normally distributed,
the median was used for the analysis when the mean was
not available. If the s.d. was not available from a study,
it was calculated from the standard error, P, c.i. or i.q.r.,
according to guidance given in the Cochrane Handbook for
Systematic Reviews of Interventions45 . If it was not possible
to calculate the s.d. from the standard error, P, c.i. or i.q.r.,
the s.d. was imputed using the largest s.d. in other trials
for that outcome.
For each outcome of interest, Stata/IC 11 (StataCorp LP,
College Station, Texas, USA) was used to draw a network
plot of all the treatments assessed for that specific outcome.
Any treatments not connected to the other treatments
through the network plot were excluded from the analy-
sis of that outcome. A Bayesian network meta-analysis was
conducted using the Markov chain Monte Carlo method in
WinBUGS 1.4 (MRC Biostatistics Unit, Cambridge, and
Imperial College School of Medicine, London, UK). The
treatment contrast (OR for binary outcomes, MD for con-
tinuous outcomes) for any two treatments was modelled as
a function of comparisons between each individual treat-
ment and an arbitrarily selected reference group46 . The
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1605
chosen reference group was the open haemorrhoidectomy
group.
The residual deviance and deviance information crite-
rion (DIC) were used for assessing between-study hetero-
geneity, in accordance with guidance from the National
Institute for Health and Care Excellence Decision Support
Unit documents44 . Three different models were run for
each outcome: fixed-effect model, random-effects model
and random-effects inconsistency model. The choice of
model was based on the model fit. The DIC provides
a measure of model fit that penalizes model complexity;
therefore, a lower DIC indicated a better model fit44 . The
simpler model, which was a fixed-effect model, was used
if the DIC values were similar between the fixed-effect
and random-effects models. The random-effects model,
which assumes variation between studies owing to hetero-
geneity and generates a wider c.i., was used if it resulted
in a better model fit as indicated by a DIC lower than
that of a fixed-effect model by at least 344 . Evidence
of inconsistency between direct and indirect comparisons
was assessed by examining the geometry of the network
diagrams carefully47 . In addition, the deviance and DIC
statistics of the consistency and inconsistency models were
compared and, if the inconsistency model resulted in a bet-
ter model fit than the consistency model, the results of the
network meta-analysis were interpreted with caution47 .
The probability of ranking of a treatment (that a treat-
ment ranks as the best treatment, second best treatment,
third best treatment, etc.) for each outcome of interest
was calculated. A probability below 90 per cent of being
the best treatment for a particular outcome was not con-
sidered by the authors to be high enough to be confi-
dently reported as the best treatment for that outcome
of interest48 . A network meta-analysis was performed to
compare the surgical treatments identified in all included
trials. A sensitivity network meta-analysis was undertaken
of more recent trials published in or after 2005. The year
2005 was selected because some of the treatment meth-
ods compared were developed more recently and were
used on patients after 2005. A further sensitivity network
meta-analysis was carried out based on larger trials with a
greater number of included patients (studies reporting on
80 or more patients).
Results
Eligible studies
A total of 3224 references were identified through elec-
tronic searches of CENTRAL (679), MEDLINE (1319),
Embase (619) and Science Citation Index Expanded
(607). A further 167 references were identified from RCT
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1606 C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis
registers (101 from World Health Organization Inter-
national Clinical Trials Registry Platform and 66 from
ClinicalTrials.gov). One more reference was identified
for further assessment by scanning reference lists of the
identified RCTs. Some 824 duplicates between databases
were excluded. A further 2359 clearly irrelevant references
were excluded after screening titles and reading abstracts.
Two hundred and nine references were retrieved for fur-
ther assessment. One hundred and eleven references were
excluded after reviewing the studies in full. In total, 98
RCTs met the inclusion criteria7 – 40,49 – 112 (Fig. 1). A total
of 7827 participants were included in the analysis (Table 1).
The risk of bias in the included trials is summarized in
Fig. 2, and described for each study in Fig. S1 (supporting
information).
Surgical treatments compared
The following elective surgical treatments were identi-
fied for the management of grade III and IV haemor-
rhoids: open haemorrhoidectomy or Milligan–Morgan
haemorrhoidectomy, performed with a scalpel, conven-
tional scissors or diathermy; closed haemorrhoidectomy or
Ferguson haemorrhoidectomy, performed with a scalpel,
conventional scissors or diathermy; submucosal haemor-
rhoidectomy or Parks’ haemorrhoidectomy, carried out
with a scalpel, conventional scissors or diathermy; sta-
pled haemorrhoidectomy or haemorrhoidopexy, proce-
dure for prolapse and haemorrhoids, or Longo procedure/
technique; THD or haemorrhoidal artery ligation opera-
tion, performed with or without mucopexy, and with or
without Doppler guidance; haemorrhoidectomy using a
LigaSure™ device; Harmonic® haemorrhoidectomy using
a Harmonic® or ultrasonic scalpel; laser haemorrhoidec-
tomy done with a Nd : YAG or carbon dioxide laser;
haemorrhoidectomy using the Starion™ system; haemor-
rhoidectomy performed with a radiofrequency device; and
haemorrhoidectomy carried out with bipolar scissors.
The results of all pairwise comparisons of the various sur-
gical treatments for the outcomes of interest are shown in
Table S2 (supporting information), and statistically signifi-
cant results only in Table S3 (supporting information). The
surgical treatments with the highest probability of ranking
from best to worst (1st to 11th) for the outcomes of interest
are summarized in Table S4 (supporting information). Fig. 3
shows an example of a network plot; similar plots were cre-
ated for all outcomes of interest.
Postoperative complications
Seventy-seven trials provided data on 6596 participants and
all 11 surgical treatments, for the network meta-analysis
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
Records identified through Additional records identified
database searching through other sources
n = 3224 n = 168
Records screened after
duplicates removed
n = 2568
Records excluded n = 2359
Full-text articles
assessed for eligibility
n = 209
Full-text articles excluded n = 111
Studies included in
qualitative synthesis
n = 98
Studies included in
quantitative synthesis
(network meta-analysis)
n = 98
Fig. 1 PRISMA diagram showing selection of articles for review
on postoperative complications; the network plot is shown
in Fig. 3. The fixed-effect model was preferred based on
the DIC statistics, and there was no evidence of incon-
sistency in the networks. The closed and radiofrequency
haemorrhoidectomy groups had significantly more postop-
erative complications than the open, stapled, LigaSure™,
Harmonic® and THD groups. Open haemorrhoidectomy
had significantly more postoperative complications than
the LigaSure™, Harmonic® and THD groups. Further-
more, Harmonic® haemorrhoidectomy resulted in sig-
nificantly fewer postoperative complications than open,
closed, stapled, submucosal and radiofrequency haemor-
rhoidectomy. The LigaSure™ and THD groups had sig-
nificantly fewer postoperative complications than the open,
closed and radiofrequency haemorrhoidectomy groups.
Urinary retention, wound complications,
constipation and anal fissure
Seventy-one trials (5536 participants; 11 treatments) pro-
vided data for the network meta-analysis on urinary reten-
tion. Twenty-six trials (2018 participants; 8 treatments)
provided data on wound complications (wound infection,
discharge, dehiscence, not healing). The random-effects
model was preferred for both outcomes based on the DIC
statistics, and there was no evidence of inconsistency. The
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Clinical outcomes and effectiveness of surgical treatments for haemorrhoids 1607

Table 1 Summary of studies included in the analysis Table 1 Continued

Reference Treatments Total* Grade IV Reference Treatments Total* Grade IV

Abo-hashem et al.29 Harmonic® versus open 80 10 Khanna et al.25 (2010) LigaSure™ versus closed 48 n.r.
(2010) Kim and Lee78 (2009) Starion™ versus 60 n.r.
Altomare et al.7 (2008) LigaSure™ versus open 273 119 Harmonic®
Ammaturo et al.49 (2012) Stapled versus open 79 n.r. Kim et al.79 (2013) Stapled versus open 122 n.r.
Arslani et al.50 (2012) LigaSure™ versus stapled 98 0 Kraemer et al.26 (2005) LigaSure™ versus stapled 50 2
Azolas et al.51 (2010) Closed versus open 48 n.r. Krska et al.80 (2003) Stapled versus open 50 n.r.
Basdanis et al.52 (2005) LigaSure™ versus stapled 95 22 Kwok et al.30 (2005) Harmonic® versus 49 n.r.
Bassi and Bergami53 Closed versus open 90 n.r. LigaSure™
(1997) Lawes et al.27 (2004)† LigaSure™ versus open 34 n.r.
Bessa54 (2008) LigaSure™ versus open 110 67 Leventoğlu et al.81 (2008) Stapled versus open 60 n.r.
Bikhchandani et al.55 Stapled versus open 84 13 versus Harmonic®
(2005) Liao et al.82 (2008) Stapled versus open 76 n.r.
Boccasanta et al.56 (2001) Stapled versus open 80 80 Mehigan et al.83 (2000) Stapled versus open 40 10
Bouini et al.57 (2012) LigaSure™ versus open 60 n.r. Mik et al.84 (2008) Closed versus open 63 63
Brown et al.58 (2001) Stapled versus open 30 n.r. Milito et al.28 (2002) LigaSure™ versus open 56 29
Bulut et al.59 (2006) Stapled versus open 30 n.r. Morpurgo et al.85 (2008) Stapled versus closed 20 0
Carrabetta et al.60 (2001) Closed versus open 103 n.r. Muzi et al.86 (2007) LigaSure™ versus open 250 81
Castellvi et al.61 (2009) LigaSure™ versus open 74 26 Nyström et al.87 (2010) Stapled versus open 180 n.r.
Cheetham et al.8 (2003) Stapled versus open 31 25 Ortiz et al.88 (2002) Stapled versus open 55 26
Chen et al.62 (2007) LigaSure™ versus stapled 86 0 Ortiz et al.89 (2005) Stapled versus open 31 31
Chung et al.17 (2005) Harmonic® versus stapled 88 0 Ozer et al.90 (2008) Closed versus open versus 87 n.r.
Chung et al.40 (2002) Harmonic® versus open 86 86 Harmonic®
versus bipolar scissors Palazzo et al.91 (2002) LigaSure™ versus open 34 n.r.
Chung and Wu63 (2003) LigaSure™ versus closed 61 45 Palimento et al.92 (2003) Stapled versus open 74 40
Correa-Rovelo et al.11 Stapled versus closed 84 24 Pandini et al.34 (2006) Laser versus open 40 3
(2002) Pattana-Arun et al.93 LigaSure™ versus closed 45 4
Dell’Abate et al.64 (2005) Stapled versus open 117 n.r. (2006)
De Nardi et al.21 (2014) THD versus open 47 n.r. Pescatori et al.94 (2000) Closed versus open 55 n.r.
Denoya et al.22 (2013) THD versus closed 42 9 Peters et al.95 (2005)‡ LigaSure™ versus open 30 8
Enriquez-Navascues Laser versus open 35 n.r. Picchio et al.96 (2006)§ Stapled versus open 74 40
et al.33 (1993) Pokharel et al.97 (2009) Closed versus open 56 30
Fareed et al.12 (2009) LigaSure™ versus closed 80 14 Racalbuto et al.98 (2004) Stapled versus open 100 n.r.
Fazeli et al.65 (2011) LigaSure™ versus open 57 n.r. Rahmani et al.99 (2012) Closed versus open 100 40
Festen et al.23 (2009) THD versus stapled 41 4⋅76 Ramadan et al.10 (2002) Harmonic® versus open 54 n.r.
Filingeri et al.15 (2004) Radiofrequency versus 102 102 Rowsell et al.100 (2000) Stapled versus open 22 0
submucosal
Sabanci et al.101 (2007) Stapled versus closed 100 n.r.
Filingeri et al.38 (2004) Radiofrequency versus 36 36
Sakr102 (2010) LigaSure™ versus open 84 25
open
Sakr et al.103 (2010) LigaSure™ versus stapled 68 17
Filingeri et al.13 (2010) Radiofrequency versus 22 22
closed Senagore et al.14 (2004) Stapled versus closed 156 n.r.

Franceschilli et al.39 (2011) Radiofrequency versus 210 17 Senagore et al.35 (1993) Laser versus closed 86 n.r.
open Shelygin et al.31 (2003) Closed versus open versus 70 27
Franklin et al.66 (2003) LigaSure™ versus open 34 n.r. Harmonic®

Ganio et al.67 (2001) Stapled versus open 100 29 Smyth et al.104 (2003)¶ Stapled versus open 40 10

Ganio et al.68 (2007) Stapled versus open 100 29 Stolfi et al.105 (2008) Stapled versus open 171 88

Gao et al.69 (2008) Stapled versus open 100 15 Tan et al.106 (2008) LigaSure™ versus open 43 n.r.

Gençosmanoğlu et al.70 Closed versus open 80 n.r. Thorbeck and Montes107 LigaSure™ versus open 112 60
(2002) (2002)

Gentile et al.71 (2011) LigaSure™ versus open 52 52 Tsunoda et al.32 (2011) Harmonic® versus 60 24
LigaSure™
Hasse et al.18 (2004) Stapled versus closed 76 n.r.
Verre et al.108 (2013) THD versus stapled 122 73
Helmy19 (2000) Stapled versus open 40 10
Wang et al.36 (2005) Laser versus closed 86 0
Ho et al.72 (2000) Stapled versus open 119 49
Wang et al.109 (2006) LigaSure™ versus closed 84 15
Ho and Ho73 (2006) Stapled versus closed 50 n.r.
Wang et al.37 (2007) Starion™ versus 64 17
Ho et al.9 (1997) Closed versus open 67 n.r.
LigaSure™
Hosch et al.16 (1998) Submucosal versus open 34 n.r.
Wilson et al.110 (2002) Stapled versus open 89 n.r.
Huang et al.74 (2007) Stapled versus closed 596 0
You et al.111 (2005) Closed versus open 80 18
Infantino et al.24 (2012) THD versus stapled 169 0
Zampieri et al.112 (2012) THD versus LigaSure™ 114 61
Jayne et al.75 (2002) LigaSure™ versus open 40 8
Kairaluoma et al.20 (2003) Stapled versus open 60 n.r. *Number of patients with grade III or IV haemorrhoids. Study reporting
Khafagy et al.76 (2009) Stapled versus open 45 n.r. long-term outcomes of participants reported previously in †Palazzo
versus THD et al.91 , ‡Jayne et al.75 , §Palimento et al.92 and ¶Mehigan et al.83 . n.r., Not
Khalil et al.77 (2000) Stapled versus closed 40 0 reported; THD, transanal haemorrhoid dearterialization.

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1608 C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Vested interest bias

Low risk of bias

0 25 50 75 100
Unclear risk of bias
High risk of bias % of studies

Fig. 2 Summary of risk of bias across all included studies

incidence of postoperative urinary retention was signif-
icantly higher in the closed haemorrhoidectomy group
compared with the LigaSure™ and Harmonic® groups.
Furthermore, the closed haemorrhoidectomy group had
significantly more wound complications than the open
and stapled haemorrhoidectomy groups. There was no
significant difference in the other comparisons for these
outcomes.
Twenty-five trials (2565 participants; 9 treatments)
provided data on constipation/faecal impaction. Closed
haemorrhoidectomy was complicated by constipation
significantly more often than the open and Harmonic®
LigaSure™
Stapled
Harmonic®
Closed
THD
Open
Laser
Bipolar scissors
Starion™
Radiofrequency
Submucosal
Fig. 3Network plot for postoperative complications. Similar
network plots were produced for each outcome of interest.
Circles represent the intervention as a node in the network; lines
represent direct comparisons using randomized clinical trials
(RCTs); the line thickness indicates the number of RCTs
included in each comparison
procedures. There was no significant difference in the
other comparisons. Postoperative anal fissure was reported
by 20 trials (1897 participants; 7 treatments) and there was
no significant difference between the surgical treatments
for this outcome. The fixed-effect model was preferred
for the above two outcomes, and there was no evidence of
inconsistency.
Postoperative bleeding and emergency reoperation
Seventy-one trials provided data for the network
meta-analysis on the proportion of patients with post-
operative bleeding (6191 participants; 11 treatments). The
fixed-effect model was preferred, and there was no evidence
of inconsistency in the network. Pairwise comparison of
the surgical treatments showed that significantly fewer
people had postoperative bleeding after THD compared
with open or stapled haemorrhoidectomy.
Thirty-nine trials reported on emergency reoperation
(3272 participants; 8 treatments). In total, 65 patients
(2⋅0 per cent) needed expedited or urgent reoperation to
treat early postoperative complications. In 57 patients
(88 per cent) reoperation was needed to stop postoperative
bleeding. In the other reoperations, five patients required
examination under anaesthesia for significant postopera-
tive pain, one patient in the stapled group required incision
and drainage of a submucosal haematoma, another patient
in the stapled group required incision of painful throm-
bosed haemorrhoidal tissue distal to the staple line, and
one patient required reoperation to treat perianal sepsis
after open haemorrhoidectomy. Network meta-analysis
of the trials reporting on reoperation showed that the
THD group had significantly fewer reoperations than
the open, closed, stapled and LigaSure™ groups. Fur-
thermore, THD had a relatively high probability of
being the best treatment for this outcome (P = 0⋅710)
(Table S3, supporting information).

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Clinical outcomes and effectiveness of surgical treatments for haemorrhoids
Duration of surgery and operative blood loss
Seventy-three trials (6140 participants; 11 treatments)
were included in the analysis of duration of surgery. The
random-effects model was preferred based on the DIC
statistics, and there was no evidence of inconsistency in the
networks. The open, closed, submucosal and laser haem-
orrhoidectomy groups had a significantly longer duration
of surgery than the stapled, LigaSure™, Harmonic®,
THD, Starion™ and radiofrequency haemorrhoidectomy
groups. In addition, closed, submucosal and laser haem-
orrhoidectomies took significantly longer than bipolar
scissors haemorrhoidectomy. The closed and laser groups
also had a significantly longer operating time than the
open haemorrhoidectomy group. Laser haemorrhoidec-
tomy was ranked the worst treatment for this outcome with
greater than 90 per cent probability (P = 0⋅909) (Table S3,
supporting information).
Twenty trials (2016 participants; 9 treatments) were
included in the analysis for operative blood loss. The
random-effects model was preferred based on the DIC
statistics, and there was evidence of inconsistency between
trials because the difference in DIC between the con-
sistency and inconsistency models was significant. The
pairwise mean differences of the various group compar-
isons showed that the open, closed and THD groups had
significantly more operative blood loss than the stapled,
LigaSure™, Harmonic®, Starion™ and bipolar scissors
groups.
Length of hospital stay, time to first bowel
movement and time to normal activities
Forty-six trials (4321 participants; 11 treatments) pro-
vided data for the network meta-analysis on length of
hospital stay. The random-effects model was preferred
based on the DIC statistics, and there was no evidence
of inconsistency in the networks. The pairwise compar-
ison of interventions showed the stapled group and the
THD group to have a significantly shorter length of hos-
pital stay than the open, closed and Harmonic® groups.
Furthermore, stapled haemorrhoidectomy was associated
with a significantly shorter length of hospital stay than
LigaSure™ haemorrhoidectomy. THD resulted in a signif-
icantly shorter hospital stay than laser haemorrhoidectomy.
In addition, open and LigaSure™ haemorrhoidectomies
had a significantly shorter length of hospital stay compared
with closed haemorrhoidectomy.
Nineteen trials (1513 participants; 7 treatments) reported
on time to first bowel movement. The fixed-effect model
was preferred based on the DIC statistics, and there was
no evidence of inconsistency in the networks. Pairwise
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1609
comparisons of the treatments showed the THD and
Harmonic® groups to have a significantly shorter time to
the first bowel movement compared with the open and
closed haemorrhoidectomy groups. THD also had a signif-
icantly shorter time to the first bowel movement than the
bipolar scissors group. Time to first bowel movement was
significantly shorter for LigaSure™ than for closed haem-
orrhoidectomy. THD ranked the best treatment for this
outcome with high probability (P = 0⋅853) (Table S3, sup-
porting information).
Time to return to work or normal activities was reported
by 42 trials (4125 participants; 11 treatments). The
random-effects model was preferred for this outcome
based on the DIC statistics, and there was no evidence
of inconsistency in the networks. Patients in the stapled,
LigaSure™ and Harmonic® groups needed a significantly
shorter time to return to normal activities than those in
the open and closed haemorrhoidectomy groups. Time to
return to normal activities was shorter after stapled than
laser haemorrhoidectomy.
Pain
Fifty-three trials (4184 participants; 10 treatments)
reported on pain on postoperative day 1. The
random-effects model was preferred for this outcome,
and there was no evidence of inconsistency in the net-
works. The pairwise mean differences of the treatments
showed open and closed haemorrhoidectomies to result in
significantly more pain on postoperative day 1 than stapled,
LigaSure™, Harmonic®, THD and Starion™ procedures.
Pain on postoperative day 7 was reported by 35 tri-
als (2856 participants; 9 treatments). The random-effects
model was used, and there was no evidence of inconsis-
tency. The open group had significantly more pain on day 7
compared with the stapled group. There was no significant
difference in the other comparisons.
Eighteen studies reported on pain on postoperative
day 14 (1231 participants; 7 treatments). The open and
closed haemorrhoidectomy groups had significantly more
pain on postoperative day 14 compared with the stapled
and LigaSure™ groups. LigaSure™ haemorrhoidectomy
resulted in significantly more pain on day 14 than sta-
pled haemorrhoidectomy. The open haemorrhoidectomy
group had significantly more pain compared with the
closed haemorrhoidectomy group.
Recurrence of haemorrhoids and recurrent
haemorrhoidal symptoms
Forty-seven trials (3863 participants; 9 treatments) pro-
vided data for the network meta-analysis on recurrence
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1610 C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis
of haemorrhoids. The fixed-effect model was preferred
based on the DIC statistics, and there was no evidence of
inconsistency. Pairwise comparison of the groups showed a
significant increase in the proportion of people with recur-
rence of haemorrhoids in the stapled and THD groups
compared with the open, closed and LigaSure™ haemor-
rhoidectomy groups. THD was associated with a higher
recurrence rate than laser and radiofrequency haemorr-
hoidectomies. THD and stapled haemorrhoidectomies had
a higher probability of doing worse than the other treat-
ments, with regard to recurrence of haemorrhoids. THD
ranked as worst treatment for this outcome, with a high
probability (P = 0⋅785) (Table S3, supporting information).
Recurrence of haemorrhoidal symptoms was reported by
47 trials (3765 participants; 7 treatments). The fixed-effect
model was preferred based on the DIC statistics, and there
was no evidence of inconsistency. The rate of recurrence
of haemorrhoidal symptoms was significantly higher for
stapled haemorrhoidectomy than for open and LigaSure™
haemorrhoidectomies. There was no significant difference
in the other comparisons.
Recurrent bleeding, recurrent pain and recurrent
pruritus
Recurrent haemorrhoidal bleeding was reported by 33
trials (2651 participants; 6 treatments), and 29 trials (1969
participants; 6 treatments) provided data on recurrent pain
or discomfort related to haemorrhoids. There was no evi-
dence of any significant difference between the different
interventions for both outcomes. Eighteen trials (1176
participants; 7 treatments) provided data on recurrence
of pruritus owing haemorrhoids, and THD was found to
have a lower rate than closed haemorrhoidectomy.
Anal stenosis, incontinence and skin tag
Fifty-one trials (4793 participants; 11 treatments)
reported on the proportion of patients complaining of
difficulty voiding owing to outlet obstruction or anal
stenosis/stricture at follow-up. Fifty-three trials (3856
participants; 9 treatments) reported on the proportion of
patients experiencing soiling or difficulty with hygiene or
incontinence at follow-up. Perianal skin tags at follow-up
were reported by 24 trials (1766 participants; 5 treatments).
Pairwise comparisons showed no significant difference
between the surgical treatments for these three outcomes.
Sensitivity analysis – recent trials
Network meta-analysis of more recent reports, pub-
lished in or after 2005, revealed that the closed
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
haemorrhoidectomy group had significantly more compli-
cations than the open, stapled, LigaSure™, Harmonic®
and THD groups. Radiofrequency haemorrhoidectomy
resulted in significantly more postoperative complications
compared with open, stapled, LigaSure™, Harmonic®
and THD treatments. Open haemorrhoidectomy resulted
in significantly more complications than the LigaSure™
procedure.
THD was associated with significantly fewer episodes
of postoperative bleeding than open, stapled and radiofre-
quency haemorrhoidectomies. THD had a relatively high
probability of being the best treatment for postoperative
bleeding (P = 0⋅704). THD also had a significantly lower
emergency reoperation rate than open haemorrhoidec-
tomy, and a relatively high probability of being the best
treatment for this outcome too (P = 0⋅713).
Pairwise comparisons of treatments reported in more
recent trials revealed that the duration of surgery was sig-
nificantly longer in the open and closed haemorrhoidec-
tomy groups than in the stapled, LigaSure™, Harmonic®,
THD, Starion™ and radiofrequency haemorrhoidectomy
groups. Furthermore, the stapled and THD groups had a
significantly shorter hospital stay compared with the open
and closed haemorrhoidectomy groups. Time to return to
normal activities was significantly shorter after stapled than
after open and closed haemorrhoidectomies.
Sensitivity analysis showed that open and closed haem-
orrhoidectomies caused significantly more pain on post-
operative day 1 than stapled and THD procedures. For
postoperative day 7, open haemorrhoidectomy resulted
in significantly more pain than stapled haemorrhoidec-
tomy. Moreover, the stapled and THD groups had signifi-
cantly higher rates of recurrence of haemorrhoids than the
open and LigaSure™ groups. In addition, stapled haem-
orrhoidectomy was associated with significantly greater
recurrence of haemorrhoidal symptoms than LigaSure™
haemorrhoidectomy.
Sensitivity analysis – larger trials
Network meta-analysis of the studies reporting on more
patients (80 patients and above) revealed that the closed
haemorrhoidectomy group had significantly more com-
plications than the open, stapled, LigaSure™ and THD
groups. Open haemorrhoidectomy had significantly more
complications than LigaSure™ haemorrhoidectomy.
Radiofrequency and submucosal haemorrhoidectomies
resulted in significantly more postoperative complications
compared with open, stapled, LigaSure™, Harmonic®,
THD and laser haemorrhoidectomies. There were fewer
episodes of postoperative bleeding after THD than after
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Clinical outcomes and effectiveness of surgical treatments for haemorrhoids
open, stapled and radiofrequency haemorrhoidectomies.
THD was also associated with a significantly lower
reoperation rate compared with open and closed haemor-
rhoidectomy, and had a high probability of being the best
treatment for this outcome (P = 0⋅916).
Moreover, the duration of surgery was significantly
longer for open and closed haemorrhoidectomies com-
pared with stapled, LigaSure™, THD and radiofrequency
procedures. Laser haemorrhoidectomy had a significantly
longer operating time than open, stapled, LigaSure™,
Harmonic®, THD, radiofrequency and bipolar scissors
haemorrhoidectomy. Radiofrequency haemorrhoidectomy
was associated with a significantly shorter operating time
than open, closed, Harmonic®, laser and submucosal
haemorrhoidectomy, and had a relatively high probability
of being the best treatment in terms of duration of surgery
(P = 0⋅892).
Pairwise comparisons of treatments reported in larger
trials revealed that hospital stay was significantly shorter
after stapled haemorrhoidectomy compared with open and
closed haemorrhoidectomy. Stapled haemorrhoidectomy
had a relatively high probability of being the best treat-
ment in terms of hospital stay (P = 0⋅780). Furthermore,
after LigaSure™ and stapled haemorrhoidectomy patients
returned significantly more quickly to normal activities
than those in the open and closed haemorrhoidectomy
groups.
Sensitivity analysis also showed that stapled and
LigaSure™ haemorrhoidectomies caused significantly
less pain on postoperative day 1 than open and closed
procedures. On postoperative day 7, stapled haemor-
rhoidectomy resulted in significantly less pain compared
with open haemorrhoidectomy. Finally, the stapled and
THD groups had significantly higher haemorrhoid
recurrence rates than the open and LigaSure™ groups.
Discussion
Many standard pairwise meta-analyses4,113 – 132 have
been published previously comparing surgical treat-
ments for haemorrhoids. One disadvantage of these
meta-analyses is that they could compare only two sur-
gical treatments directly, rather than all available surgical
treatments at once. In addition, most of the meta-analyses
published on the surgical treatment of haemorrhoids
grouped conventional and excisional haemorrhoidec-
tomies together, rather than comparing them individually.
For example, open and closed haemorrhoidectomies
were grouped together for comparison with LigaSure™
haemorrhoidectomy114,121,122,125,130 . Open, closed and sub-
mucosal haemorrhoidectomies were also grouped together
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1611
(performed using scissors, diathermy, laser, LigaSure™
or Harmonic® scalpel) and were compared with stapled
haemorrhoidectomy4,114,115,118,120,126,129,131 .
Importantly, this network meta-analysis allowed simul-
taneous comparison of all surgical treatments available for
grade III and IV haemorrhoids. A network meta-analysis
was ideal for this topic, where multiple interventions have
been used and compared for the same disease and outcomes
in different head-to-head comparisons. Another advantage
of this network meta-analysis over previous standard pair-
wise meta-analyses was that it combined direct evidence
within trials and indirect evidence across trials, facilitating
indirect comparisons of multiple interventions that have
not been studied in a head-to-head fashion133,134 . There-
fore, it allowed the relative effectiveness of different sur-
gical treatments to be assessed even when they had not
been compared directly in individual RCTs. Because net-
work meta-analyses include evidence from both direct and
indirect comparisons, the power may be better than in
standard pairwise meta-analyses that include only direct
evidence135 . Moreover, compared with a standard pair-
wise meta-analysis, a network meta-analysis may yield
more reliable and definitive results, and allows visualiza-
tion and interpretation of a wider picture of the avail-
able evidence, and calculation of treatment rankings with
probabilities133,134 .
Only RCTs reporting on elective haemorrhoidectomy
for grade III and IV haemorrhoids were considered
for this network meta-analysis. Studies of other design
were excluded because of the risk of bias in such trials,
and because it was not appropriate to perform network
meta-analysis on studies with different designs as this
would have made the interpretation more difficult. On one
hand, this led to some important non-randomized studies
being excluded from the analysis but, on the other hand,
the bias of the included studies and the heterogeneity
between them were inherently less owing to their study
design. The overall quality of the included trials based on
the Cochrane Collaboration’s risk of bias tool was found
to be adequate, except with regard to blinding of partic-
ipants and personnel (performance bias) and blinding of
outcome assessment (detection bias). One limitation of
a network meta-analysis can be the inconsistency in the
results between direct and indirect comparisons; never-
theless, in the present network meta-analysis there was
no evidence of inconsistency in the networks for any of
the outcomes investigated. However, it is important to
note that failure to detect inconsistency does not imply
consistency47 . Moreover, the amount of evidence a treat-
ment carries, and the number of comparisons available
between treatments, determines the diversity and strength
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1612 C. Simillis, S. N. Thoukididou, A. A. P. Slesser, S. Rasheed, E. Tan and P. P. Tekkis
of a network meta-analysis135 . Severe imbalance in terms of
the amount of evidence available may affect the power and
reliability of the network meta-analysis, as inferences may
be driven largely from the evidence of few treatments and
comparisons135 . For example, in the present study, some
comparisons were informed by several RCTs by either
direct or indirect evidence (for example 29 RCTs com-
pared stapled versus open haemorrhoidectomy), whereas
other comparisons were only sparsely informed (only 1
RCT compared THD with open haemorrhoidectomy).
Two commonly used excisional procedures worldwide
are open (Milligan–Morgan) and closed (Ferguson) haem-
orrhoidectomies. Postoperative pain and postoperative
complications are believed to be the most important dis-
advantages of these techniques, and this was confirmed
by the present study. Open and closed haemorrhoidec-
tomies had significantly more postoperative complications
than LigaSure™, Harmonic® and THD procedures,
and resulted in significantly more postoperative pain
than stapled, THD, LigaSure™ and Harmonic® haem-
orrhoidectomies. The increased complication rates and
higher levels of pain related to open and closed haemor-
rhoidectomies resulted in a longer hospital stay and a later
return to normal activities. Furthermore, open and closed
haemorrhoidectomies were associated with greater opera-
tive blood loss and a longer operating time compared with
the other surgical techniques. Nevertheless, low recur-
rence rate is perceived to be the most important advantage
of open and closed haemorrhoidectomies, and this was
confirmed here: open and closed haemorrhoidectomies
were found to have a lower recurrence rate than THD
and stapled haemorrhoidectomies. Pairwise comparison
of open and closed haemorrhoidectomies demonstrated
significantly more postoperative complications with closed
haemorrhoidectomy, suggesting an advantage of open over
closed haemorrhoidectomy.
Alternative surgical techniques for excision of
haemorrhoids have been developed with the aim of
reducing postoperative pain and improving perioper-
ative outcomes, including faster recovery and earlier
return to normal daily activities. Standard pairwise
meta-analyses114,121,122,124,125,130 comparing conventional
haemorrhoidectomy with LigaSure™ haemorrhoidec-
tomy showed the latter to have better outcomes with
regard to duration of surgery, operative blood loss, post-
operative pain, length of hospital stay and time to return
to normal activities. In addition, a previous standard
pairwise meta-analysis123 that compared conventional
with Harmonic® haemorrhoidectomy showed that the
Harmonic® procedure resulted in fewer postoperative
complications, less postoperative pain and earlier return
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
to work. Similarly, the present network meta-analysis
showed that LigaSure™ and Harmonic® haemorrhoidec-
tomies resulted in fewer postoperative complications, a
shorter duration of surgery, less operative blood loss and
decreased postoperative pain compared with open and
closed haemorrhoidectomies. The decreased complica-
tion rate and reduced pain were reflected in the shorter
time to the first bowel movement and the quicker return
to normal activities after LigaSure™ and Harmonic®
haemorrhoidectomies.
Stapled haemorrhoidectomy (or haemorrhoidopexy)
is another technique developed to decrease postop-
erative pain, resulting in faster recovery; neverthe-
less, concerns have been raised regarding its high
recurrence rate. Previous standard pairwise meta-
analyses4,114,115,117,118,120,126,128,129,131 comparing con-
ventional with stapled haemorrhoidectomy showed
the stapled procedure to have better outcomes with
regard to operating time, postoperative pain, length
of hospital stay and time to return to normal activ-
ity. However, stapled haemorrhoidectomy was also
reported to have higher rates of skin tags, haemor-
rhoid recurrence and recurrent prolapse than conventional
haemorrhoidectomy4,114,115,117,118,120,129,131 . Furthermore,
previous pairwise meta-analyses113,119,132 comparing sta-
pled versus LigaSure™ haemorrhoidectomy showed the
stapled procedure to have a higher recurrence rate, with no
difference in postoperative complications, postoperative
pain and length of hospital stay. Similarly, the present
network meta-analysis showed that stapled haemor-
rhoidectomy needed a shorter operating time and resulted
in less postoperative pain than open and closed haemor-
rhoidectomies. As a result of the decreased pain levels,
stapled haemorrhoidectomy resulted in a shorter hospital
stay and quicker return to normal activities. Nevertheless,
the recurrence rate was higher after stapled haemor-
rhoidectomy than after open, closed and LigaSure™
procedures. Furthermore, stapled haemorrhoidectomy
was associated with more postoperative complications
compared with Harmonic® haemorrhoidectomy and a
higher postoperative bleeding rate than THD. Stapled
haemorrhoidectomy is expensive and the cost of this tech-
nique should be taken into consideration in the decision
process, together with its higher rate of complications and
recurrences. The increased cost of the stapling instrument
may be largely offset by the shorter hospital stay, decreased
operating time and earlier return to work.
A previous standard pairwise meta-analysis127 com-
paring THD with stapled haemorrhoidectomy showed
no difference between the two treatments with regard
to duration of surgery, postoperative complications and
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Clinical outcomes and effectiveness of surgical treatments for haemorrhoids
recurrence of haemorrhoids. Nevertheless, the present
network meta-analysis demonstrated that fewer people
had postoperative bleeding after THD compared with
open or stapled haemorrhoidectomy, and this resulted in
THD being associated with fewer emergency reoperations
than open, closed, stapled and LigaSure™ procedures,
with a high probability of being the best treatment for
reoperation rate (P = 0⋅710). In addition, THD was found
to have fewer postoperative complications, a shorter oper-
ating time and decreased levels of postoperative pain than
the other surgical techniques. These resulted in THD
having a shorter length of hospital stay and an earlier
time to the first bowel movement. On the other hand,
THD had a higher recurrence rate than open, closed,
LigaSure™, laser and radiofrequency haemorrhoidec-
tomies and, importantly, the highest probability of being
the worst treatment for recurrence of haemorrhoids
(P = 0⋅785). The low cost of THD, low complication rate,
shorter operating time and decreased levels of postopera-
tive pain, but higher recurrence rate, may suggest THD as
a safe, quick and easy initial surgical option. On the con-
trary, open haemorrhoidectomy, which is associated with
increased postoperative complications and greater post-
operative pain, could be a better approach for refractory
haemorrhoids owing to its low recurrence rate.
This network meta-analysis has shown that each surgi-
cal treatment for haemorrhoids has pros and cons that
should be taken into consideration when deciding which
technique to use. The technology available in each surgical
department and the cost of surgery also play a role in the
decision-making process. Every surgeon should be aware
of the individual advantages and disadvantages of each sur-
gical treatment, and should discuss these with the patient.
The patient’s beliefs and priorities should be taken into
consideration; for example, whether their priority is faster
recovery and earlier return to normal activities, or a lower
risk of recurrence. The patient should be provided with all
the information available in this review and be allowed to
make a fully informed decision. This will ensure that the
best treatment and appropriate personalized care is pro-
vided to all patients.
Further studies are needed to assess patient expecta-
tions before surgery and satisfaction after surgery, in both
the short and long term. Further higher-quality RCTs
are needed to compare surgical treatments for haemor-
rhoids, particularly with improved blinding of participants
and personnel, and blinding of outcome assessors. Future
RCTs should assess and compare the economic cost of the
different surgical procedures available for haemorrhoids.
They should also investigate whether different surgical
approaches should be used for single versus circumferential
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1613
haemorrhoids. Finally, further studies should be designed
to assess bowel habit, possibly using a bowel assessment
questionnaire, before and after different surgical treat-
ments for haemorrhoids.
Disclosure
The authors declare no conflict of interest.
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Supporting information
Additional supporting information may be found in the online version of this article:
Appendix S1 Systematic review protocol (Word document)
Table S1 Detailed search strategy (Word document)
Table S2 Odds ratios and mean differences for the pairwise haemorrhoid treatment comparisons for the outcomes of
interest (Word document)
Table S3 Statistically significant pairwise odds ratios and mean differences (Word document)
Table S4 Surgical treatments with the highest probability of ranking from best to worst (1st to 11th) for the
outcomes of interest
Fig. S1 Risk of bias for each included study (Word document)
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Published by John Wiley & Sons Ltd
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