Department of Surgery, South Auckland Clinical Campus, University of Auckland, Middlemore Hospital, Auckland, New Zealand.
BJS Open. 2021 Sep 6;5(5). doi: 10.1093/bjsopen/zrab091.
Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids.
A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.
Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.
Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.
目前有多种治疗早期中度症状性痔的方法，每种方法都有其各自的疗效、并发症和风险。本研究旨在比较 II 级-III 级痔的介入治疗的相对临床结果和效果。
根据 PRISMA 标准对 1980 年至 2020 年期间发表的所有 RCT 进行系统评价；使用 MEDLINE、Embase 和 CENTRAL 数据库确定手稿。纳入标准为比较 II 级-III 级痔手术干预的 RCT。主要观察指标为：至少 6 周随访时症状复发、第 1 天视觉模拟量表（VAS）测量的术后疼痛和术后并发症（出血、尿潴留和肠失禁）。在进行偏倚评估和异质性分析后，进行贝叶斯网络荟萃分析。
共确定了 79 项 RCT，包括 9232 名患者。对网络荟萃分析中的 14 种不同治疗方法进行了分析。总体而言，59 项 RCT（73%）被认为存在高度偏倚风险，最大的风险来自结果测量领域。在直接治疗比较中发现了不同程度的异质性，特别是在症状复发和术后疼痛方面。54 项研究报告了痔症状复发，涉及 7026 名患者和 14 种治疗方法。闭合痔切除术的复发风险最低，其次是开放式痔切除术、黏膜结扎加黏膜固定术、吻合器痔上黏膜环切术和多普勒引导痔动脉结扎术加黏膜固定术。34 项研究报告了 3812 名患者和 11 种治疗方法的疼痛。直流电电疗、多普勒引导痔动脉结扎术加黏膜固定术和红外线凝固术的疼痛评分最低。46 项研究记录了 5696 名患者和 14 种治疗方法的术后出血。开放式痔切除术的术后出血风险最大，其次是吻合器痔上黏膜环切术和闭合痔切除术。30 项研究比较了 10 种治疗方法，涉及 3116 名参与者，报告了尿潴留。开放式痔切除术和吻合器痔上黏膜环切术的尿潴留风险明显高于橡胶圈结扎和多普勒引导痔动脉结扎术加黏膜固定术。9 项研究比较了 5 种治疗方法，涉及 1269 名参与者，报告了肠失禁。开放式痔切除术和吻合器痔上黏膜环切术的肠失禁概率最高。
开放式和闭合式痔切除术以及吻合器痔上黏膜环切术与更严重的疼痛、更多的术后出血、尿潴留和肠失禁相关，但症状复发率最低。在做出决定之前，应与患者讨论每种治疗方法的风险和益处。
