Introduction Aim of this study is to assess comparative evidence on short and long term outcomes of transanal hemorrhoidal dearterialization (THD) vs. stapled hemorrhoidopexy (SH), conventional hemorrhoidectomy (CH) and ligasure hemorrhoidectomy (LH).

Method Litterature review of published prospective controlled trials of THD. Potentially relevant studies were identified by the title and the abstract, searched and selected in the MEDLINE, EMBASE, and Cochrane Library databases using the keywords transanal dearterialization, prospective, haemorrhoids, THD, hemorrhoidectomy, artery ligation without language restrictions. Full articles were obtained and assessed in detail. Primary outcome measure was recurrence rate. Secondary outcome measures were postoperative pain and morbidity.

Results Thirteen studies (THD vs. SH = 5; THD vs. CH = 6; THD vs. LH = 1; THD vs. SH vs. CH = 1) including 947 patients were analysed. There were 452 THD patients, 267 stapled hemorrhoidopexy (SH), 228 conventional hemorrhoidectomy (CH) 68 ligasure hemorrhoidectomy. Six patients had grade I haemorrhoids, 79 patients grade II, 554 patients grade III, 166 patients grade IV and 142 were unspecified. Minimum follow up length ranged from 1 week to 36 months. Mean operative time (minutes) was 33 for THD procedure, 27 for SH and 19 for CH. Postoperative pain was assessed in 12 studies (THD vs. SH = 6; THD vs. CH = 6). All studies demonstrated a trend in favour of THD reaching statistical significance in 7 of the studies.

Early complications occurred in 83/427 THD (19.4%), 60/267 SH (22.5%), 54/135 CH (40%) patients. Postoperative bleeding occurred in 10/303 THD (3.3%), 10/165 SH (6.1%), 7/90 CH (7.7%), 12/68 LH (17.6%) patients (P < 0.03). Late complications occurred in 16/239 THD (6.7%), 16/147 SH (10.9%) and 14/158 CH (8.9%) patients (P < 0.05). Overall recurrent or persistent symptoms were present in 13.7% (62/452) of patients in the THD group, 10.1% (27/267) SH and 6.1% (14/228) in the CH group (P < 0.05). Three studies comparing THD vs. SH and 6 comparing THD to CH reported results at a minimum follow up of 12 months. When analysing recurrences according to follow up length, recurrence rate was respectively 12.3% (12/97) for THD, 16.6% (16/96) for SH and 26.6% for CH (4/15) at less than 12 months and 16.6% (50/301) for THD and 6.5% (11/170) for SH and 7.1% (10/140) for CH at 12 months or more.

Conclusion Comparative evidence on THD is still scarce. However, THD procedure has shown significantly less postoperative bleeding and pain compared to both SH and CH. Late complications are also less frequent following THD. Long-term symptomatic relief seems to be better after SH and CH.

Disclosure of interest None Declared.