Haemorrhoidal artery ligation: Is Doppler guidance useful? A systematic review and meta-analysis of randomized controlled trials

Aim: Haemorrhoidal arterial ligation (HAL) with or without mucopexy (recto-anal repair, RAR) is a minimally invasive technique for the treatment of haemorrhoidal disease. It is still debated if it should be performed with Doppler guidance (DG-HAL) or without. The primary aim of this study was to find evidence that the use of Doppler guidance reduces the risk of recurrence. The secondary aim was to evaluate the benefit of Doppler guidance on postoperative complications. Methods: A comprehensive literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2020). The population, intervention, comparison, outcomes and study design (PICOS) framework was used for eligibility criteria. Data were extracted independently by two reviewers for initial screening and for eligibility to be included in the meta-analysis of randomized controlled trials. Random effects meta-analysis, leave-one-out meta-analysis and meta-regression were performed to assess the main outcomes. Results: Seven randomized controlled trials, published between 2008 and 2023, were selected. They included 514 patients (mean age 49.13 years, 46% men) with different haemorrhoidal degrees. The HAL technique was performed in 255 patients and DG-HAL in 259 patients. The meta-analysis revealed that the DG-HAL procedure was associated with a significant risk of recurrence (P = 0.007) and similar postoperative pain (P = 0.623) compared to the HAL procedure. In a subgroup analysis of patients treated with a combined RAR procedure, no differences were found between the DG-HAL-RAR and HAL-RAR regarding the risk of recurrence (P = 0.36) and postoperative pain (P = 0.31). Conclusion: In conclusion, this meta-analysis did not find superiority of DG-HAL over HAL with or without RAR in reducing postoperative complications and recurrence.