Network meta-analysis of randomized controlled trials comparing the procedure for prolapse and hemorrhoids, Milligan-Morgan hemorrhoidectomy and tissue-selecting therapy stapler in the treatment of grade III and IV internal hemorrhoids(Meta-analysis)

Abstract

Background: Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to update and expand our previous work to compare the safety and efficacy of the procedure for prolapse and hemorrhoids (PPH), Milligan-Morgan hemorrhoidectomy (MMH) and tissue-selecting therapy stapler (TST) in the treatment of grade III and IV internal hemorrhoids.

Methods: We performed a network meta-analysis. We searched the Cochrane library, Embase, PubMed, Medline, Web of Science, CNKI, Wangfang, and VIP databases up to May 20, 2019. All randomized controlled trials (RCTs) comparing PPH, MMH and TST in the treatment of grade III and IV internal hemorrhoids were included. We performed a Bayesian network meta-analysis to integrate the adverse events of all treatments. This work is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. This study was registered with PROSPERO, number CRD42019137270.

Result: Twenty-two RCTs that recruited 3511 patients were identified. Among these patients, 1379 patients underwent PPH, 805 patients underwent TST, and 1327 patients underwent MMH. In terms of adverse events, TST presented the lowest urinary retention rates and fecal incontinence rates. TST exhibited fewer incidences of anal stenosis than PPH and MMH. Importantly, PPH showed the weakest effects on reducing recurrence rates in hemorrhoid patients.

Conclusions: The current study indicated that TST showed optimal potential superior clinical effects for grade III and IV hemorrhoids compared to PPH and MMH. However, high-quality large sample RCTs are still expected.

Keywords: Hemorrhoids; Network meta-analysis; Randomized controlled trial; Surgical procedures.