Doppler-Guided Versus Digitally Guided Transanal Hemorrhoidal Dearterialization: A Systematic Review and Meta-Analysis

Abstract

Introduction

Transanal hemorrhoidal dearterialization (THD) has emerged as a minimally invasive alternative to conventional hemorrhoidectomy, often performed with Doppler guidance (DGHAL) to facilitate arterial ligation. However, some studies suggest that digitally guided THD (HAL) may offer comparable outcomes with reduced costs. This systematic review and meta-analysis aim to compare the efficacy and safety of DGHAL versus HAL in patients with hemorrhoidal disease.

Methods

Following PRISMA 2020 guidelines, a systematic review was registered in PROSPERO (CRD42024625878). Searches in PubMed, EMBASE, and Cochrane Library identified randomized controlled trials (RCTs) comparing DGHAL and HAL. Primary outcomes included prolapse recurrence, postoperative bleeding, pain, and operative time. Statistical analyses were performed using RevMan 5.4, with odds ratios (OR) and mean differences (MD) at 95% confidence intervals (CI). Risk of bias was assessed using Cochrane RoB 2.

Results

Ten RCTs with 961 patients were included. No significant differences were found between DGHAL and HAL in late bleeding (OR 1.38, 95% CI 0.68–2.79, P = 0.62), prolapse recurrence at one year (OR 1.60, 95% CI 0.62–4.13, P > 0.05), intermediate pain (MD 0.78, 95% CI -0.51–2.07, P = 0.24), or operative time (MD 3.87 min, 95% CI -18.94–26.67, P > 0.05).

Conclusion

Digitally guided THD appears to be a cost-effective alternative to Doppler-guided THD, with comparable outcomes in terms of bleeding, prolapse recurrence, postoperative pain, and operative time. These findings suggest that the additional cost of Doppler guidance may not be justified in routine clinical practice. Further studies focusing on specific patient subgroups may help refine indications for each technique.

 

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Keywords

hemorrhoidal disease - transanal hemorrhoidal dearterialization - doppler-guided hemorrhoidal artery ligation - hemorrhoid surgery - meta-analysis

Introduction

Hemorrhoidal disease (HD) is among the most prevalent benign anorectal conditions, affecting both sexes, though it occurs more frequently in men at a ratio of 2:1.[1] [2] [3] The symptoms of HD are predominantly reported in industrialized and westernized societies, with key risk factors including hereditary predisposition, obesity, pregnancy, constipation, high-fat diets, alcohol consumption, spicy foods, and insufficient water intake.[2] [4] [5] [6] [7] While a large proportion of patients respond well to conservative treatments—such as dietary and lifestyle modifications, medications, and topical ointments—surgical intervention becomes necessary for some patients over the course of their lives.[4] [5] In such cases, surgical treatment is primarily indicated for those whose symptoms persist despite optimized clinical management.[8] ^, [9]

In the surgical management of hemorrhoids, less invasive, non-excisional procedures have been developed as alternatives to traditional hemorrhoidectomy, offering improved postoperative outcomes.[9] Within this spectrum of alternatives, Doppler-guided transanal hemorrhoidal dearterialization (THD-M or DGHAL), often combined with anorectal repair, has been recommended for refractory grade II, grade III, and selected grade IV hemorrhoidal disease.[10] This approach involves the selective high ligation of up to six submucosal arterial branches supplying the hemorrhoids, effectively desarterialising them and correcting prolapse through anorectal repair (lifting). A specialized anoscope, equipped with a Doppler sensor on its lateral bridge, facilitates auditory detection of submucosal arterial pulses, enabling precise identification and ligation of targeted arteries.[10]

Notably, some studies have questioned the added value of the Doppler transducer, a device that increases procedural costs, suggesting that its use does not significantly enhance the outcomes of hemorrhoidal dearterialization. These findings imply that the Doppler device could be omitted in favor of more cost-effective digitally guided ligation techniques.[11] Against this backdrop, the present systematic review and meta-analysis seek to compare Doppler-guided THD (DGHAL) with digitally guided THD (HAL), providing evidence to guide cost-effective clinical decision-making.

 

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Methods

This is a Systematic Review with Meta-Analysis, designed using the PICOT strategy, developed based on the Cochrane Handbook for Systematic Reviews of Interventions protocol, and following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The study was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the protocol CRD42024625878.

Data Source and Search Strategy

We systematically searched PUBMED/Medline, EMBASE, and Cochrane from database inception in April 2024, without language restriction. The search terms included “haemorrhoids”, “haemorrhoidal patients”, “Hemorrhoid”, “Hemorrhoids”, “dearterialization”, “artery ligation”, “AL”, “HL”, “DGHL”, “DGAL”, “THD”, “doppler”, “ultrasound”, “USG”. After removing duplicates, two authors (M.M and F.M) screened titles and abstracts independently. The preselected articles were reviewed in full text by both researchers to ensure adherence to the review's criteria and maintain the systematic review's quality. Discrepancies were resolved through consultation with a senior third researcher (G.A).

 

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Eligibility Criteria

We considered studies eligible for inclusion if they were (a) RCTs, enrolling (b) patients with grade I, II, III, or IV hemorrhoidal disease; (c) comparing THD with Doppler guidance versus THD without Doppler guidance; and (d) presented data including prolapse recurrence, bleeding, patient satisfaction, and operative time.

 

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Data Extraction

Two authors (M.M and F.M.) independently extracted data from each study including authors, enrollment period, publication year, population, sample size, intervention, control, hemorrhoids degree, baseline patient's characteristics, total number of patients, number of events, and endpoint definitions.

 

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Endpoints

Our endpoints included recurrent prolapse, bleeding, post-operative pain, and time of surgery.

 

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Risk of Bias and Statistical Analysis

The quality assessment of the selected articles was performed using the Cochrane risk-of-bias tool for randomized trials (RoB 2) for randomized controlled trials.[12]

Statistical analysis was conducted using mean difference (MD), standardized mean difference (SD), and odds ratio (OR) as measures, utilizing the RevMan 5.4 software from the Cochrane Library.

 

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Results

Study Identification and Selection

After applying the search strategy in April 2024, a total of 849 studies were identified: 374 in PUBMED, 384 in EMBASE, and 91 in Cochrane. Of these, 255 were excluded due to duplication across databases. The remaining 549 articles underwent title and abstract screening, with 350 excluded for being unrelated to the review topic, 151 excluded for not being randomized controlled trials, and 79 excluded for comparing surgical techniques outside the scope of the study.

Subsequently, 14 studies were selected for full-text review. Among these, 2 were excluded for not reporting the outcomes of interest, 1 was excluded due to overlapping populations with a larger study, and 1 was excluded for being a conference abstract with insufficient data for statistical analysis. Ultimately, 10 studies were included in this systematic review. The study selection process is illustrated in [Fig. 1].

Fig. 1 Study screening and selection

 

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General Characteristics of the Analyzed Studies

The selected studies encompassed a total sample of 961 participants with hemorrhoids classified across varying severity levels (grades I to IV, according to the Goligher scale). Follow-up durations ranged from 6 months to 3 years. Baseline characteristics of the patients included in these studies are detailed in [Table 1]. Furthermore, a subgroup analysis was conducted to assess outcomes according to hemorrhoidal disease severity, stratified by Goligher grades, as presented in [Table 2].

Table 1 Baseline characteristics of included studies and patients

Study	Year	Intervention	Control	HD degree	Number of patients	Age IG	Age CG	Fem IG (%)	Fem CG (%)
Ahmad	2020	DG-HAL	HAL	I, II, III	120	−	−	−	−
Aigner	2016	DG-HAL	HAL	III	40	49.2 ± 12.6	57.5 ± 16.2	45%	45%
Alembarejabi	2022	Mucopexy with DG-HAL	Mucopexy without DG-HAL	III, IV	36	44.7 ± 7.3	40.9 ± 8.3	50%	56%
Elshazly	2020	DG-HAL	Suture fixation anopexy	III	200	−	−	−	−
Gupta	2011	DG-HAL + ligation and mucopexy	Ligation and mucopexy	III	48	44 ± 11.2	47.4 ± 10.4	50%	52.17%
Huang	2016	DG-HAL	'Tying, binding and fixing operation'	III	160	51.74 ± 12.63	51.63 ± 12.15	41.25%	46.25%
Perivoliotis	2020	DGHAL +RAR under spinal anesthesia	HAL + hemorrhoidopexy under pudendal nerve block	I, II, III	60	52.87 ± 17.1	52.47 ± 18.3	43.3%	43.3%
Popovtsev	2021	DG-HAL + RAR	HAL + RAR	II, III	120	43.4 ± 12.5	39 ± 12.3	43.33%	43.33%
Schuurman	2012	DG-HAL + RAR	HAL + RAR	II, III	73	50 ± 13	51 ± 13.7	28.57%	38.64%
Zhai	2016	DH-HAL	Suture fixation	III	100	50.56 ± 14.44	43.60 ± 14.97	68%	68%

DG-HAL, Doppler guided hemorrhoidal artery ligation; Fem, female; GC, control group; HAL, hemorrhoidal artery ligation; HD, hemorrhoidal disease; IG, intervention group; RAR, recto anal repair.

Table 2 Subgroup description according to DH Golligher Scale

Study	Year	N total	N HD I degree	N HD II degree	N HD III degree	N HD IV degree	Important observations
Ahmad	2020	120	38	53	29	0	−
Aigner	2016	40	0	0	40	0	−
Alembarejabi	2022	36	0	0	*	*	Evaluate III and IV degrees without distinction
Elshazly	2020	200	0	0	200	0	−
Gupta	2011	48	0	0	48	0	−
Huang	2016	160	0	0	*	*	Described DH III-IV degree as mixed severe.
Perivoliotis	2020	60	2	19	39	0	−
Popovtsev	2021	120	0	57	63	0	−
Schuurman	2012	73	0	19	63	2	33 patients with II-III mixed DH
Zhai	2016	100	0	0	100	0	−

HD, hemorrhoidal disease; N, number of patients.

 

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Methodological Quality Assessment and Risk of Bias

The methodological quality and risk of bias of the selected articles were assessed using RoB 2 tool[12] for randomized controlled trials. The evaluation covered five domains proposed by the instrument: (a) biases in the randomization process; (b) biases due to deviations from intended interventions; (c) biases due to missing outcome data; (d) biases in the measurement of outcomes; and (e) biases in the selection of reported results. Articles were subsequently classified as having a low, moderate, or high risk of bias. In an overall analysis, presented in [Table 3], Elshazly[13] was evaluated with a high risk of bias; the rest of the RCTs had a moderate overall risk of bias.

Table 3 Risk of bias (RoB 2)

STUDY	Bias from randomization process	Bias due to deviations from intended interventions	Bias due to missing outcome data	Bias in measurement of the outcomes	Bias in selection of the reported result	Overall risk of bias
Ahmad, 2020	Low	Low	Low	Some concerns	Low	Low
Aigner, 2016	Low	Low	Low	Low	Low	Low
Alembarejabi, 2022	Some concerns	Low	Some concerns	Low	Low	Some concerns
Elshazly, 2020	Some concerns	Some concerns	High	High	Some concerns	High
Gupta, 2011	Low	Low	Low	Low	Low	Low
Huang 2016	Low	Low	Some concerns	Low	Low	Some concerns
Perivoliotis, 2020	Low	Low	Low	Low	Low	Low
Popovtsev, 2021	Some concerns	Low	Low	Low	Low	Some concerns
Schuurman, 2012	Low	Low	Some concerns	Low	Low	Some concerns
Zhai, 2016	Low	Low	Some concerns	Low	Low	Some concerns

 

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Combined Analysis of Studies

Late Bleeding

Bleeding at 6 months showed no significant difference between the use of Doppler or not (OR 1.38; 95% CI 0.68–2.79; P = 0.62; I² = 0%) ([Fig. 2]).

Fig. 2 Late Bleeding

Ahmad et al.[14] reported a bleeding rate of 16% at 6 months in patients treated with DGHAL, compared to 15% in those treated with HAL, indicating no differences between the techniques. Similarly, Aigner et al.[15] observed bleeding in 25% of patients undergoing DGHAL and in 10% of those treated with HAL, without any statistically significant difference. Alembajari et al.[16] found bleeding in 5% of HAL patients and none in those treated with DGHAL, again showing no differences between the approaches. Finally, Popovtsev et al.[17] recorded bleeding in 8.3% of patients undergoing DGHAL and 5% in those treated with HAL, without identifying differences between the techniques.

 

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Late Prolapse

The combined analysis of the studies, as shown in [Fig. 3], revealed no statistically significant difference between the groups, with an OR of 1.60 [0.62, 4.13], indicating comparable results for DGHAL and HAL regarding prolapse in one year.

Fig. 3 Late prolapse

Ahmad et al.[14] reported that 12 patients (20%) treated with DGHAL experienced prolapse, compared to 14 patients (23.3%) treated with HAL, with an OR of 0.82 [0.34, 1.96], showing no statistically significant difference. Aigner et al.[15] observed prolapse in 3 patients (5%) treated with DGHAL and in 3 patients (5%) treated with HAL, with an OR of 1.00 [0.18, 5.67], also without statistical significance. Gupta et al.[18] reported 3 prolapse events (12.5%) in DGHAL patients compared to 4 events (16.7%) in HAL patients, with an OR of 0.71 [0.14, 3.60], again showing no difference between groups. Similarly, Zhai et al.[19] documented 4 prolapse events (8%) in DGHAL patients and none in HAL patients, with an OR of 9.77 [0.51, 186.52], with no statistically significant difference between groups. In contrast, Perivoliotis et al.[20] recorded 15 prolapse events (50%) in DGHAL patients compared to 5 events (16.7%) in HAL patients, with an OR of 5.00 [1.51, 16.56], showing a higher prolapse rate in the DGHAL group.

 

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Intermediate Postoperative Pain

All studies utilized the visual analog scale (VAS) to measure pain, with variations in the specific days of assessment.

Gupta et al.[18] reported a significant increase in pain in the Doppler-treated group, while Perivoliotis et al.,[20] Schuurman et al.,[11] and Alembajari et al.[16] indicated comparable postoperative pain levels between the groups. Perivoliotis et al.[20] was the only study to observe a significant difference in pain on the seventh postoperative day, favoring the non-Doppler technique.

Regarding intermediate postoperative pain, the combined analysis of the studies showed a mean difference of 0.78 [-0.51, 2.07], indicating that, although some studies favored HAL in terms of intermediate postoperative pain, the overall difference between DGHAL and HAL was not statistically significant (P = 0.24), as illustrated in [Fig. 4].

Fig. 4 Intermediate post operative pain

Gupta et al.[18] reported an average pain score of 4.4 for DGHAL patients compared to 2.2 for HAL patients, with a mean difference of 2.20 [0.88, 3.52], favoring HAL. Alembajari et al.[16] found no significant difference between groups, with an average pain score of 6.7 for both and a mean difference of 0.00 [-0.98, 0.98]. Perivoliotis et al.[20] reported an average pain score of 4.53 for DGHAL patients and 1.63 for HAL patients, with a mean difference of 2.90 [1.84, 3.96], also favoring HAL. Schuurman et al.[11] reported a pain score of 3.95 in the DGHAL group versus 4.5 in the HAL group, with a mean difference of -0.60 [-1.06, -0.14], showing no statistically significant difference. Zhai et al.[19] reported an average pain score of 1.77 in the DGHAL group and 2.03 in the HAL group, with a mean difference of -0.26 [-1.06, 0.54], also without statistical significance.

In the study by Schuurman et al.,[11] patients recorded pain daily during the first 7 postoperative days using the VAS, ranging from 0 (no pain) to 10 (worst pain possible). Perivoliotis et al.[20] assessed pain using the VAS at 12 hours and 7 days after surgery. The study noted that patients in the non-Doppler ligation group experienced significantly lower pain on the seventh postoperative day compared to the Doppler group (VAS 2.5 vs. 6.33). Alembajari et al.[16] evaluated pain 48 hours after surgery using the VAS (0–10). No significant differences were observed between groups on the second postoperative day (VAS: 7.06 in the non-Doppler group vs. 6.67 in the Doppler group). Additionally, oral analgesic consumption was recorded over 14 days. Gupta et al.[18] recorded pain scores on days 2, 4, and 6 weeks postoperatively using the VAS (0–10). In the immediate postoperative period, pain was significantly higher in the Doppler group (VAS 4.4) compared to the non-Doppler group (VAS 2.2, P = 0.002). Finally, Zhai et al.[19] assessed pain on the first, second, and third days after surgery using the VAS (0–10). The study provided specific pain scores for these days but lacked detailed quantitative comparisons between groups immediately following the procedure.

 

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Operation Time

In the evaluation of operative time, the combined analysis showed no significant difference between the groups, with an overall mean difference of 3.87 minutes [-18.94, 26.67], suggesting comparable surgical durations for DGHAL and HAL, as illustrated in [Fig. 5].

Fig. 5 Time of surgery

Gupta et al.[18] reported an average operative time of 31 minutes for the DGHAL group compared to 9 minutes for the HAL group, with a mean difference of 22.00 minutes [9.28, 34.72], favoring HAL. Huang et al.[21] observed an average operative time of 12.73 minutes in the DGHAL group and 35.57 minutes in the HAL group, resulting in a mean difference of -22.84 minutes [-24.57, -21.11], favoring DGHAL. Perivoliotis et al.[20] reported 35.03 minutes for the DGHAL group and 16.07 minutes for the HAL group, with a mean difference of 18.96 minutes [15.72, 22.20], favoring HAL. Finally, Popovtsev et al.[17] observed an average operative time of 33.7 minutes in the DGHAL group and 35 minutes in the HAL group, with a mean difference of -1.30 minutes [-4.70, 2.10], showing no difference between the procedures.

 

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Discussion

In the surgical management of hemorrhoidal disease, there has been a growing preference for non-excisional techniques, such as transanal hemorrhoidal dearterialization (THD), which can be performed with or without Doppler guidance and may include mucopexy. However, there remains considerable debate regarding the impact of Doppler-equipped anoscopes compared to digital identification of arteries on treatment outcomes.

This systematic review and meta-analysis of 10 randomized clinical trials, including 961 patients with varying grades of hemorrhoids, compared Doppler-guided and digitally guided THD. No statistically significant differences were observed between the techniques regarding bleeding at 6 months, prolapse recurrence at one-year, intermediate postoperative pain (first seven postoperative days), or operative time.

For bleeding at 6 months, Alemrajabi et al.[16] reported lower bleeding rates in the HAL group (5%) compared to none in the DGHAL group. In contrast, Aigner et al.[15] observed bleeding in 25% of patients treated with DGHAL compared to 10% in those treated with HAL. In the study by Alembajari et al.,[16] all procedures were performed by the same surgeon and surgical team, using an unspecified anoscope in both groups. The intervention group underwent DGHAL with mucopexy, while the control group received HAL with mucopexy. Surgical time was not evaluated. Similarly, in Aigner et al.,[15] all patients were operated on by the same surgeon using the THD Slide anoscope. Arteries were ligated selectively in the DGHAL group using Doppler and non-selectively via mucopexy in the HAL group. Neither study reported statistically significant differences between the groups.

Regarding late prolapse recurrence (one year after surgery), the combined analysis revealed no differences between the techniques. However, Perivoliotis et al.[20] reported prolapse recurrence in 50% of patients treated with DGHAL compared to 5% of those treated with HAL. It is noteworthy that patients in the DGHAL group presented with more severe hemorrhoids than those in the HAL group, which likely influenced these results. This outcome should be considered alongside findings from studies such as Ratto et al.,[22] who, in an analysis of 1,000 patients, emphasized the importance of incorporating mucopexy alongside selective high ligation in DGHAL, particularly for advanced prolapse cases.

Additionally, previous studies have suggested that the use of Doppler in THD may increase procedural costs without necessarily improving clinical outcomes (Schuurman et al.[11]; Aigner et al.[15]). This is especially relevant in resource-limited settings where access to Doppler equipment may be restricted. Studies such as Gupta et al.[18] have also shown that digital-guided ligation can be performed effectively without Doppler assistance, aligning with the findings of this review.

This study has limitations, particularly regarding subgroup outcome analysis, as the included studies combined populations with varying grades of hemorrhoidal disease. Additionally, the lack of sufficient studies reporting early postoperative bleeding limited the analysis of this outcome. The timing of pain assessments also varied across studies, with later measurements within the intermediate postoperative period (days 1–7) often reflecting lower pain levels. To address these limitations, a large number of randomized studies were included, and methodological quality was rigorously assessed using the RoB 2 tool.

By consolidating evidence from multiple studies, this meta-analysis provides a comprehensive comparison of the two techniques. The results indicate that digitally guided THD may be an effective and cost-efficient alternative to Doppler-guided methods, particularly in settings with limited resources. However, further studies with subgroup analyses are needed to better identify which patient groups may benefit most from each approach.

 

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Conclusion

This meta-analysis, comparing Doppler-guided versus digitally guided transanal hemorrhoidal dearterialization, demonstrates that the digitally guided technique does not compromise clinical outcomes, particularly regarding bleeding, prolapse, postoperative pain, and operative time.

 

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Conflict of Interest

The authors declare that there is no conflict of interest.

Authors' Contribution

MCM: conceptualization, data curation, formal analysis, methodology, project administration, software, supervision, writing-original draft, writing-review and editing; PALS: conceptualization, writing-original draft, writing-review and editing; GEA: conceptualization, data curation, formal analysis, methodology, project administration, software, supervision, writing-original draft, writing-review and editing; FSM: software, supervision, writing-original draft, writing-review and editing.

Data Availability Statement

The data that support the findings of this study are available from the authors upon reasonable request.

ORCID IDs

Marília Cardoso Massoni – https://orcid.org/0009-0008-3713-5757

Felipe Santos Marimpietri – https://orcid.org/0009-0009-3827-342X

Paulo André Lago Silva – https://orcid.org/0000-0002-0028-1303

Glicia Estevam de Abreu – https://orcid.org/0000-0003-3170-2294

• References

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Publikationsverlauf

Eingereicht: 07. März 2025

Angenommen: 21. Juli 2025

Artikel online veröffentlicht:
07. Oktober 2025