Long-term impact of haemorrhoidal artery ligation on anal function and continence

Abstract

Aims
Haemorrhoidal artery ligation (HALO) and variants including Doppler-guided HAL (DG-HAL), HAL with rectoanal repair (HAL-RAR), and transanal haemorrhoidal dearterialisation (THD) serve as minimally invasive alternatives to excisional haemorrhoidectomy, reducing pain while preserving sphincter function. Long-term faecal incontinence remains a concern due to its quality-of-life impact. This systematic review assessed prevalence, severity, and patterns of incontinence beyond six months post-procedure across HAL techniques.

Methods
PRISMA 2020 guidelines directed searches of PROSPERO, MEDLINE, PubMed, Scopus, Cochrane Library, and ScienceDirect for 2015–2024 studies reporting continence >6 months after HAL-based procedures. Six studies (3 RCTs, 1 prospective, 2 retrospective cohorts; total n=671 patients) met PICOS criteria, with Wexner Incontinence Scores reported or retrospectively mapped. Quality appraisal used CASP Cohort Checklist.

Results
Seventeen (2.5%) of 671 patients developed postoperative faecal incontinence. Of these, 14 (82%) cases were mild (Wexner 1–4) and transient, resolving within 3–6 months; 3 (18%) were moderate (Wexner 5–8), primarily in HAL-RAR (9/158 [5.7%]). Standard HAL showed 0/76 (0%) cases; THD had 1/104 (1.0%); DG-HAL had 7/293 (2.4%). No severe incontinence occurred.

Discussion
HALO techniques demonstrate excellent long-term continence safety (overall 2.5% low-grade incontinence). HAL-RAR's higher risk (5.7%) warrants counselling. Standardised scoring and multicentre trials are recommended.