Efficacy and safety of endoscopic sclerotherapy vs traditional surgery in the treatment of internal hemorrhoids: A meta-analysis

Abstract

BACKGROUND

Internal hemorrhoids are among the most common colorectal diseases worldwide. Although traditional surgeries (TS) are widely used, postoperative complications or discomfort may occur to varying degrees. In recent years, endoscopic sclerotherapy (ES) has gradually emerged as a minimally invasive alternative; however, its overall clinical value compared with that of TS has not yet been clearly confirmed.

AIM

To evaluate the impact of ES in comparison to TS on internal hemorrhoid outcomes.

METHODS

A comprehensive search was conducted across several databases, including the PubMed, EMBASE, Cochrane Library, Clinical trials.gov, China National Knowledge Infrastructure, Wanfang, and VIP databases. This search aimed to identify randomized controlled trials (RCTs) that compared ES with TS in patients who underwent internal hemorrhoid surgery. The primary outcome assessed was clinical efficacy, whereas the secondary outcomes included complications and other essential clinical metrics. A total of 17 RCTs involving 1689 patients were included in the meta-analysis.

RESULTS

The results of the pooled analysis indicated that, compared with TS, ES exhibited superior clinical efficacy. Furthermore, ES had a minimal effect on work resumption and demonstrated superior efficacy in controlling bleeding and reducing hemorrhoid prolapse in comparison to TS. Compared with TS, ES significantly reduced the incidence of postoperative complications, including bleeding, anal bulge, anal edema, urinary retention, and infection. Additionally, ES was associated with lower treatment costs, shorter hospitalization durations, shorter healing times, shorter operation times, and less blood loss. In patients with internal hemorrhoids, compared with TS, ES resulted in faster recovery, a lower risk of complications and superior efficacy.

CONCLUSION

Therefore, ES is a safe and effective surgical method for the treatment of internal hemorrhoids.

Key Words: Hemorrhoids; Sclerotherapy; Colonoscopy; Minimally invasive surgical procedures; Randomized controlled trial

Core Tip: This is the first meta-analysis to compare endoscopic sclerotherapy (ES) with traditional surgery for the treatment of internal hemorrhoids. ES provided higher efficacy, fewer complications and lower costs, offering a minimally invasive alternative for grade I-III hemorrhoids.

INTRODUCTION

Hemorrhoidal disease is among the most prevalent anorectal conditions, affecting a significant percentage of adults and rarely occurring in children regardless of sex. The true prevalence of hemorrhoids in the general population remains unknown and may vary by country. The incidence rate of hemorrhoids among adults is 39%, with 99.5% of these individuals experiencing 1-3 internal hemorrhoids and 44.74% presenting with symptoms associated with the condition[1]. The primary symptoms of hemorrhoids include bleeding, prolapse, itching, soiling, and pain. These symptoms affect approximately 25% of the population, imposing a significant burden on both the community and healthcare facilities[2].

Hemorrhoids are classified based on their anatomical relationship to the dentate line. Internal hemorrhoids arise from the proximal aspect of the dentate line, whereas external hemorrhoids originate from the distal aspect[3]. Internal hemorrhoids are the most prevalent type of hemorrhoids and primarily present with bleeding and prolapse symptoms. These hemorrhoids are classified into four grades according to the classic Goligher staging system[4]. The treatment of internal hemorrhoids can be categorized into conservative and surgical approaches depending on the severity of symptoms. Conservative treatment encompasses dietary recommendations, lifestyle modifications, and pharmacological interventions. If conservative treatment is ineffective, surgical intervention becomes necessary. Traditional surgical options, such as hemorrhoidectomy (Milligan-Morgan or Ferguson techniques), procedures for prolapse and hemorrhoid (PPH) and tissue-selecting therapy stapler, are appropriate for grade IV internal hemorrhoids. For grade I-III hemorrhoids, minimally invasive surgical options, including sclerotherapy, rubber band ligation, and infrared coagulation, are available. Among these, sclerotherapy is recognized as the simplest and least minimally invasive surgical invasive method[3,5,6]. Sclerotherapy was first used for the treatment of hemorrhoids by Blanchorde in 1928; however, it was gradually supplanted due to significant complications. Over time, sclerotherapy has matured in clinical practice[7]. Sclerosing agent injection therapy is currently recommended for the treatment of grade I-III internal hemorrhoids. The underlying principle of this therapy is to induce fibrosis, which effectively adheres the mucosa to the underlying muscle[8]. Commonly used drugs for sclerotherapy include lauromacrogol, aluminum potassium sulfate and tannic acid[9], as well as Xiaozhiling[10] and Shaobei injection[11]. The accuracy of the sclerosing agent injection site is particularly important. The injection site should target the submucosa at the base of the hemorrhoid tissue rather than penetrating. Historically, the administration of sclerosing agents requires the use of an anoscope, which frequently results in misplacement of the injection and the emergence of complications of varying severity; these include pain, impotence, prostatitis, mucosal ulceration or necrosis, prostatic abscess, and even abdominal abscess[12,13]. Therefore, with respect to these complications, the accuracy of sclerosing agent injection is of paramount importance.

The development of endoscopy has provided an unprecedented clear and wide field of vision for sclerosing agent injection therapy, enhancing the precision of the injection and reducing the occurrence of complications. Consequently, the injection of sclerosing agents under endoscopy has gained recognition among a growing number of clinicians in China. While endoscopic sclerotherapy (ES) for internal hemorrhoids is becoming more prevalent, it has not yet garnered widespread acceptance among the public, primarily due to insufficient convincing evidence. The aim of this study was to compare the effects of ES and traditional surgery (TS) on the surgical outcomes of internal hemorrhoids to confirm the clinical efficacy and safety of ES.

MATERIALS AND METHODS

Publication search

Two reviewers (Li SC and Li XH) independently performed a literature search in PubMed, EMBASE, the Cochrane Library, Clinicaltrials.gov, China National Knowledge Infrastructure, Wanfangdata (Wanfang) and the VIP database for all randomized controlled trials (RCTs) that assessed the impact of ES for internal hemorrhoids that were published from the inception of the database through August 25, 2025. The retrieval strategy adopted a combination of subject words and free words. The detailed search strategies are provided in Supplementary Table 1. This systematic review has been registered in PROSPERO.

Inclusion and exclusion criteria

Inclusion criteria: (1) The study evaluated the impact of ES for internal hemorrhoids; (2) The outcome measures included clinical efficacy, complications, and core clinical outcomes (treatment costs, length of hospital stay, healing time, operation time, surgical blood loss); and (3) All the original studies were RCTs and reported no statistically significant differences between groups in terms of baseline characteristics such as age, sex, or grades of hemorrhoids (P > 0.05).

Exclusion criteria: (1) The experimental group underwent endoscopic ligation, transanoscope sclerotherapy, or TS; (2) The control group was treated with endoscopic internal hemorrhoid treatment or Milligan-Morgan surgery; (3) The subjects had previous surgical treatment for hemorrhoids; (4) The study had unreliable efficacy or poor safety; (5) The patients had combined anorectal diseases (such as anal fissure, anal fistula, and rectal polyps); or (6) The study had incomplete data. Two authors (Wu SY and Chen YS) independently assessed the articles for compliance with the inclusion/exclusion criteria, resolved disagreements, and reached a unified decision.

Study selection and data extraction

Two reviewers (Li SC and Chen YS) independently performed the primary screening of potentially eligible studies based on the title, abstract and MeSH terms. All the articles selected through primary screening were then read in full to ensure study eligibility. Any disagreements were resolved by discussion with a third reviewer (Xie F). Data on baseline information and outcomes were extracted from the final set of included studies using specially designed tables. If studies were found to report insufficient information, attempts were made to contact the authors.

Assessment of risk of bias

The methodology for each RCT was independently assessed by two reviewers (Li SC and Chen YS) according to the Cochrane Collaboration’s risk of bias tool[14], which includes the following criteria: (1) Random sequence generation; (2) Allocation concealment; (3) Blinding of participants and personnel; (4) Blinding of outcome assessment; (5) Incomplete outcome data; (6) Selective reporting; and (7) Other bias. For each entry, based on the risk of bias assessment guidelines, we classified the studies as having a low, high, or uncertain risk of bias. All disagreements were resolved by discussion until a consensus was achieved.

Outcome measures

Primary outcome measures included: (1) Clinical efficacy; (2) Symptom score defined according to the Li[15] classification, with scores ranging from 1 to 5, with higher scores indicating more severe symptoms; and (3) Symptom improvement rate. Secondary outcome measures included: (1) Postoperative bleeding; (2) Anal bulge; (3) Anal edema; (4) Urinary retention; (5) Anal pain; and (6) Infection. The third outcome measure was the core clinical outcome, which included: (1) Treatment costs; (2) Hospital stay; (3) Healing time; (4) Operation time; and (5) Surgical blood loss.

Statistical analysis

Meta-analyses were performed by using risk ratios (RRs) for dichotomous outcomes, and standardized mean differences (SMDs) were used for continuous outcomes. Pooled estimates are presented with 95%CIs. When heterogeneity was found to be statistically significant (P < 0.05 or I² > 50%), a random effects model was applied. Otherwise, a fixed effects model was adopted to calculate the pooled RRs or SMDs. Statistical analyses were performed using the statistical program Review Manager, version 5.4 (Cochrane Collaboration, Oxford, United Kingdom). P < 0.05 indicated a statistically significant difference.

RESULTS

Literature search and study characteristics

A total of 149 studies were screened, and 36 full-text articles were assessed for eligibility. Finally, 17 RCTs[15-33] were included in the current systematic review. A flowchart depicting the study selection process is presented in Figure 1. The eligible articles were published between 2015 and 2024 and included a total sample size of 1689 patients. All the studies were published in Chinese. The mean ages of the participants in the studies ranged from 31.61 years to 57.0 years. Both male and female adult patients were included in the studies. The main characteristics of the included studies are presented in Table 1. Each reviewer performed an assessment of the risk of bias for each methodological component. A summary of the risk of bias for the included RCTs is presented in Figure 2. Most studies were determined to have a low risk of bias in terms of random sequence generation and allocation concealment. However, owing to the nature of the intervention measures, assessment of the blinding of participants and staff in all the studies revealed a high risk of bias. The overall risk of selective reporting and other biases was relatively low (Supplementary Table 2).

Figure 1 Preferred reporting items for systematic reviews and meta-analysis flow diagram.

Figure 2 Risk of bias assessment of the included studies. A: Risk of bias graph: Review authors’ judgements about each risk of bias item presented as percentages across all included studies; B: Risk of bias summary: Review authors’ judgements about each risk of bias item for each included study. Green (+): Low risk of bias; Yellow (?): Unclear risk of bias; Orange (-): High risk of bias.

Table 1 Characteristics of the trials included in this meta-analysis, mean ± SD.

Ref.	Country	Grade	Group	ES/TS (n)	Sex (female/male)	Age (ES + TS) (year)
Liu et al[21], 2015	China	II, III	ES	86	58/761	48.90 ± 14.60
			TS	48		47.10 ± 15.20
Li[15], 2019	China	I-III	ES	30	25/351	41.21 ± 4.31
			TS	30		40.14 ± 3.13
Xia et al[23], 2019	China		ES	53	47/591	40.82 ± 3.81
			TS	53		40.82 ± 2.91
Ke[16], 2020	China	II, III	ES	58	61/551	42.30 ± 2.20
			TS	58		42.10 ± 2.10
Li et al[17], 2020	China	I-III	ES	30	13/471	34.85 ± 3.24
			TS	30		35.25 ± 3.34
Ding et al[18], 2021	China	I-IV	ES	30	32/281	43.10 ± 12.10
			TS	30		42.20 ± 11.70
Lin et al[19], 20211	China	I-III	ES	40	28/521	37.91 ± 4.87
			TS	40		38.11 ± 4.99
Wang et al[20], 2021	China	I-III	ES	30	29/311	38.10 ± 1.89
			TS	30		39.90 ± 1.75
Lv and Pan[22], 2021	China	I-III	ES	40	31/491	42.80 ± 5.10
			TS	40		44.50 ± 4.80
Chen et al[24], 2021	China	II, III	ES	40	34/461	43.37 ± 15.13
			TS	40		43.51 ± 15.27
Li et al[25], 2025	China	I-III	ES	30	21/391	46.30 ± 2.50
			TS	30		45.90 ± 2.30
Zhou et al[26], 2021	China	I-III	ES	69	72/631	54.10 ± 8.20
			TS	66		51.20 ± 7.60
Chen et al[29], 2023	China	II, III	ES	60	49/711	46.01 ± 9.98
			TS	60		45.36 ± 10.15
Yu et al[30], 2023	China	I-III	ES	60	49/711	46.19 ± 12.91
			TS	60		41.95 ± 15.39
Wang et al[31], 2023	China	II, III	ES	122	121/1231	52.70 ± 4.30
			TS	122		54.60 ± 2.40
Wu and Li[32], 2024	China		ES	52	39/651	47.08 ± 4.25
			TS	52		46.59 ± 4.28
Zheng et al[33], 2024	China	I-III	ES	35	27/431	47.92 ± 5.60
			TS	35		47.65 ± 5.40

¹Sex data are presented as totals for both the endoscopic sclerotherapy and traditional surgery groups combined, as the original studies did not provide separate group data.

ES: Endoscopic sclerotherapy; TS: Traditional surgery.

Primary outcome measures

Clinical efficacy: Thirteen studies[15-19,21,22,25,26,29-31,33], including 1338 patients, reported the clinical efficacy. Compared with TS, ES yields better results in terms of hemostasis and a reduction in working interference time, while the two treatments have comparable efficacy in terms of the relief of anal pain and prolapse (RR = 1.07; 95%CI: 1.04-1.10; P < 0.0001, z test; I² = 71%; Figure 3A).

Figure 3 Forest plot of clinical efficacy. A: Clinical efficacy; B: Symptom score; C: Symptom improvement rate.

Symptom score: Three studies[15,23,32] reported on the outcome “affecting work” and found that ES had a weaker effect on work than did TS did (SMD = 2.02; 95%CI: 1.77-2.28; P < 0.0001, z test; I² = 0%). Four studies[15,20,23,32] reported bleeding scores and reported that compared with TS, ES resulted in less bleeding (SMD = 1.26; 95%CI: 0.72-1.80; P < 0.0001, z test; I² = 96%). Five studies[15,20,23,25,32] reported the anal pain scores and reported no significant difference between ES and TS (SMD = 0.95; 95%CI: -0.29 to 2.19; P = 0.13, z test; I² = 99%). Three studies[15,23,32] reported the incidence of hemorrhoid prolapse and reported no significant difference between ES and TS (SMD = 1.47; 95%CI: 0.84-2.09; P < 0.0001, z test; I² = 96%) (Figure 3B).

Symptom improvement rate: Three studies[22,25,26] reported the bleeding improvement rate and reported no significant difference between ES and TS (RR = 1.15; 95%CI: 0.97-1.36; P = 0.10, z test; I² = 68%). One study[26] reported the rate of anal pain improvement and reported no significant difference between ES and TS (RR = 1.34; 95%CI: 1.07-1.68; P = 0.01). Only one study[22] reported the rate of improvement in hemorrhoid prolapse and reported no significant difference between ES and TS (RR = 1.30; 95%CI: 1.01-1.67; P = 0.04) (Figure 3C).

Secondary outcome measures

Seven studies[16,19,24,29-31,33] reported postoperative bleeding results and reported that compared with TS patients, ES patients experienced less postoperative bleeding (RR = 0.22; 95%CI: 0.08-0.57; P = 0.002; z test; I² = 0.0%; Figure 4A). Four studies[16,17,26,30] reported anal bulge results and reported no significant difference between ES and TS (RR = 0.50; 95%CI: 0.15-1.69; P = 0.27, z test; I² = 90.0%; Figure 4B). Seven studies[17-19,21,24,26,30] reported anal pain results and reported no significant difference between ES and TS patients (RR = 0.49 95%CI: 0.21-1.12; P = 0.09, z test; I² = 97%; Figure 4C). Five studies[18,22,26,29,31] reported anal edema results and reported that, compared with TS patients, ES patients had less anal edema (RR = 0.21; 95%CI: 0.14-0.31; P < 0.0001, z test; I² = 0%; Figure 4D). Seven studies[18,22,24,29-31,33] reported urinary retention results and reported that compared with TS, ES resulted in less urinary retention (RR = 0.16; 95%CI: 0.06-0.44; P < 0.0001, z test; I² = 0.0%; Figure 4E). Eleven studies[16-19,21,22,24,29-31,33] reported infection results and reported that compared with TS patients, ES patients had a lower infection rate (RR = 0.26; 95%CI: 0.12-0.58; P < 0.0001, z test; I² = 100%; Figure 4F).

Figure 4 Forest plot of complications after endoscopic sclerotherapy. A: Postoperative bleeding; B: Anal bulge; C: Anal pain; D: Anal edema; E: Urinary retention; F: Infection.

Third outcome measures

Four studies[19,21,24,33] reported treatment cost results and reported that ES had lower treatment costs than did TS (SMD = -3448.66; 95%CI: -4343.46 to -2553.86; P < 0.0001, z test; I² = 100.0%; Figure 5A). Seven studies[18,19,21,24,29,31,33] reported hospital stay results and reported that ES patients had shorter hospital stays than TS patients did (SMD = -3.29; 95%CI: -5.08 to -1.50; P = 0.000; z test; I² = 99.0%; Figure 5B). Three studies[18,21,25] reported healing time results and reported that compared with TS patients, ES patients had shorter healing times (SMD = -7.01; 95%CI: -9.41 to -4.61; P < 0.0001, z test; I² = 72.0%; Figure 5C). Ten studies[16,18,19,21,22,24,26,29,31,33] reported operation time results and reported that ES patients had shorter operation times than TS (SMD = -12.76; 95%CI: -17.45 to -8.07; P < 0.0001, z test; I² = 98.0%; Figure 5D). Four studies[16,19,21,24] reported surgical blood loss results and reported that compared with TS patients, ES patients had less surgical blood loss (SMD = -24.41; 95%CI: -42.33 to -6.50; P < 0.0001, z test; I² = 100.0%; Figure 5E).

Figure 5 Forest plot of core clinical outcomes. A: Treatment costs; B: Hospital stay; C: Healing time; D: Operation time; E: Surgical blood loss.

Publication bias and sensitivity analysis

A qualitative method was used to test for potential publication bias. The funnel plot was almost symmetrical (Supp-lementary Figure 1), indicating that there was no significant publication bias. When the sequential exclusion method was used, excluding any one item did not change the results, suggesting a relatively stable dataset.

DISCUSSION

Endoscopy offers a novel approach to the contemporary field of hemorrhoid treatment, presenting an unprecedentedly clear and expansive field of vision, along with an enhanced operational space and increased flexibility. Through endoscopy, valuable imaging data can be stored, facilitating retrospective analysis and enhancing educational opportunities. Compared with traditional internal hemorrhoid sclerotherapy, ES for internal hemorrhoids not only alleviates patient apprehension toward surgery but also minimizes the risk of bleeding, pain and other complications. However, the primary reason for the public reluctance to accept ES is the insufficient compelling evidence regarding its efficacy and safety.

This meta-analysis aimed to compare the clinical efficacy and complications associated with conventional internal hemorrhoid sclerotherapy with those associated with endoscopic techniques. More than 1000 patients were included in this meta-analysis, and all the studies reviewed were conducted in China. This focus is justified, as ES has gained widespread application in Chinese hospitals in recent years.

The results of this study indicate that, for primary outcome measures, when a clinical choice between ES and TS is made, the main symptoms of the patient should be the guiding factor: For internal hemorrhoids of grades I-III, which are characterized mainly by bleeding, ES is more suitable; if long-term fixation of the prolapsed structure is needed, TS remains a reliable option. With respect to symptom improvement rates, only one study reported improvement rates for each method. When ES and TS were compared in terms of improvement rates for anal pain and hemorrhoidal prolapse, no statistically significant differences were found between the two groups.

These results can be attributed to the distinct mechanisms of action and inherent limitations of the two approaches. With respect to pain management, electrical stimulation exerts its effects by initiating a robust chemical inflammatory response, which leads to the localized release of pain-inducing substances such as prostaglandins and bradykinin[34], continuously stimulating nerve endings and thereby causing a deep and persistent burning pain or aching sensation. In contrast, TS produces distinct sensory nerve pain characterized by a sharp, cutting sensation; however, this pain is primarily transient, arising from the acute mechanical trauma associated with the surgery and gradually diminishing as the wound heals. More importantly, the perioperative pain management guidelines established by organizations such as the American Pain Society indicate that contemporary multimodal analgesic strategies-including long-acting local anesthetics for wound infiltration, nonsteroidal anti-inflammatory drugs, and the on-demand administration of opioids-can effectively manage both the intensity and duration of such acute pain[35]. As a result, during long-term follow-up, there was no significant difference in the core efficacy indicators of pain improvement between the two methods. TS achieves immediate results by directly removing the prolapsed hemorrhoidal tissue. However, if the resection range is inappropriate, it may not only damage the fine closure function of the anal cushions but also cause anal stenosis or new pulling sensations due to uneven local scar formation[36]. In contrast, ES operates based on the mechanism of chemical damage to the vascular endothelium, triggering sterile inflammation. The extensive fibrosis thus produced can firmly fix the relaxed mucosa to the deep anal muscle wall, effectively alleviating prolapse symptoms through suspension and fixation[37]. Although ES is minimally invasive, its mechanical strength for fibrosis fixation has limitations, resulting in no statistically significant difference in the core efficacy indicators for controlling prolapse between the two methods during long-term follow-up. In summary, the advantages of ES include specific perioperative indicators, such as work impact and blood loss. However, regarding the core therapeutic effects of pain and prolapse control, ES is comparable to TS. These findings provide a crucial basis for clinical decision-making: If rapid recovery and improved hemostasis are prioritized, ES is an excellent choice; conversely, if long-term structural stability is the focus, TS presents a viable alternative. Although ES is minimally invasive, its mechanical strength for fibrosis fixation has limitations, resulting in no significant difference in the core efficacy indicators for controlling prolapse between the two methods at long-term follow-up.

Postoperative pain, urinary retention, and bleeding remain the most common complications following hemorrhoid surgery. A minority of patients may experience additional complications, such as anal prolapse, anal edema, infection, and anal stenosis[27]. Notably, ES significantly reduces the incidence of postoperative bleeding, anal edema, urinary retention, and infection. This reduction may be attributed to the decreased stimulation of the anal canal and the simpler surgical technique associated with ES. Furthermore, some patients in the TS group underwent external hemorrhoidectomy. ES is typically performed with complete gastrointestinal bowel preparation, whereas TS rarely requires such preparation and is usually conducted via enema. Patients in the ES group generally experienced delayed bowel movements compared with those in the TS group, resulting in their wounds being exposed to fecal stimulation at a later stage. With respect to postoperative urinary retention, TS often involves spinal anesthesia, which suppresses and affects the micturition center, leading to urinary retention. In contrast, endoscopic treatment typically involves intravenous anesthesia, thereby reducing the risk of urinary retention[28]. These findings suggest that ES facilitates a smoother postoperative recovery process with enhanced patient comfort. However, no significant difference was observed between the two procedures in terms of the incidence of anal protrusion and anal pain, indicating that certain postoperative discomforts remain challenging to completely avoid and necessitate a comprehensive assessment based on individual circumstances.

In terms of core clinical outcomes, compared with TS, ES resulted in lower treatment costs, shorter hospital stays, faster healing times, shorter operative durations, and less intraoperative blood loss. For patients with grade I-III internal hemorrhoids, ES represents a less invasive and simpler surgical approach than TS does, resulting in shorter procedure times and minimal intraoperative bleeding. Furthermore, the small incisions and precise manipulation associated with ES accelerate wound healing, reduce discomfort from postoperative dressing changes, and shorten hospital stays, thereby facilitating outpatient procedures. Consequently, patients who underwent ES experienced faster discharge, higher satisfaction, and greater comfort than those who underwent TS did. This approach not only alleviates the financial burden on patients but also enhances healthcare resource utilization, demonstrating significant health economic value.

This study has several limitations. First, the control group included in the RCT covered various surgical methods, such as PPH, Ferguson, and Ruiyun procedure for hemorrhoids. However, the original literature did not stratify the reports by surgical subtype, making it impossible to conduct subgroup analysis. Therefore, the results of this meta-analysis should be understood as the average effect of ES compared with “the commonly used clinical hemorrhoid surgeries”, rather than a judgment of the superiority or inferiority of a specific surgical method. In the future, one-to-one RCT of ES against a single surgical method (such as PPH or Ferguson) need to be conducted to obtain more targeted evidence. Second, ES showed significant advantages in reducing postoperative bleeding, edema and urinary retention (I² = 0%), but the reliability of outcomes related to anal pain, operation time, and costs was compromised due to considerable unexplained heterogeneity. Future RCTs should standardize operative procedures, cost calculation methods, and severity stratification, as well as prospectively register ligation protocols, to enhance future subgroup analyses. Moreover, the Cochrane Collaboration's risk of bias assessment indicated that all the studies exhibited at least one instance of high risk or uncertain risk of bias. The absence of participant and personnel blinding, coupled with a lack of allocation concealment, was prevalent. Finally, outcome assessments were frequently unblinded, culminating in overall low methodological quality.

CONCLUSION

Current evidence on endoscopic treatment for hemorrhoids predominantly stems from the use of single-center, small-sample studies and suffers from a lack of unified operational standards and high-quality evidence-based data. This study is the first to include 17 RCTs involving 1689 patients and demonstrates that ES outperforms TS across more than 10 indicators, including efficacy, postoperative bleeding, edema, urinary retention, hospital stay duration, and cost. While endoscopic techniques show promising prospects, large-scale multicenter studies are still needed to define precise indications and contraindications and to establish standardized protocols for guiding clinical decision-making.