Abstract: Three trials (of poor methodological quality) met the inclusion criteria. Complete remission of haemorrhoidal symptom was better with excisional haemorrhoidectomy (EH) (three studies, 202 patients, RR 1.68, 95% CI 1.00 to 2.83). There was significant heterogeneity between the studies (I2 = 90.5%; P = 0.0001). Similar analysis based on the grading of haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04 to 1.45; P = 0.01). However, no significant difference was noticed in grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94 to 1.21; P = 0.32) Fewer patients required re-treatment after EH (three trials, RR 0.20 CI 0.09 to 0.40; P < 0.00001). Patients undergoing EH were at significantly higher risk of postoperative pain (three trials, fixed effect; 212 patients, RR 1.94, 95% CI 1.62 to 2.33, P < 0.00001). The overall delayed complication rate showed significant difference (P = 0.03) (three trials, 204 patients, RR 6.32, CI 1.15 to 34.89) between the two interventions. The present systematic review confirms the long-term efficacy of EH, at least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the expense of increased pain, higher complications and more time off work. However, despite these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment modalities seems to be similar following both the techniques implying patient's preference for complete long-term cure of symptoms and possibly less concern for minor complications. So, RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results but with out the side effects of EH while reserving EH for grade III haemorrhoids or recurrence after RBL. More robust study is required to make definitive conclusions. One additional study was identified from the updated search (Ali 2005). However, after careful review and discussion among the authors, it was decided that this study did not meet the necessary criteria for including in the analysis. Hence, the results and conclusion remains the same.

Plain-language summary: This review is based upon three randomised controlled trials comparing RBL with EH, with a total of 216 patients. The trials showed that with EH, haemorrhoids did not come back as often as with RBL. EH was better for advanced haemorrhoids, known as grade III haemorrhoids. For less severe grade II haemorrhoids, RBL and EH were equally effective. EH caused more pain after the procedure, more minor complications, and required more time off work. Patient satisfaction was similar for both treatments. This review has been up dated as of October 2010 and the search was carried out with previously used search strategy to identify any possible new randomised controlled study to include in the statistics. Only one additional paper was identified with a potential possibility to include in the study (Ali 2005). However, after a combined common decision from all the authors, it was decided to exclude the paper for the statistics because of the poor data presentation and randomisation method.  After up to date search, the conclusion has not changed and the review authors conclude that RBL should be the primary treatment used for grade II haemorrhoids, and EH reserved for patients who failed after repeated RBL or grade III haemorrhoids. They recommend more research be done comparing these techniques with the many newer ones, especially stapled haemorrhoidopexy, to determine which treatment is best.