Combined mucopexy & Milligan-Morgan's technique in circumferential 4th degree haemorrhoids: Prospective observational cohort study

Abstract

BackgroundIt is well known that a large excisional haemorrhoidectomy could be certain cause of post-operative severe complications like incontinence, ectropion or anal stenosis. ObjectiveOur aim is to reduce post-operative complications avoiding a large haemorrhoidectomy in patients suffering of a circumferential 3-4th degree prolapsed haemorrhoids. DesignThis was a prospective, single institution study with propensity score matching performing a classic stapled mucopexy followed by the excision of the internal mucosae prolapse combining at the same operative time a concomitant classic Milligan and Morgan's technique of the remnant external piles. PatientsThe study population were 54 eligible patients, study included 32, to demonstrate feasibility and safety of our proposals. 20 males, 12 females, mean age 51.9 years (range 21–84) underwent combined mucopexy and haemorrhoidectomy in one single surgical procedure between January 2017 and December 2019. ResultsA total of thirty-two patients were included prospectively and consecutively; 18 patients (33.4% of the universe) presented anatomical variations on the CMHP and variations on the IHED (10), associated anal fissures (2), modified piles with HPV condylomata (2), non-stoppable anticoagulation treatment (2), immunity treated disease (1), no evidence of a haemorrhoidal mucosal prolapse and minor pile's components (1) and they were definitely excluded of the study. There were no significant differences in the postoperative complication rates. The length of the operation was (48, 05 min +/- 5, 30 min). Some special bleeding had required at the end of the procedure a supplementary haemostasis with absorbable single suture in six patients (18, 8%), men (12, 5%) women (6, 3%). The stapled haemorrhoidal mucopexy allowed a faster functional recovery with shorter time off work (weighted mean difference 9.45 days; p < 0.00001), earlier return to normal activities (weighted mean difference, 15.85 days; P = 0.03), and better wound healing (odds ratio, 0.1; P = 0.0006). No stenosis, neither ectropion. LimitationsBecause of a single limited study including a single operative group. ConclusionsOur results confirm the strategy, demonstrating that the combined technique drastically reduces the risk of anal stenosis, ectropion, incontinence or recurrence of the prolapse. By the restoration of the anal canal anatomy under visual control and preservation of the required mucosal and cutaneous bridges results are reproducible and sure.