Milligan-Morgan Group Research Articles

Whitehead Hemorrhoidectomy: Is It Time for a Second Look?

Abstract Background: Hemorrhoidal problems are common causes of patient complaints. Most of the hemorrhoid-related issues can be managed conservatively; however, some patients with grade III and IV hemorrhoids are referred for surgical management. Several techniques including classic hemorrhoidectomy and dearterialization with or without Doppler guidance have been described. Although not as frequently performed, the Whitehead procedure remains occasionally utilized. Objectives: The goal of this study is to assess the short- and long-term outcomes of the Whitehead procedure in comparison to the Milligan–Morgan procedure. Design: Retrospective review. Patients and Methods: A review of all patients undergoing surgical treatment for grade III and IV hemorrhoids at 7th city hospital in Kyiv, Ukraine, between 2015 and 2021 was conducted. The rates of perioperative complications of the Whitehead procedures and overall outcomes were compared to the Milligan–Morgan techniques. Main Outcome Measures: Primary outcome included postoperative pain and secondary outcomes included short- and long-term postoperative complications. Sample Size: Three hundred and twenty-three patients were included in the study. Results: One hundred and seventy-three patients underwent the Whitehead procedure and 140 patients underwent the Milligan–Morgan procedure. There was no difference in age, sex, and comorbidities between the groups. There were no statistical differences between short-term complications, but the Whitehead group experienced less pain throughout the 14 days after surgery. All the patients were seen and examined 6 months after surgery; the patients who underwent the Whitehead procedure showed less prolapse when compared to those in the Milligan–Morgan group without increase in other complications. Conclusions: Whitehead hemorrhoidectomy is safe and shows less pain during recovery without remarkable increase in long-term complications. Limitations: This was a retrospective review and non-validated instruments were used in surveys. Conflict of Interest: The authors have no conflict of interest to declare.

Comparison of Pedicle Coagulation Hemorrhoidectomy With LigaSure Versus Conventional Milligan Morgan Hemorrhoidectomy in Reducing Post-operative Pain: A Randomized Controlled Trial.

Background Hemorrhoids refer to the abnormal enlargement of the anal cushions. They are a common anorectal problem with a prevalence of 5% in the general population aged greater than 40 years. The objective of this study was to compare Milligan-Morgan open hemorrhoidectomy with pedicle ligation with LigaSure (Medtronic, Dublin, Ireland) in terms of postoperative pain on day 1 and day 7. It is important to assess the technique that is associated with lower postoperative pain because both of these techniques are still practiced in the developing world. Methods It was a randomized controlled trial conducted in the Department of Surgery, Rawalpindi, Pakistan. A total of 100 patients were selected and were allotted into the two groups by lottery method. Patients aged from 15 to 60 years who presented with symptomatic third and fourth-degree hemorrhoids were included after taking informed consent. Patients who had a previous or concomitant anorectal disease, patients who had undergone previous surgery for hemorrhoids, and those who were anesthetically unfit for surgery (American Society of Anesthesiologists (ASA) class 3 or above) were excluded from the study. Pain was assessed using the Visual Analogue scale (VAS). Data was entered and analyzed using SPSS v. 23.0 (IBM Corp., Armonk, USA). Chi-square tests were applied. P-value <0.05 was taken as statistically significant. Results Out of 100 patients, 68 (68%) were males while 32 (32%) were females. The mean age was 40.56±9.24 years. Postoperative pain at day 1 was 9.24±0.51 in the Milligan-Morgan group while that in the LigaSure group was 8.44±0.64 (p<0.0001). Postoperative pain at day 7 was 5.00±0.85 in the Milligan-Morgan group while it was 3.04±1.08 in the LigaSure group (p<0.0001). Conclusion LigaSure is a newer technique that helps to reduce complications as compared to other traditional hemorrhoidectomy procedures. Many patients avoid hemorrhoidectomy as it is associated with painful postoperative recovery. Pedicle coagulation with LigaSure was better than conventional Milligan-Morgan hemorrhoidectomy in terms of reducing the mean postoperative pain on 1st day and 7th day. Reducing the postoperative painhelps in greater patient satisfaction and lesser requirement of analgesiaamong patients of 3rd and 4th-degree hemorrhoids undergoing hemorrhoidectomy.

Stapled Hemorrhoidopexy Versus Milligan–Morgan Hemorrhoidectomy in Circumferential Third-Degree Hemorrhoids: Long-Term Results of a Randomized Controlled Trial

BackgroundThe literature indicates higher recurrence rates for stapled hemorrhoidopexy than for conventional techniques. This could be due to inappropriate patient selection. ObjectiveThe aim of this study was to evaluate the short- and long-term outcome after stapled hemorrhoidopexy compared with the Milligan–Morgan procedure in a homogeneous patient population with circumferential third-degree hemorrhoids. Design and PatientsOne hundred thirty patients were enrolled into a randomized controlled study, of which 122 were clinically evaluated at weeks 1, 2, and 4, and thereafter each year for a minimum of 3 years. Patients completed a questionnaire for symptoms, function, and pain. Pain was assessed using a visual analog scale. Recurrences were determined by anoscopy and self-report. SettingsThe study was performed at the University Hospital Hamburg. Main Outcome MeasuresEndpoints were pain, recurrence, bleeding, itching/burning, urinary retention, incontinence symptoms, and prolonged rate of wound healing. ResultsThe cumulative recurrence rates after 5 years were 18 % (n = 11) in the stapled hemorrhoidopexy group and 23 % (n = 14) in the Milligan–Morgan group (p = 0.65). Patients who underwent stapled hemorrhoidopexy had significantly less postoperative pain with mean VAS scores at week 1: 3.1 vs. 6.2; week 2: 0.5 vs. 3; week 4: 0.05 vs. 0.6 (p < 0.001), and demonstrated less burning/itching sensation 4 weeks after surgery compared with the Milligan–Morgan group (4.9 vs. 19.7 %; p < 0.001). The postoperative bleeding rate was 4.9 % in both groups and the rate of urinary retention did not differ significantly (4.9 % vs. 1.6 %; p = 0.309). Postoperative incontinence symptoms (6.6 % versus 3.3 %; p = 0.40) resolved within the first 6 months. LimitationsDetailed measurement of incontinence was not possible because postoperative symptoms resolved between consultations, and pathological results were examined retrospectively. ConclusionsThe results show a similar rate of recurrence in the long term and suggest increased patient comfort in the early postoperative course after stapled hemorrhoidopexy. In patients with circumferential third-degree hemorrhoids, stapled hemorrhoidopexy is as effective as the Milligan–Morgan procedure.

Médicos residentes podem realizar com segurança e eficiência técnicas de Milligan-Morgan, Ferguson e grampeadores no tratamento cirúrgico das hemorróidas?

RACIONAL: A cirurgia para hemorróidas sintomáticas é necessária em quase 10% dos pacientes. Embora, a literatura sobre o tratamento cirúrgico da doença hemorroidária seja muito grande, os dados relativos à hemorroidectomia ou hemorroidopexia realizadas por residentes de treinamento é limitado. OBJETIVO: Analisar os resultados destes procedimentos em uma instituição de ensino. MÉTODOS: Foram analisados retrospectivamente os dados de todos os pacientes que se submeteram ao tratamento cirúrgico para hemorróidas entre1995 e 2007 em uma única instituição. Residentes supervisionados realizaram todos os procedimentos. As técnicas foram comparadas com base no tempo operatório, permanência hospitalar, morbidade e eficácia a longo prazo. RESULTADOS: Trezentos e trinta e três pacientes foram incluídos no estudo, 182 homens (54,6%), com idade média de 45,3 anos (± 12,02). Hemorróidas de terceiro grau foram a principal indicação (81,7%). Milligan-Morgan foi o procedimento mais comumente realizado (57%), seguido por Ferguson e hemorroidopexia grampeada. A média de tempo operatório foi significativamente menor no grupo hemorroidopexia grampeada quando comparado com os procedimentos abertos e fechados: 49,4 ± 29,3 min vs 61,1 ± 26,5 e 67,1 ± 28,3, respectivamente (p=0,0034). Não houve diferença estatisticamente significativa entre os grupos quanto às complicações pós-operatórias ou à taxa de reoperação. O tempo de internação foi significativamente maior no grupo Milligan-Morgan quando comparado com Ferguson e grampeamento (1,41 ± 0,86 dias vs 1,19 ± 0,43 vs 1,16 ± 0,37, respectivamente). Recorrência sintomática, taxas de reoperação e o uso de ligadura elástica foram semelhantes entre os grupos. CONCLUSÃO: Os residentes sob supervisão pode executar Milligan-Morgan, Ferguson e grampeamento hemorroidário com baixa incidência de complicações e bons resultados a longo prazo. O grampeamento foi associado com menor tempo operatório, enquanto Milligan-Morgan foi correlacionada com maior tempo de hospitalização.

Efficacy of the procedure for prolapse and hemorrhoids combined with external hemorrhoids excision in the treatment of III or IV mixed hemorrhoids

To investigate the efficacy of the procedure for prolapse and hemorrhoids (PPH) combined with external hemorrhoids excision in the treatment of III or IV mixed hemorrhoids. One hundred and twelve patients with III or IV mixed hemorrhoids admitted for surgical treatment were randomly divided into three groups: PPH 1 group (34 cases), PPH2 group (36 cases), and Milligan-Morgan group (42 cases). PPH1 group received the standard PPH operation, PPH2 received PPH and external hemorrhoids excision, and Milligan-Morgan group received Milligan-Morgan hemorrhoidectomy. Postoperative 24 h-pain index, pain index when defecating, bleeding, anal discomfort feeling , wound edema, the ability of controlling feces, operating time, hospitalization time and charges were recorded. The change of anal dynamics was detected by anorectal manometry. All the patients were followed-up for 0.5-1 year. There were no significant differences among the three groups in bleeding, anal discomfort feeling, the ability of controlling feces (P>0.05). The postoperative 24 h-pain index of PPH1 group was lower than those of the other two groups (P<0.05). PPH1 group and PPH2 group were better than Milligan-Morgan group in pain index when defecating, wound edema, operating time, and hospitalization time (P<0.05). Milligan-Morgan group was better than the other two groups in postoperative urinary retention and hospital charges (P<0.05). The change of anal duct pressure of Milligan-Morgan group was less than those of the other two groups (P<0.05). Within 0.5-1.0 year follow-up, 3 patients got thrombosed external hemorrhoid in PPH1 group, 2 patients recurred and 1 patient got thrombosed external hemorrhoid in Milligan-Morgan group, no recurred patients in PPH2 group. PPH combined with external hemorrhoid excision is a safe and effective treatment for mixed hemorrhoids, which is suitable for mixed hemorrhoids with severe external hemorrhoids.

Sept ans d’hémorroïdopexies : des premiers essais contrôlés aux méta-analyses

BackgroundSurgical haemorrhoidectomy is reputed to be a painful procedure for a benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial.MethodFourty patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to either Milligan-Morgan haemorrhoidectomy (n = 20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3, and 6–10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure.FindingsThe stapled group had shorter anaesthesia time (median 18 [range 9–25] vs 22 [15–35] minutes). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2.1 [0.2–7.6] vs 6.5 [3.1–8.5], 95.1 % CI difference medians 1.9–4.7, p < 0.0001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (−2.8 [−4.4 to 1.3] vs 0.7 [−1.8 to 3.4]). Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3–60] vs 34 [14–90]). Early and late complications, patient-assessed symptom control, and functional outcome appear similar after short-term follow-up.InterpretationThe circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study.

Randomized clinical trial of the effects on anal function of Milligan–MorganversusFerguson haemorrhoidectomy

Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy. A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale. Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047). Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.

Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy

Background The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy. Methods After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction. Results The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group ( P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) ( P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2–19 months). Conclusions Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.

Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial

Summary Background Surgical haemorrhoidectomy has a reputation for being a painful procedure for a fairly benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial. Methods 40 patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to MilliganMorgan haemorrhoidectomy (n=20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3, and 6–10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure. Findings The stapled group had shorter anaesthesia time (median 18 [range 9–25] vs 22 [15–35] mins). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2·1 [0·2–7·6] vs 6·5 [3·1–8·5], 95·1% CI difference medians 1·9–4·7, p0·0001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (–2·8 [4·4 to 1·3] vs 0·7 [1·8 to 3·4]. Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3–60] vs 34 [14–90]. Early and late complications, patient-assessed symptom control, and functional outcome appear similar after short-term follow-up Interpretation The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study. Lancet 2000; 355: 782–85 See Commentary page xxx

Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial

Surgical haemorrhoidectomy has a reputation for being a painful procedure for a fairly benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial. 40 patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to Milligan-Morgan haemorrhoidectomy (n=20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3, and 6-10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure. The stapled group had shorter anaesthesia time (median 18 [range 9-25] vs 22 [15-35] mins). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2.1 [0.2-7.6] vs 6.5 [3.1-8.5], 95.1% CI difference medians 1.9-4.7, p<0.0001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (-2.8 [-4.4 to 1.3] vs 0.7 [-1.8 to 3.4]. Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3-60] vs 34 [14-90]. Early and late complications, patient-assessed symptom control, and functional outcome appear similar after short-term follow-up. The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study.