Milligan-Morgan Research Articles

Clinical Trial: Management of Post-Haemorrhoidectomy Wound Healing by Bergamot Flavonoid-Based Gel and Sodium Hyaluronate: An Observational, Multicentric Trial

Objective: Haemorrhoidal disease (HD) is a very diffuse anorectal condition that involves a large part of the population, both male and female of every age. Among the procedures proposed to treat HD, conventional excisional surgery remains one of the most performed. Milligan-Morgan (MM) technique is one of the most used haemorrhoidectomy techniques. In this technique, the wounds are left open and re-epithelialization requires almost 3-5 weeks, in which patients generally experience pain and intense discomfort improving over the weeks.
 Methods: The aim of this study was to evaluate the effect of topic administration of Benebeo Gel®, mainly composed by bergamot-derived flavonoids and hyaluronic acid, on post-operative wound healing after open MM haemorrhoidectomy. An observational prospective study was carried out, involving 205 patients aged between 18 and 75.
 Results and Conclusion: The results after 2 weeks of treatment seem to be promising with a very good clinical outcome and patient satisfaction within 1 month.

Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis.

This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids. PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis. A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L(Ligasure), M-M(Milligan-Morgan), F(Ferguson), H(Harmonic), OH(open Harmonic), CH(closed Harmonic), PPH(procedure for prolapse and hemorrhoids), TST(tissue selecting technique), T-S(TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24h and PPH had the most postoperative pain after 24h. Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24h.

Comparative Study of Short-Term Outcome between Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy

Background: Due to the fear of postoperative pain and complications associated with open Milligan-Morgan (MM) surgery, mildly symptomatic patients often hesitate and delay undergoing surgical treatment for internal haemorrhoids. Laser Hemorrhoidoplasty (LHP) has been gaining popularity recently in the management of hemorrhoid. This study aimed to evaluate the efficacy of the LHP compared with MM surgery in the management of internal haemorrhoids. Materials and methods: This multi-center, open label, randomized controlled trial included 60 patietns with secondand third-degree internal haemorrhoids. The patients were randomized in a 1:1 ratio to receive either LHP (Group I) or conventional MM hemorrhoidectomy (Group II). Primary outcome parameter was postoperative pain assessed by Visual Anlougue Scale (VAS) at 24 hours, 7 days and 30 postoperative days. Results: Both the groups were comparable in terms of the demographic characteristics. The mean operation time was significantly lower in group I than group II (19.13±3.42 vs. 28.67±4.54 minutes, p<0.001). The mean VAS score of pain at 24 hours and 7 days postoperative were significantly lower in group I than in group II (p<0.001 and p<0.004, respectively). At postoperative, 30 days the mean VAS scores were similar in both groups (p=0.722). The mean total days of consumed analgesic were significantly shorter in group I than in group II (7.94±5.79 vs. 11.01±2.96 days, p<0.001). The mean time to return to regular activity was significantly earlier in group I than in group II (8.76±3.58 vs. 13.6±3.47, p<0.001). Postoperative bleeding was less in group I than in group II (6.6% vs. 26.7%). The mean length of hospital stay, rate of complete resolution and need for medical treatment for residual symptom and repeated surgery were similar between two groups. Conclusion: LHP was associated with reduction of postoperative pain, postoperative bleeding, and administered with analgesics. So, if available LHP is preferred to open hemorrhoidectomy. IAHS Medical Journal Vol 5(2), Dec 2022; 15-19

LigaSure hemorrhoidectomy vs Milligan morgan hemorrhoidectomy: A Quasi-Experimental Study.

Objective: To explore the efficacy of two surgical procedures by comparing the mean operative time, average blood loss and postoperative pain score during conventional and LigaSure. Study Design: Quasi-experimental study. Setting: Department of Surgery, Aziz Fatimah Hospital, to compare the efficacy of two surgical procedures regarding perioperative and postoperative variables. Period: One Year (1st July 2020 -30th June 2021). Material & Methods: Sixty patients with grade three and four haemorrhoids were randomized into two groups with 30 patients each. A questionnaire comprising all the variables was filled out and analyzed in SPSS 21. Results: Thirty patients were randomized into two groups, with group A comprising 21 (70%) females and, 9 (30%) males and 24 (80%) females, 6(20%) males in group B undergoing conventional hemorrhoidectomy. The study was single-blind, as the patients were unaware of the procedure they underwent. The mean age in group A was 39 years, and in group, B was 43 years. The mean operative time calculated was 38.4±2.77 and 51.7±2.60 in LigaSure and Milligan Morgan Hemorrhoidectomy, respectively, with a P-value calculated <0.00001. The average blood loss in LigaSure was 31.3 ± 5.76 and 49 ± 7.11 in Milligan morgan hemorrhoidectomy. Moreover, the pain assessment score on day one and all other variables were statistically significant, with a P-value of <0.00001. Conclusion: Ligasure hemorrhoidectomy is a safer surgical procedure associated with less operative time, blood loss and postoperative pain with shorter hospital stay and rapid wound healing.

Milligan–Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study

BackgroundSeveral surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan–Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL–RAR) technique.MethodsA retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL–RAR group. Primary end points were recurrence rates and patients’ satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables.ResultsA total of 124 patients were identified, submitted either to HAL–RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females–male / female ratio: 3.6) with a median age of 47 years old (range 18–69) were included in the HAL–RAR group while 47 patients (40 males and 7 females–male / female ratio: 5.7) with a median age of 52 years old (range 32–71) comprised the MM group. At a median follow up of 41 months (minimum 24 months–maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL–RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL–RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99—p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70—p 0.0013) in the HAL–RAR group.ConclusionsIn patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL–RAR. In patients with bleeding as the main presenting symptom of HD, HAL–RAR was associated with better patients’ satisfaction rates and similar recurrence rates compared to MM.

Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis.

Laser hemorrhoidoplasty (LHP) is known as a new minimally invasive and painless procedure for symptomatic hemorrhoids. However, Milligan-Morgan (MM) may offer the best result of long-term cure rates. In this study, we aim to compare the efficacy between LHP and MM for hemorrhoidal disease treatment. Using specific keywords, we comprehensively go through the potential articles on PubMed, Europe PMC, and Google Scholar sources until April 19, 2022. All published studies on LHP and MM hemorrhoidectomy were collected. Statistical analysis was done by using Review Manager 5.4 software. Twelve studies with a total of 1756 patients with hemorrhoid grades II-IV were included for the analysis. Our pooled analysis revealed that LHP was associated with shorter operative time (p < 0.00001), shorter length of hospital stay (p = 0.0005), lower risk of urinary retention (p = 0.005) and anal stenosis (p = 0.0004), and lower VAS 24-h post-operative (p < 0.00001) when compared with MM. However, LHP and MM did not differ in terms of recurrence rate (p = 0.70). LHP was superior to MM procedure in terms of shortening the recovery time and minimizing post-operative complications for patients with hemorrhoidal disease.

Comparison of Milligan Morgan Versus Stapled Hemorrhoidectomy in Patients Attending Tertiary Care Hospital

Background and Aim: Hemorrhoids are common anorectal problems that cause fear by bleeding, pruritus burden, and thrombosis pain. Prolapse and hemorrhoids are managed by stapled hemorrhoidectomy (SH). Initially, Stapled hemorrhoidectomy seemed to be a good alternative for Milligan Morgan (MM) hemorrhoidectomy verified by various studies. However, recent studies found that long-term assessment of stapled hemorrhoidectomy gives poor outcomes in terms of postoperative complications and patient’s satisfaction. Therefore, the present study aimed to compare the Milligan Morgan versus stapled Hemorrhoidectomy in patients attending Tertiary Care Hospital. Methodology: This prospective study was carried out on 120 patients at the Department of Surgery Unit-I Sheikh Zayed Medical College Rahim Yar Khan from 1st May 2021 to 31th April 2022. All the patients of either gender with an age range from 18 years to 60 years after 2nd degree hemorrhoids failure of multiple rubber band ligations and 3rd and 4th degree hemorrhoids were enrolled. Concomitant anal disease patients such as ano-rectal cancer, fissure, fistula, and abscess were excluded. Patients were divided into two categories: Group-I Stapled Hemorrhoidectomy and Group-II Milligan Morgan. Post-operative complications such as stenosis and urinary retention during hospitalization were recorded. All the data were entered and analyzed using SPSS version 25. Results: The overall mean age of Group-I and Group-II was 46.78±12.66 years and 48.91±14.82 years respectively. Each group comprised 60 patients. Out of the SH group, 35 (58.3%) were males and 25 (41.7%) were females. Of the MM Group-II, male and females were 44 (73.3%) and 16 (26.7%) respectively. About 53 (88.3%) patients in Group-I and 32 (53.3%) patients in Group-II had relief from bleeding and other symptoms. The surgical duration in Group-I and Group-II was 22.9 ± 12.9 minutes and 34.8 ± 9 minutes with statistical significance (p=0.000) respectively. The vessel spurting ligation and postoperative hemorrhage was developed in 5 (8.3%) in SH group patients. Post-operative bleeding and intervention was found in 26 (43.3%) patients in Group-II. The prevalence of postoperative pain requiring analgesia was found in 20 (33.3%) in Group-I and34 (56.7%) in Group-II respectively. After treatment, fecal incontinence was developed in none of the patients in both groups. The postoperative complications such as anal tag, tenderness, bleeding, urinary retention, and wound discharge were higher in Group-II as compared to Group-I with statistical insignificance (p&lt; 0.05). Conclusion: The present study found that hemorrhoids could be effectively treated by Stapled hemorrhoidectomy compared to Milligan-Morgan procedure in terms of postoperative pain, hospital stay, and usage of analgesics, reduced postoperative complications, patient’s satisfaction, and time taken for operation. Beside lesser complications, fecal incontinent, severe pain, and other complications could result from stapling technique. Post-operative pain and complete pain relief was significantly lower in MM group. Hospitalization in the SH group was shorter than the MM group. Hemorrhoid recurrence was null in both SH and MM group. Keywords: Hemorrhoid Surgery, Stapled Hemorrhoidectomy, Milligan-Morgan

Evaluation of post-operative complications after Milligan- Morgan haemorrhoidectomy versus Stapled Haemorrhoidopexy techniques

Abstract Background Haemorrhoidal disease is one of the oldest illnesses known to mankind. It leads to significant pain, discomfort and poor quality of life. It is one of the common diseases which affect mankind but it is difficult to give an accurate figure of the prevalence because although many patients present with symptoms, many do not and some never bring it to notice of clinicians. The word hemorrhoids means flow of blood, the word pile means a ball, indicating two cardinal symptoms of this disease; bleeding per rectum and mass per anus. Aim of the work Aim of the work is to detect and compare the post-operative complications (Pain, Bleeding and anal stenosis) after 2 of the most commonly used techniques for management of the clinically diagnosed third and fourth stage hemorrhoids: Milligan-Morgan hemorrhoidectomy and stapler hemorrhoidopexy. Patient and Methods After obtaining approval from The College Ethical Committee, the study entitled "Evaluation of Postoperative Complications after Open MM Hemorrhidectomy versus Stapled Hemorrhoidopexy" was conducted on a total of 30 patients with hemorrhoids undergoing either conventional hemorrhoidectomy by Milligan Morgan (MM) technique or stapler hemorrhoidopexy. The patients were selected randomly after fulfilling the inclusion criteria in the department of general surgery, Ain Shams University hospitals over a period of 4 months starting from 1 August 2019 to 1 December 2019. Patients were admitted via surgical outpatient clinic. Patients were randomly distributed to 2 groups (A &amp; B), each group containing 15 patients. Results A total of 30 patients who underwent either conventional hemorrhoidectomy (CH) or stapler hemorrhoidopexy (SH) in The Department of Surgery, Faculty of Medicine, Ain Shams University included in this study for 4 months started from 1/8/2019 and ended in 1/12/2019 and the following results are obtained. Conclusion Haemorrhoidal disease is considered as one of the commonest ano-rectal diseases. Non-surgical measures whatever drug therapy or office procedures, can be presented to the patients with stage 1 and stage 2 haemorrhoids. However, when these measures fail, surgical intervention must be thought for the patients with stage 3 and stage 4 haemorrhoids. Surgical intervention should be tailored to each patient in accordance to the seriousness of symptoms, the magnitude of the external anorectal element and the presence of any concurrent ano-rectal morbidity. At present, there are many surgical interventions obtainable for treatment of prolapsing piles disease and most of them yielding acceptable success rates. Conventional Haemorrhoidectomy (CH) whatever open (Milligan Morgan) or closed (Ferguson) is considered the gold standard for surgical intervention of piles but due to the severe associated post-operative pain, especially with defecation, Stapled Haemorrhoidopexy (SH) seems to present shorter operative time, less post-operative pain, less bleeding and anal stricture and also less time off work in comparison with CH. Although rare but horrible complications have been noted with SH, which dictate that SH should be performed only by experienced surgeons. Eventually we strongly recommend the use of stapler devices for haemorrhoidectomy when and where possible especially for high grade and prolapsing haemorrhoids although more research and study should be made in this concern for more confirmation of our results due to decreased specimen size and short post-operative follow up period in our study.

Comparison of Milligan Morgan Hemorrhoidectomy and Stapled Hemorrhoidectomy In Recent Years For Patients With Grade III And IV Hemorrhoids: A Meta-Analysis

Abstract Background Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to compare of milligan morgan (MM) hemorrhoidectomy and stapled hemorrhoidectomy (ST) for patients with grade III And IV Hemorrhoids. Objective To compere between Milligan-Morgan hemorrhoidectomy and Stapled hemorrhoidectomy as regards postoperative anal stenosis and fecal incontinence in recent years for treatment grade III and IV hemorrhoids using a meta-analysis approach. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2020. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion It is concluded that ST appeared to be the best surgical procedure than MM for grade III and IV hemorrhoids based on the current evidence.

A comparative study to evaluate milligan morgan hemorrhoidectomy versus pile suture method in management of haemorrhoids

Background: A pile suture technique was described originally by the Farag in 1978 was better in terms of post- operative pain, bleeding, hospital stay and early return to work which are the distressing effects of conventional Milligan Morgan Hemorrhoidectomy which is well accepted surgical procedure for haemorrhoids. This study is designed to compare the pile suture and Milligan Morgan Hemorrhoidectomy.Methods: After fulfilling the criteria, 60 patients were randomly allocated to the group A (Pile Suture [PS] n -30) and group B (Milligan Morgan Hemorrhoidectomy [MM] n – 30). The techniques were evaluated with respect to the operative time, pain scores, bleeding, hospital stay, return to work, and recurrence.Results: The mean age of patients was 44.33 years and 42.77 years in the pile suture group and MM group respectively. Grade III or IV hemorrhoids were more common in men (i.e., 80% and 60% in the pile suture and MM group, respectively). The mean operative time was shorter in the PS 20.10 minutes versus 51.47 minutes in the MM group (P .001). The bleeding and pain scores were less in the PS. Mean hospital stay was 4 days and 6.6 days in the PS and MM group, respectively. The patients in the pile suture group returned to their routine activities earlier (i.e., within 7.33 days) as compared with 16.87 days in the MM group.Conclusions: Therefore, pile suture method can be considered as less traumatic for the patients and method can be recommended as a safer alternative to Milligan Morgan haemorrhoidectomy.

Comparison of mean pain score using topical and oral metronidazole in post milligan morgan hemorrhoidectomy patient; A randomized controlled trial.

Background and Objectives:Milligan Morgan Hemorrhoidectomy is one of the most commonly performed surgeries. Post-operative pain is the major cause of morbidity in post hemorrhoidectomy patients. Metronidazole has an established role in relieving post hemorrhoidectomy pain. The objective was to evaluate the pain score by using topical and oral metronidazole in post Milligan Morgan hemorrhoidectomy patients.Methods:A prospective randomized controlled trail was done in surgical departments of Akbar Niazi Teaching Hospital, Islamabad. A total of 166 consecutive patients with 3rd and 4th degree hemorrhoids were presenting in surgical OPD and who underwent Milligan Morgan hemorrhoidectomy between July 2018 and December 2018 were included in the study. Patients allocated in two groups, Group-A received topical metronidazole 10% post hemorrhoidectomy for seven days and Group-B were given oral metronidazole 400mg for 07 days. Analgesics were given on patient’s requirement. Patients post hemorrhoidectomy pain was recorded by using VSA scale at baseline (1st day) and on 7th post-operative day. Data analysis was done by using SPSS 21. Pain calculated by compared in terms of mean, standard deviation between groups and independent sample T test was used. Association between demographic details like gender and ages of the patients with pain scale on 7th day was measured and chi-square distribution was used.Results:Total 166 patients were included in this study. The mean ages of the patients were 44.07±10.62 years with minimum 20 and maximum 60 years. Out of 166 patients, female were 55 (33.1%) and male were 111 (66.9%). Results showed significantly lower pain in patients using topical metronidazole as compared to oral metronidazole (p=0.001). Association of pain with respect to ages was insignificant (p=0.202) whereas between genders inside the groups showed significant difference (p=0.028).Conclusion:These results showed that topical metronidazole significantly reduces pain in post hemorrhoidectomy patients as compared to oral metronidazole overall and even when data stratified among age, gender and type of hemorrhoids.

Laser hemorrhoidoplasty versus Milligan-Morgan hemorrhoidectomy - short term outcome

Background/Aim. According to the ?vascular? theory, arterial inflow into the upper hemorrhoidal artery leads to venous dilatation of the hemorrhoidal plexus. Laser hemorrhoidoplasty (LHP) is a new treatment applied to outpatients in whom the hemorrhoid arterial blood flow is coagulated (nourishes by hemorrhoidal plexus) by laser. The aim of this study was to compare two groups of patients treated by two different methods: by laser (LHP) and with open surgical procedure ? the Milligan Morgan (MM) method. Methods. This study included 200 patients with grade 3 hemorrhoidal disease older than 18 years, divided into two groups: 100 patients treated with the LHP, while the other 100 patients with the MM hemorrhoidectomy. Parameters used to compare two applied surgical methods were: duration of hospitalization, postoperative pain, the presence of bleeding and time needed to return to normal life. Results. The results reveal a statistically significant difference between these two methods. The level of postoperative pain was lower in the group of patients treated with the LHP compared to the group of patients treated with the MM method (p &lt; 0.0001). The group treated with the LHP manifested less bleeding in comparison with the group treated with the open surgical method (MM). Length of hospitalization and duration of surgery were significantly shorter in the group treated with the LHP method than in the group treated by the MM method. Conclusion. According to our results, it is clear that the LHP method has many advantages over the MM hemorrhoidectomy in patients with grade 3 hemorrhoidal disease.

Comparative study between intrahemorrhoidal diode laser treatment and Milligan–Morgan hemorrhoidectomy

Objective The aim of this study was to compare between intrahemorrhoidal diode laser coagulation with Milligan–Morgan (MM) hemorrhoidectomy. Background Because of the increased number of patients suffering from hemorrhoids and increased complications of MM hemorrhoidectomy, using intrahemorrhoidal diode laser therapy in this study was proved to be beneficial in terms of being easily used, noninvasive, nontoxic, painless, and highly effective. Patients and methods This study included 60 patients with symptomatic hemorrhoids of grades II and III. Thirty patients were treated with intrahemorrhoidal diode laser coagulation and the remaining were treated with MM hemorrhoidectomy. We measured operative time, postoperative pain, complications, and resolution of symptoms. We followed up patients for 3 months for evaluating healing, resolution of symptoms, and complications. Results Postoperative pain scores at the first 24 h were significantly lower in the laser group compared with the MM group (P Conclusion Intrahemorrhoidal therapy with a 980-nm diode laser is associated with reduction of postoperative pain, intraoperative bleeding, and administered with analgesics. Our results suggest that intrahemorrhoidal diode laser treatment if available is preferred to open hemorrhoidectomy.

A Randomized Controlled Trial Comparing Laser Intra-Hemorrhoidal Coagulation and Milligan–Morgan Hemorrhoidectomy

ABSTRACTPurpose: To compare laser intra-hemorrhoidal coagulation with Milligan–Morgan (MM) hemorrhoidectomy. Method: Patients with symptomatic grade II or III internal hemorrhoids according to the Goligher's classification (refractory to medical treatment) were enrolled in this double-blinded randomized controlled trial study. In the laser group, hemorrhoidal columns were coagulated using a 980-nanometer (nm) radial laser emitting fiber (three, 15-W pulses of 1.2 s each, with 0.6-s intervals). Operative time, postoperative pain and complications, and recovery or resolution of symptoms were measured. Patients were followed up for at least one year for evaluating healing, resolution of symptoms, and late complications. Results: Postoperative pain scores (at 12, 18, and 24 hr after surgery) were significantly lower in the laser group compared with the MM group (p <.01). The operative time and intra-operative blood loss were more in the MM group (p <.001). The administration of analgesics was significantly reduced in the laser group (p <.05). Two patients in the laser group were presented with thrombosis of external hemorrhoid 7–10 days after the procedure, which was resolved with medical treatment, but no patients in the MM group developed hemorrhoidal thrombosis (p >.05). One-year follow-up showed comparable results in terms of the resolution of symptoms and sustainable cure. Conclusions: Intra-hemorrhoidal coagulation with 980-nm diode laser reduces postoperative pain, intra-operative bleeding, and administered analgesics with a comparable resolution rate of hemorrhoid symptoms. However, for the patients who experience complications, such as hemorrhoidal thrombosis, the overall pain may be equivalent to or even worse than conventional hemorrhoidectomy.

Comparative study between open (milligan morgan) haemorrhoidectomy and stapled haemorrhoidectomy

Background: Haemorrhoids are one of the commonest afflictions of mankind from times immemorial. It is said that 40 percent of population have symptoms due to haemorrhoids at some time of their lives, a price possibly man has had to pay following the evolution of his erect posture. Conventional haemorrhoidectomy is a commonly performed operation for haemorrhoids, it has good results but is a painful procedure resulting in a hospital stay for variable days and time off work for two to six weeks. Stapled haemorrhoidectomy has come up as a new and promising procedure causing minimal post-operative pain, early discharge and quick return to work. Methods: In all 50 patients were included in the study - 25 underwent open and 25 underwent stapled haemorrhoidectomy. Computerised analysis of the data was done with the help of software computer programme MS Excel and Statistical 1984-1999. Significance levels were determined by using averages, standard deviation, unpaired student t test, Mann Whitney U test (for non-parametric skewed distribution) and Fischer exact test. If p value < 0.01 or < 0.001, the difference is highly significant. If p value < 0.05, the difference is significant Results: the stapled procedure for haemorrhoids is superior to Milligan Morgan haemorrhoidectomy in terms of post-operative pain, operative time and return to normal activities. It is straightforward and easy to learn. Early functional and symptomatic outcomes have been satisfactory and appear to be similar or better than those achieved using conventional technique. However, long term follow up with respect to these factors is necessary. Conclusions: Stappled haemorrhoidectomy is superior to open haemorrhoidectomy in terms of less intraoperative blood loss,less time for surgery,less pain in postoperative period, less stay in hospital,less post operative complications and early return to work.

What is the Technique without a Proper Classification?

Dear Sir, We read with interest the commentary by Morelli [1] and we are in agreement with the need to investigate the classifications evolution in association with the treatment techniques. This is the important conceptual message which is contained within the commentary. In fact, also in our experience [2], the classification has a significant effect on patient selection and choice of treatment.Recently, small randomized-controlled trials comparing stapled haemorrhoidopexy (SH) with traditional excisional surgery have shown it to be less painful and that is associated with quick recovery [3-6]. The reports also suggest a better patient’s acceptance and a higher compliance with day-case procedures potentially making it more economical. At the same time, several studies comparing SH and Milligan-Morgan (M-M) surgery demonstrated that stapled technique, associated with less pain in the immediate postoperative period, presents a higher risk of recurrence and residual prolapse, with necessity of reintervention and some other symptomatic treatment in long term follow-up [7-9]. Recently, several studies reported a higher percentage of haemorrhoid recurrence after SH, especially in patients with fourth degree haemorrhoids. They suggest that the treatment of second, third and fourth degree haemorrhoids by SH technique, gives optimal results in terms of less postoperative pain, faster return to work and shorter hospital stay, indicating a higher recurrence rate in fourth-degree haemorrhoids patients when the long-term evaluation is considered [8,10,11]. Therefore even if the SH is a safe and effective treatment for haemorrhoids, needs a rigorous patients selection. Furthermore, by applying the SH technique, there is the risk of intraoperative and immediate postoperative complications, such as closing or perforation of rectum, pelvic sepsis and mechanical circular suture dehiscence [10,11].Basing on the clinical evidence and literature revision, the decision to use SH or M-M, should be primarily based on the priorities and preferences of the patient (pain reduction and a rapid return to work / activities in the short-term, or reduction in the risk of recurrence in the long term), and the preference of the surgeon [12].A new technique based on doppler-guided ligation of the terminal branches of the superior haemorrhoidal artery was introduced in 1995 as an alternative to haemorrhoidectomy. Several studies reported that there are some terminal branches from the superior rectal artery-corresponding to the distribution of the anal cushions which varies widely in number and position.The rationale of this treatment was later supported by the findings from vascular studies, which demonstrated that patients with haemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries. Therefore, ligating the arterial supply to haemorrhoidal tissue by suture ligation may improve haemorrhoidal symptoms. DGHAL is most effective for second- or third-degree haemorrhoidsIn a study of Miyamoto et al. [13] is described that there were always more than three (usually six) terminal branches of haemorrhoidal

Milligan-Morgan Hemorrhoidectomy vs Stapled Hemorrhoidopexy.

Background:The stapled hemorrhoidopexy (SH) is a procedure for prolapse and hemorrhoids . At first SH seemed to be a good alternative for the Milligan Morgan (MM) hemorrhoidectomy and preliminary results in early 2000 confirmed it. However, further studies and evaluation of long-term results showed poorer outcomes.Objectives:This study aimed to evaluate and compare the results of these 2 surgical procedures in terms of recovery, improvement of symptoms and incidence of complications.Materials and Methods:This study was conducted from April 2008 to August 2010. A total of 80 patients were divided into 2 groups of 40 each. In the SH group, there were 24 males (60%) and 16 females (40%) with a mean age of 48 ± 12.5 yrs. In the MM group, there were 30 males (75%) and 10 females (25%) with a mean age of 50.6 ± 17.3 yrs. Patients with grade 3 and 4 prolapsed hemorrhoids were entered in the study. Data were entered using SPSS software and analyzed using t-test and Chi-square test.Results:The two groups had no significant difference in terms of age or sex. Duration of surgery was 35 ± 7 minutes in the SH and 23.6 ± 13.5 minutes in the MM group. This difference was statistically significant (P = 0.000). Post-operative pain and complete pain relief was slightly lower in the MM group (not significant). Hospital stay was significantly longer in the MM group (P = 0.003). Return to work was similar in both groups. Three patients in the SH group (7.5%) and 2 in the MM group (5%) had hemorrhoid recurrence.Conclusions:Both techniques are efficient treatment methods for grade III and IV hemorrhoids and are associated with greater than 95% recovery rate. Overall, outcomes are the same in both techniques. Lower postoperative pain was the only advantage of SH over MM technique.

HEMORRHOIDECTOMY VS RUBBER BAND

Objectives: To compare open hemorrhoidectomy and Rubber Band Ligation (RBL) in the management of 2nd and 3rd degree hemorrhoids in terms post operative and hospital stay. Design: Experiential Randomized Control Trial. Setting: Department of surgery, Allied Hospital and Independent University Hospital Faisalabad. Period: Dec 2008 to May 2009. Patients &amp; Methods: 100 consecutive patients with second and third degree hemorrhoids were randomly divided into two groups. Group A (50 patients) were operated by open hemorrhoidectomy (Milligan morgan technique) while in group B (50 patients) rubber band ligations was performed. Open hemorrhoidectomy was performed under spinal anesthesia while rubber bands were applied with local xylocaine gel using Barron’s rubber band ligator. All the three hemorrhoids were ligated in single session. Results: Average hospital stay was 24 hours in patient operated by open hemorrhoidectomy as compared to one hour in rubber band ligation. 60% patients in group A developed moderate to severe pain requiring I/V morphine derivatives while 40% developed mild pain and treated with NSAIDS. In group B only 20% patients developed moderate pain and were dealt with I/M diclofenac sodium. Eightyeight percent patients in group A and 60% patients in group B developed mild to moderate bleeding in first postoperative week, which was self limiting. 6 patients developed severe bleeding after hemorrhoidectomy requiring blood transfusion. During six month follow up, two patients (4%) of open hemorrhoidectomy and 3 patients (6%) of RBL presented with recurrence and respective procedures were repeated. Conclusions: Rubber band ligation is safe, quick, economical and effective method for the treatment of 2nd and 3rd degree hemorrhoids.

Open and closed haemorrhoidectomy for fourth degree haemorrhoids - comparative one center study

We compared results of two techniques of haemorrhoidectomy: open Milligan-Morgan (MM) and closed Ferguson (CF) techniques. Length of hospitalization, pain complaints, return to full activity, wound healing time were considered. We included the group of 63 patients: 29 patients (16 women) were randomly allocated to MM operation and 34 patients (15 women) to CF operation. Follow-up study was performed after 2, 4, 24 weeks and six and eighteen months postoperatively. We did not note any statistically significant differences in relation to hospitalization time 30.9 days (MM) and 30.8 days (CF). Postoperative urine retention was similar: 5 (17.2%) patients (MM) and 7 (20.6%) patients (CF). No differences in the intensity of postoperative pain was observed. Patients returned to work after 293 days (MM) and 342 days (CF) (p = 0.059). We observed no infection of the wound in MM group but in four patients from CF group (11.8%); (p = 0.053). However overall wound healing time was shorter after CF method than after MM method: 233 vs. 274 days, respectively (p = 0.053). Our study confirms that the results after MM and CF haemorrhoidectomy are similar. We found a trend towards faster wound healing after CF procedure, however there was a trend towards higher wound infection in that group. There was also a trend towards shorter recovery time in patients after MM operation.

A comparative study between radiofrequency ablation with plication and Milligan-Morgan hemorrhoidectomy for grade III hemorrhoids

Milligan-Morgan (MM) hemorrhoidectomy is the most favored treatment for prolapsed hemorrhoids. However, it may be associated with severe postoperative pain, long periods of convalescence and other complications. In alternative, I use a procedure of radiofrequency ablation and plication (RAP) of hemorrhoids. The present study compared the two procedures in terms of surgical parameters, postoperative pain and complications. A total of 60 patients with grade III hemorrhoids were randomized to undergo radiofrequency ablation and plication (31 patients) or MM hemorrhoidectomy (29 patients). The patients were followed up to 2 years. Duration of surgery was significantly longer in the MM group as was postoperative hospitalization (p<0.05). Post-defecation pain and pain at rest were much less in the RAP group (p<0.05). Wound healing period (17 vs. 38 days) and time to return to work (7 vs. 17 days) were the other significant findings favoring RAP procedure. Early complications occurred more frequently in MM group, but late complications like external skin tags (4 vs. 2 patients) were more common in RAP group. One asymptomatic recurrence was noted in RAP group. Radiofrequency ablation and plication of hemorrhoids is associated with significantly less postoperative pain, shorter hospital stay and earlier return to normal activity. It can be considered as an alternative to the Milligan-Morgan hemorrhoidectomy.