A Retrospective Study of Milligan-Morgan Versus LigaSure Hemorrhoidectomy in the Treatment of Symptomatic Hemorrhoids at an Institute in North India.

Objective The present study aimed to assess and compare the surgical outcomes of hemorrhoidectomies performed using two different techniques: conventional Milligan-Morgan and another popular vessel sealing approach of LigaSure hemorrhoidectomy. Methods This retrospective study was conducted at our tertiary care hospital and involved patients who underwent either of the surgical procedures from June 2016 to March 2022. The patient demographics and data on the duration of operation, hospital stay, and postoperative recovery were collected and evaluated. Results Of the 91 cases reviewed, a total of 44 patients underwent Milligan-Morgan open hemorrhoidectomy and 47 had LigaSure hemorrhoidectomy. The mean operative time was significantly shorter for LigaSure hemorrhoidectomy (33.84 ±9.18 vs. 23.15 ±3.36 minutes for Milligan-Morgan and LigaSure, respectively, p<0.0001). Additionally, in comparison to Milligan-Morgan open hemorrhoidectomy, the LigaSure hemorrhoidectomy group exhibited a significant reduction in hospital stay (2.20 ±0.79 vs. 1.47 ±0.50 days), lower pain score [6.55 ±1.19 vs. 5.30 ±1.10 on the visual analog scale (VAS) on day one and 2.25 ±1.26 vs. 1.47 ±0.78 VAS on day seven], and faster return to normal activities (18.18 ±4.30 vs. 14.85 ±3.15 days). Conclusions When pitted against the traditional Milligan-Morgan method, the LigaSure approach to performing a hemorrhoidectomy is superior, owing to the shorter duration of operation, shorter hospital stays, lesser pain, and earlier return to normal activities. In light of these findings, surgeons may consider choosing this procedure to improve surgical outcomes and efficiency.

[Anorectal melanoma: Clinical case]. / Melanoma anorrectal: un caso clínico.

Background: Anorectal melanoma (AM) is a rare and aggressive type of tumor, with varied and inconclusive scientific information. Its preoperative diagnosis is challenging due to its rarity and similarity to other anorectal conditions. It represents only 1.3% of melanomas and affects more women than men. Approximately 20-30% of AM cases are amelanotic, complicating endoscopic detection and leading to misdiagnoses. AM is often confused with hemorrhoids, polyps, and rectal cancer in two thirds of patients due to similar symptoms. The causes and risk factors of AM are not well understood, but they are suspected to differ from cutaneous and ocular melanomas. Diagnosis is performed through biopsy and immunohistochemical staining. Colonoscopy helps to characterize the lesions, and histological examination is crucial for definitive diagnosis. Clinical case: 50-year-old woman with rectal bleeding and proctalgia. AM was diagnosed through colonoscopy, and transanal resection with hemorrhoidectomy was performed. Conclusions: Management of AM is complicated by the lack of randomized trials. Resection surgery is the standard treatment, but there is no established protocol. Wide local excision may be an option for limited cases. Further research is needed to improve the management and treatment of AM. Early detection and complete surgical removal are crucial for enhancing survival in these patients.

Introducción: el melanoma anorrectal (MA) es un tipo raro y agresivo de tumor, cuya información científica es variada y poco concluyente. Su diagnóstico preoperatorio es un desafío debido a su rareza y a su similitud con otras afecciones anorrectales. Representa solo el 1.3% de los melanomas y afecta más a mujeres que a hombres. Aproximadamente el 20-30% de los casos de MA son amelanóticos, lo que complica su detección endoscópica y conduce a diagnósticos erróneos. El MA se confunde con hemorroides, pólipos y cáncer de recto en dos tercios de los pacientes debido a síntomas similares. Las causas y factores de riesgo del MA aún no se conocen bien, pero se sospecha que son diferentes de los melanomas cutáneos y oculares. El diagnóstico se realiza mediante biopsia y tinción inmunohistoquímica. La colonoscopía permite caracterizar las lesiones y el examen histológico es crucial para el diagnóstico definitivo. Caso clínico: mujer de 50 años con rectorragia y proctalgia. Se diagnosticó MA mediante colonoscopía y se realizó una resección transanal con hemorroidectomía. Conclusiones: el manejo del MA es complicado por la falta de ensayos aleatorizados. La cirugía de resección es el tratamiento habitual, pero no hay un protocolo establecido. La escisión local amplia puede ser una opción para casos limitados. Se necesita más investigación para mejorar el manejo y tratamiento del MA. La detección temprana y la extirpación quirúrgica completa son cruciales para mejorar la supervivencia en estos pacientes.

Pre-cooling for Reducing Pain from Local Anesthetic Injections for Hemorrhoidectomy: An Open-label, Randomized, Crossover Trial.

Objectives: Excisional hemorrhoidectomy (EH) is sometimes same-day surgery under local anesthesia (LA); however, the LA injection can be painful. We conducted an open-label, crossover, randomised controlled trial to evaluate the efficacy and safety of pre-cooling in reducing pain associated with LA injection. Methods: Patients aged ≥ 20 years undergoing bilateral EH were randomly assigned to 1 of 2 pre-cooling sequences: a cooling-first sequence and a cooling-second sequence. In the first intervention phase, 2 minutes of pre-cooling was applied before LA injection in patients randomized to the cooling-first sequence; patients in the cooling-second sequence were asked to wait for 2 minutes (without pre-cooling) before LA injection. The pre-cooling sequences and the perianal sides targeted for injection were reversed in the second intervention phase. The primary outcome was the visual analogue scale (VAS) rating for pain from LA injection, which was obtained twice for each patient. Adverse events due to pre-cooling (e.g., skin disorders) were documented. Results: Of 114 screened patients, 51 were randomized to the cooling-first (n = 26; analyzed: n = 26) or cooling-second sequence (n = 25; analyzed: n = 25). The 2-minute pre-cooling was completed by 48 patients (94%). VAS scores for LA injection pain decreased significantly with pre-cooling compared to without (difference estimate, -1.71; 95% confidence interval, -2.12 to -1.31; p< 0.001). No adverse events were reported. Conclusions: Two minutes of skin pre-cooling effectively and safely reduces LA injection pain in patients undergoing EH.

Analgesic Efficacy of EMLA Cream Among Patients Undergoing Hemorrhoidectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Post-hemorrhoidectomy pain is a concerning complication for patients and doctors, mainly due to perianal skin dissection and the complex innervation of the area. Therefore, our aim is to explore the analgesic efficacy and safety of EMLA cream among patients undergoing hemorrhoidectomy. We conducted a comprehensive search of five electronic databases (PubMed, Scopus, Web of Science, Embase, Cochrane) from inception until July 6, 2024. A risk of bias assessment was performed using the Risk of Bias Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB-2). Only randomized controlled trials (RCTs) were included. Our outcomes of interest were pain assessment using the Visual Analogue Scale (VAS) score, patient satisfaction, meperidine dosage, frequency of meperidine requests, and single urinary catheterization. We used RevMan software to conduct the statistical analysis. Dichotomous data were pooled as relative risk (RR), while continuous data were pooled as mean difference (MD). Four RCTs were included in our review. Two RCTs showed a low overall risk of bias, while one RCT showed a high risk, and the last one showed some concerns. Our analysis showed a significant difference between the two groups, favoring the EMLA group over the control group, upon arrival at the recovery room and at night on the day of the operation (MD=-1.76, 95% CI (-3.17, -0.36), p=0.01 and MD=-1.65, 95% CI (-2.48, -0.81), p=0.0001, respectively). However, there was no significant difference between the two groups in the morning on the day after the operation (MD=-0.9, 95% CI (-2.02, 0.21), p=0.11). Moreover, patients who used EMLA cream reported increased patient satisfaction compared to those who did not. However, there was no significant difference between both groups in terms of the use of urinary catheterizations. In conclusion, our study showed that applying EMLA cream over the perianal area after hemorrhoidectomy can effectively reduce postoperative pain and decrease the required opioid dosage and patient requests. This ultimately leads to increased patient satisfaction. However, further studies are still required to confirm these findings.

Exploring factors impacting patient decisions in hemorrhoid surgery: A questionnaire survey in Taiwan.

Background: Minimally invasive hemorrhoid surgeries like Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL) and Stapled Hemorrhoidopexy (PPH) offer benefits over traditional methods. This study investigated public perceptions and attitudes towards these surgeries, exploring awareness, preferences, and influencing factors. Methods: A detailed questionnaire was disseminated to 2011 participants from various regions of Taiwan in December 2023, gathering data on demographics, understanding of minimally invasive surgery, and attitudes towards hemorrhoid surgery. Chi-square tests were used for analysis (p < 0.05). Results: Hemorrhoid prevalence was similar across sexes and age groups. About 70 % preferred medical centers or district hospitals for surgery. Postoperative complications were a primary concern, with significant sex differences. Approximately 70 % preferred minimally invasive surgery if costs were below NT$50,000. Medical personnel showed higher awareness of minimally invasive surgery benefits. Most participants relied on personal networks and medical social media for information. Conclusions: The study revealed generally positive perceptions of minimally invasive hemorrhoid surgery, with cost being a significant factor. Knowledge gaps exist, particularly among non-medical personnel. Future initiatives should aim to enhance public awareness of minimally invasive surgery benefits, and policy considerations should address financial aspects of healthcare decisions.

Analysis of Two Treatment Modalities for Post-surgical Pain after Hemorrhoidectomy.

Background: This non-randomized study aimed to compare the efficacy of two pharmacological treatments, "around-the-clock" analgesic treatment (ACAT) and "on-demand" analgesic treatment (ODAT), for managing postoperative pain following hemorrhoidectomy. Material and Methods: The study, conducted from July 2016 to December 2020, included 5335 hemorrhoidectomy patients. Participants were divided into ACAT (3767) and ODAT (1568) groups. The study was registered at clinicaltrials.gov (NCT04953182). Results: Patients had a mean age of 47.47 years, with 59.98% males. Postoperatively, 14.13% reported severe pain, 36.49% moderate, 34.28% mild, and 15.09% no pain. ACAT group's maximum pain was 3.04 (VAS), ODAT 4.95 (p; average pain was 0.79 (ACAT) and 1.45 (ODAT). Discharge pain was 0.42 (ACAT) and 0.63 (ODAT) VAS. The ACAT group consistently reported lower levels of pain across all measured instances. Higher BMI and younger age were pain risk factors (p=.049, p .001 respectively). ACAT administration resulted in reduced opioid usage, with meperidine showing a 68.38% decrease, morphine 43.57% less, tramadol 46.82% less, oxycodone reduced by 38.74%, and codeine by 53.40%. Additionally, the use of non-opioid analgesics was notably lower in the ACAT group, ranging from 16% to 59% less compared to the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain, with only 14% experiencing severe pain. A fixed schedule multimodal pain regimen, regardless of procedure and anesthesia type, reduces pain from moderate to mild post-hemorrhoidectomy. This approach also decreases opioid and non-opioid analgesic requirements. Higher BMI and younger age are identified as risk factors for elevated postoperative pain.

Myrrh sitz bath for wound healing after hemorrhoidectomy: A retrospective study of adverse effects and treatment outcomes.

Background and Aim: Hemorrhoids affect 75% of people worldwide. surgical hemorrhoidectomy remains the definitive intervention for severe cases. Postoperative wound care is critical, and alternative treatments, like Myrrh, are of growing interest due to their potential wound-healing properties. This study aimed to compare the safety, efficacy, and treatment outcomes of Myrrh sitz baths with standard clinical care in promoting wound healing after hemorrhoidectomy. Methods: A retrospective cohort study was carried out using medical records from Abha Private Hospital for the period of January-December 2022. The data of patients who underwent hemorrhoidectomy were collected and categorized based on postoperative wound care into two groups: Group A for Myrrh-based wound care as a self-medication and Group B for standard wound care. Results: The study included 67 patients who underwent hemorrhoidectomy. Out of these patients, 52 had standard wound care, while 15 used Myrrh-based wound care as self-treatment without medical advice. The Myrrh group patients were significantly older with more comorbidities. The Myrrh group had significant Grade III wound healing outcomes 9/15 (60%) compared to the standard care group 2/52 (3.8%) (p < 0.001). However, despite the better healing outcomes, the Myrrh group had a significantly higher complication rate 7/15(46.7%) than the standard care group 1/52 (1.9%) (p < 0.001). These results indicate that despite the good healing capacity of Myrrh, cautious usage must be considered. Conclusion: Myrrh sitz baths appear more effective than standard wound care in enhancing healing after hemorrhoidectomy. However, increased complications suggest the necessity for comprehensive evaluation and research on its safety profile. These findings can guide future research and clinical practices related to postoperative wound care.

Pyogenic liver abscess after Milligan-Morgan hemorrhoidectomy.

Milligan-Morgan(M-M) hemorrhoidectomy is regarded as the primary treatment option for patients diagnosed with grade III or IV hemorrhoids. Here, we present the case of a 50-year-old male who developed pyogenic liver abscesses as an unusual complication following M-M hemorrhoidectomy. Severe complications subsequent to hemorrhoid surgery are infrequent. A review of the PubMed database spanning the 30-year period between 1994 and 2024 yielded only four publications documenting patients who experienced liver abscesses following open hemorrhoidectomy. Furthermore, the patient exhibited symptoms of a liver abscess as early as the second day post-surgery, despite having no history of diabetes or liver disease, making this occurrence truly uncommon.

Effect of Pressure and Nonpressure Dressings on Postoperative Complications in Patients With Mixed Hemorrhoids: A Single-blind Controlled Study.

PURPOSE: To compare the clinical effects of nonpressure and pressure dressings on the postoperative complications of modified Milligan-Morgan hemorrhoidectomy. DESIGN: Randomized controlled trial. METHODS: A total of 186 patients with grade II to III mixed hemorrhoids who had been excluded from cardiovascular and cerebrovascular diseases and anorectal surgery were included and randomly assigned to the nonpressure dressings group and the pressure dressings group by random number table. The incidence of acute urinary retention and medical adhesive-related skin injury, pain, hemostatic effect, anal distension, anal edema, use of analgesics, length of hospital stay, and hospitalization costs were compared between the two groups. The Consolidated Standards of Reporting Trials checklist for randomized controlled trials was used in this study. FINDINGS: The incidence of acute urinary retention in both men and women was significantly lower in the nonpressure dressing group (relative risk [RR] = 0.20, 95% confidence interval [CI] [0.13, 0.37], P = .002); (RR = 0.47, 95% CI [0.22, 0.76], P = .015). The postoperative pain at 6 hours/18 hours/25 hours was significantly lower in the nonpressure dressing group (P < .001, P = .004 < 0.05, P = .009). The anal distension at 6 hours and the number of patients who used analgesics were significantly lower in the nonpressure dressing group (P < .001). The incidence of medical adhesive-related skin injuries was significantly lower in the nonpressure dressing group (RR = 0.061, 95% CI [0.020, 0.189], P < .001). No primary bleeding was observed in both groups. However, there were no significant differences between both groups in terms of anal edema scores, length of stay, or hospitalization expenses. No adverse events were reported in either group during the study period. CONCLUSIONS: Nonpressure dressings can effectively reduce the incidence of acute urinary retention and medical adhesion-related skin injury after surgery for grade III to IV mixed hemorrhoids. They can also safely relieve pain and distension.

Diode laser hemorrhoidoplasty versus conventional Milligan-Morgan and Ferguson hemorrhoidectomy for symptomatic hemorrhoids: Meta-analysis.

Conventional hemorrhoidectomy is the mainstay of treatment for symptomatic haemorrhoids, but reported postoperative complications remains the main concern. On the contrary, with its minimally invasive nature, laser hemorrhoidoplasty showed the potential to reduce postoperative complications and discomfort. Therefore, we performed a systemic review and meta-analysis to evaluate the postoperative outcome of laser hemorrhoidoplasty compared to conventional hemorrhoidectomies, including Milligan-Morgan and Ferguson techniques. Of all studies from PubMed, EMBASE, Cochrane database, and Google Scholar, we included 17 trials with 1196 patients, of whom 596 (49.8 %) underwent laser hemorrhoidoplasty and 600 (50.2 %) underwent conventional hemorrhoidectomy. The primary outcomes were operative blood loss and postoperative haemorrhage, and the secondary outcomes were the operative time, postoperative pain score, complications, and haemorrhoid recurrence. In this study, we found that laser hemorrhoidoplasty showed benefits in operative blood loss (weighted mean difference [WMD]: -16.43 ml, 95 % confidence interval [CI]: -23.82 to -9.04), postoperative hemorrhage/bleeding (odds ratio [OR]: 0.16, 95 % CI: 0.10 to 0.28), operative time (WMD: -12.42 min, 95 % CI: -14.56 to -10.28), postoperative pain score on day 1 (WMD: -2.50, 95 % CI: -3.13 to -1.88), and anal stenosis (OR: 0.14, 95 % CI: 0.03 to 0.65) in comparison with conventional hemorrhoidectomy. However, incidence of fecal/flatus incontinence, urinary retention and hemorrhoid recurrence were not significantly different between the 2 groups. Consistent results were found in 5 subgroup analyses, including studies with low risk of bias, studies using 1470 nm laser, and studies using 980 nm laser, studies conducted in Asia, and studies conducted in Europe and America.

Protocol of a clinical trial on the effectiveness of pudendal nerve block with and without neurostimulation in reducing posthemorroidectomy pain.

INTRODUCTION: Hemorrhoidal pathology is the most frequent proctological problem with a prevalence of 44% of the adult population. The most effective treatment is surgery but it also has the highest postoperative pain rate with moderate to severe pain rates of 30-40% during the first 24-48 hours. Here lies the importance of seeking measures to improve this situation, such as the pudendal nerve block with local anesthetic. However, the variability of the pudendal nerve sometimes makes its blockade ineffective and for this reason nerve location methods are sought to achieve a higher rate of success. The main aim of the study is to compare pain in the immediate postoperative period (24 h) after hemorrhoidectomy in patients with pudendal nerve block guided by anatomical references and guided by neurostimulation. METHODS: The present project proposes the performance of a single-center, triple-blind, randomized clinical trial of efficacy, carried out under conditions of routine clinical practice. Patients over 18 years old with hemorrhoids refractory to medical treatment, symptomatic grade III-IV and grade II hemorrhoids that do not respond to conservative procedures in a third level hospital in Spain and that are subsidiaries of surgery in major ambulatory surgery will be included. Demographic variables, variables on hemorrhoidal pathology, details of surgery, verbal numeric pain scale in the preoperative period and surgical complications will be collected. RESULTS: Not avaliable until the end of the study. CONCLUSIONS: The pudendal nerve block guided by anatomical landmarks has been shown to be useful in postoperative pain control after hemorrhoidectomy although the use of the neurostimulator has not been well studied and we believe it may improve outcom.

Is routine histopathological analysis of hemorrhoidectomy specimens necessary? A systematic review and meta-analysis.

BACKGROUND: Hemorrhoidectomy is a common procedure used to treat symptomatic hemorrhoids. However, the necessity and cost-effectiveness of routinely conducting histopathological analysis on excised tissue samples are uncertain. METHODS: A systematic review was conducted using MEDLINE and EMBASE up to December 2023 for studies assessing the histopathological outcomes of hemorrhoidectomy specimens. Meta-analysis was performed on articles with combinable results to determine the pooled proportions of cancer and anal intraepithelial neoplasia (AIN) using the random effects model. RESULTS: From 2974 initial search results, 12 studies were included in the review, with 48,365 resected specimens from hemorrhoidectomy. Among these, there were 11 retrospective studies and one prospective study. A meta-analysis of 11 studies revealed that the prevalence of anal cancer was low, at 0.13% (95% CI: 0.05%-0.31%). The prevalence of anal cancer and AIN combined was 1.16% (95% CI: 0.53%-2.52%). CONCLUSION: This literature review estimated the probability of malignancy detection in hemorrhoid specimens sent for histopathological evaluation. The low incidence of malignant findings implies that routine analysis of hemorrhoidectomy samples may not be cost-effective. However, existing studies have yet to establish definitive risk factors for abnormal histological diagnoses to aid in the selection of specimens for selective histopathology.

Modified whitehead hemorrhoidectomy versus partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids: A retrospective analysis.

Background: Grade IV circular hemorrhoids are difficult to treat. We aim to describe the modified whitehead hemorrhoidectomy procedure and to assess the effectiveness and safety of this procedure for grade IV circular hemorrhoid patients. Methods: Patients with grade Ⅳ circular hemorrhoids who underwent modified Whitehead hemorrhoidectomy and partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids were retrospectively reviewed. Clinical data were extracted from the database at our institution, and long-term postoperative complications were assessed through repeated outpatient examinations and telephonic communication. Results: A total of 205 patients were included in this study. The mean operative time was 59.2 ± 13.8 min. The average hospital stay was 4.6 ± 1.0 days. For postoperative complications, 66 (32.2%) patients had urinary retention, 10 (4.9%) patients had a sense of incomplete rectal emptying, 5 (2.4%) patients had anal incontinence, and 6 (2.9%) patients had wound infection. For long-term postoperative complications, 3 (1.5%) patients experienced mild to moderate anal stricture, 2 (1%) patients experienced mucosal ectropion, they all had smooth recoveries, and none of them needed secondary surgery. None of these patients had a hemorrhoid recurrence. A total of 205 patients who received modified Whitehead hemorrhoidectomy and 161 who received partial hemorrhoidectomy were included. There were no residual hemorrhoids in patients who received modified Whitehead hemorrhoidectomy, and none had hemorrhoid recurrence. Fifty-eight patients who received partial hemorrhoidectomy had hemorrhoidal residues, and 19 patients experienced hemorrhoid recurrence. After modified Whitehead hemorrhoidectomy, 3 patients developed anal stenosis, and 2 had mucosal ectropion. Four patients developed anal stricture after partial hemorrhoidectomy, and none had mucosal ectropion. They all had smooth recoveries, and none of them needed a secondary surgery. For the mean duration of surgery, postoperative bleeding, postoperative pain, wound infection, sense of incomplete rectal emptying, anal incontinence, and urinary retention, no statistically significant differences were found between the two groups. Conclusions: Compared with partial hemorrhoidectomy, modified whitehead hemorrhoidectomy is an effective and safe surgical procedure and does not significantly increase the risk of anal stenosis and mucosal ectropion for grade IV circular hemorrhoid patients. Prospective randomized controlled trials are needed to verify our results.

Management of Hemorrhoids and Anal Fissures.

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

Manual Reduction of Strangulated Internal Hemorrhoids Using Sugar: A Case Report.

Emergency hemorrhoidectomy for strangulated internal hemorrhoids should be avoided when possible. Manual reductions can relieve pain and prevent the need for emergency surgery. Herein, we present a 51-year-old female patient. Over the preceding 20 years, she experienced prolapsed internal hemorrhoids every time she defecated and had been performing manual reductions herself. Due to significant pain and difficulty during the manual reduction of the hemorrhoids, she was transported to the emergency room. Anal inspection revealed prolapsed internal hemorrhoids and partial congestion. After 10 minutes of applying Lidocaine Hydrochloride Jelly 2% and Escherichia coli culture suspension/hydrocortisone ointment, the manual reduction was still difficult. Based on previous reports of using sugar to reduce stomal prolapse, we applied sugar directly to the hemorrhoids. Ten minutes later, the number of prolapsed hemorrhoids decreased, and manual reduction was possible. After one day of hospitalization for bed rest, the patient was discharged once it was confirmed that there was no prolapse of the internal hemorrhoids and that her pain had improved. Two weeks later, a grade III internal hemorrhoid was observed, which had markedly reduced in size compared with the time of admission. Using sugar to reduce strangulated internal hemorrhoids manually can be useful due to its simplicity, minimal invasiveness, and cost-effectiveness.

Analysis of factors impacting postoperative pain and quality of life in patients with mixed hemorrhoids: A retrospective study.

BACKGROUND: Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery. They are venous clusters formed by congestion, expansion, and flexion of the venous plexus in the lower part of the rectum. Mixed hemorrhoids bleed easily and recurrently, and this can result in severe anemia. Hence, they may have a negative effect on the health of the patient and surgical treatment is required. Milligan-Morgan hemorrhoidectomy has been widely used since 1937 for the treatment of grade III and IV hemorrhoids. However, most patients experience different degrees of postoperative pain that may cause anxiety. AIM: To assess the factors influencing pain scores and quality of life (QoL) in patients with mixed hemorrhoids post-surgery. METHODS: The clinical data of patients with mixed hemorrhoids who underwent Milligan-Morgan hemorrhoidectomy were collected retrospectively. The basic characteristics of the enrolled patients with mixed hemorrhoids were recorded, and based on the Goligher clinical grading system, the hemorrhoids were classified as grades III or IV. The endpoint of this study was the disappearance of pain in all patients. Quantitative data were presented as mean ± SD, such as age, pain score, and QoL score. Student's t-test was used to compare the groups. RESULTS: A total of 164 patients were enrolled. The distribution of the visual analog scale pain scores of all patients at 3, 7, 14 and 28 d after surgery showed that post-surgery pain was significantly reduced with the passage of time. Fourteen days after the operation, the pain had completely disappeared in some patients. Twenty-eight days after the surgery, none of the patients experienced any pain. Comparing the World Health Organization Quality of Life - BREF self-reporting questionnaire scores of patients between 14 and 28 d after surgery, we observed that the quality-of-life scores of the patients post-surgery had significantly improved. There were six items that were compared at 14- and 28-d post-surgery. The mean QoL score 28 d after surgery (4.79 ± 0.46) was higher than that at 14 d post-surgery (3.79 ± 0.57). The mean health condition score 28 d after surgery (4.80 ± 0.41) was also higher than that at 14 d post-surgery (4.01 ± 0.62). The mean physical health score 28 d after surgery (32.10 ± 2.96) was significantly higher than that at 14 d post-surgery (23.41 ± 2.85). The mean psychological health score 28 d after surgery (27.22 ± 1.62) was significantly higher than that at 14 d post-surgery (21.37 ± 1.70). The mean social relations score 28 d after surgery (12.21 ± 1.59) was significantly higher than that at 14 d post-surgery (6.32 ± 1.66). The mean surrounding environment score 28 d after surgery (37.13 ± 2.88) was significantly higher than that at 14 d post-surgery (28.42 ± 2.86). The differences in quality-of-life scores at day 14 and day 28 post-surgery were observed to be statistically significant (P < 0.001). CONCLUSION: Milligan-Morgan hemorrhoidectomy can significantly improve the postoperative QoL of patients. Age, sex, and the number of surgical resections were important factors influencing Milligan-Morgan hemorrhoidectomy.

Intradermal methylene blue analgesic application in posthemorrhoidectomy pain management: a randomized controlled trial.

Introduction: Unbearable post-hemorrhoidectomy pain is a well-documented challenge, significantly impacting patient well-being and satisfaction after surgery, often influencing patients to decline in undergoing this procedure. It is widely recognized that methylene blue has an effect of reducing inflammation and pain by reduces the production of nitric oxide and inhibiting the action potentials production in nerves. This study aims to explore the potential benefits of postoperative regional administration of methylene blue in providing extended relief from post-hemorrhoidectomy pain. Methods: This study included 97 patients aged 18-75 undergoing hemorrhoidectomy for stage III or IV hemorrhoids. A double-blind, randomized controlled trial compared postoperative intradermal injections of 1% methylene blue to 0.5% Marcaine as the control group. Two-week follow-up assessed pain. Statistical analysis, adherence to ethical standards, and registration were conducted. Result: No significant differences were found in baseline demographics, surgical parameters, or complications between the Methylene Blue and control groups. Intervention group remained lower in mean pain score until the 12th day. Methylene blue group reported significantly lower postoperative pain scores from days 1 to 7, with no significant differences afterward. Conclusion: This ongoing randomized controlled trial reveals the potential analgesic benefits of intradermal injection 1% methylene blue. It demonstrates comparable efficacy in reducing post-hemorrhoidectomy pain, with negligible side effects and complications.

Risk Factors for Readmission in Excisional Hemorrhoidectomy at a Tertiary Teaching Center.

INTRODUCTION: Unplanned readmission is often seen after excisional hemorrhoidectomy. This study aims to explore associations between patient and operative factors, and readmission rates in excisional hemorrhoidectomy. METHODS: We performed a retrospective analysis of all excisional hemorrhoidectomies performed in Capital and Coast District Health Board for an 8-year period from January 1, 2012, to December 31, 2020. The primary outcome measure was 30-day readmissions post hemorrhoidectomy. Univariate and multivariable logistic regression analyses were performed to identify risk factors to readmisson. A decision tree model was designed to further look at the interactions between risk factors. RESULTS: There were a total 370 patients undergoing 389 excisional hemorrhoidectomies over the study period. There were 47 (12.1%) readmissions. The commonest reasons for readmission were pain (48.9%) and bleeding (38%). 17% of readmitted patients required operative intervention. Readmission was associated with the use of advanced energy devices (OR 2.21; P = 0.027). Trainees were more likely to use advance energy devices than consultants (51% versus 38%, P = 0.010). Consultants were involved in more procedures requiring a removal of 3 pedicles or more than trainees (43% versus 30%, P = 0.010). A decision tree model predicts readmission based on primary operator experience, age, advanced energy device use, and patient ethnicity. CONCLUSIONS: Two risk models are presented showing the complex relationship between the factors associated with readmission after hemorrhoidectomy. Advanced energy device use was associated with an increased risk of readmission after hemorrhoidectomy in our population. Future work could involve targeted interventions to patients at increased risk of readmission such as preprocedural and postprocedural information, early interval follow-up and targeted analgesia regimes.

Sclerotherapy with 3% polidocanol foam for the treatment of mucocutaneous bridges and/or residual piles after open excisional hemorrhoidectomy.

Injection sclerotherapy is an effective and safe treatment in selected cases. It might be used as the first treatment for I-III degree hemorrhoidal disease (HD), but also as a bridge therapy for more severe cases not amenable to invasive treatments. However, concerning the long-term recurrence rate, open excisional hemorrhoidectomy remains the gold standard in cases of III- and IV-degree HD. In this context, it is recommended to perform the excision of no more than three piles and to preserve the muco-cutaneous bridges to avoid post-operative anal stenosis. The aim of this study is to evaluate surgical outcomes and efficacy of the combined treatment of open excisional hemorrhoidectomy and the use of ST on the remnant muco-cutaneous bridges/residual piles. This was a single-center retrospective study and a total of 18 patients with IV-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification, were enrolled between January 2023 and June 2023 and their follow-up continued until October 2023 after reaching 3 months of follow-up. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey Incontinence Score were used to assess symptoms and their impact on quality of life and continence. A total of 77.8% (14/18) of the patients were symptom-free (hemorrhoidal disease symptom score (HDSS) score = 0) after 3 months. Moreover, a statistically significant decrease in the median HDSS and short health scale for HD (SHS-HD) score was registered from 16 preoperatively (T0) to 2 at 3-month follow-up (T3). Neither post-operative bleeding nor any type of complications occurred. The use of sclerotherapy in combination with the traditional open excisional hemorrhoidectomy has shown promising results. Further structured studies are needed and greater dissemination and education of the general surgeon on the subject is necessary.