Modified procedure for prolapse and hemorrhoids: Lower recurrence, higher satisfaction

Abstract

Background: Hemorrhoidal prolapse is a common benign disease with a high incidence. The treatment procedure for prolapse and hemorrhoids (PPH) remains an operative method used for internal hemorrhoid prolapse. Although it is related to less pos-operative pain, faster recovery and shorter hospital stays, the postoperative recurrence rate is higher than that of the Milligan-Morgan hemorrhoidectomy (MMH). We have considered that recurrence could be due to shortage of the pulling-up effect. This issue may be overcome by using lower purse-string sutures [modified-PPH (M-PPH)].

Aim: To compare the therapeutic effects and the patients' satisfaction after M-PPH, PPH and MMH.

Methods: This retrospective cohort study included 1163 patients (M-PPH, 461; original PPH, 321; MMH, 381) with severe hemorrhoids (stage III/IV) who were admitted to The 2^nd Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from 2012 to 2014. Early postoperative complications, efficacy, postoperative anal dysfunction and patient satisfaction were compared among the three groups. Established criteria were used to assess short- and long-term postoperative complications. A visual analog scale was used to evaluate postoperative pain. Follow-up was conducted 5 years postoperatively.

Result: Length of hospital stay and operating time were significantly longer in the MMH group (8.05 ± 2.50 d, 19.98 ± 4.21 min; P < 0.0001) than in other groups. The incidence of postoperative anastomotic bleeding was significantly lower after M-PPH than after PPH or MMH (1.9%, 5.1% and 3.7%; n = 9, 16 and 14; respectively). There was a significantly higher rate of sensation of rectal tenesmus after M-PPH than after MMH or PPH (15%, 8% and 10%; n = 69, 30 and 32; respectively). There was a significantly lower rate of recurrence after M-PPH than after PPH (8.7% and 18.8%, n = 40 and 61; P < 0.0001). The incidence of postoperative anal incontinence differed significantly only between the MMH and M-PPH groups (1.3% and 4.3%, n = 5 and 20; P = 0.04). Patient satisfaction was significantly greater after M-PPH than after other surgeries.

Conclusion: M-PPH has many advantages for severe hemorrhoids (Goligher stage III/IV), with a low rate of anastomotic bleeding and recurrence and a very high rate of patient satisfaction.

Keywords: Hemorrhoids; Milligan-Morgan hemorrhoidectomy; Patient satisfaction; Postoperative complications; Procedure for prolapse and hemorrhoids; Recurrence.

Figure 1

Patients with prolapsing hemorrhoids treated with a modified procedure for prolapse and hemorrhoids. A: Preoperative hemorrhoids status; B: The hemorrhoids were exposed; C: Absorbable sutures were fixed in a modified location, the circular stapler was tightened, and the gun was fired; D: The mucosa was dissected.

Figure 2

Length of hospital stay and operating time. A: Mean length of hospital stay was significantly longer after Milligan-Morgan hemorrhoidectomy (8.05 ± 2.50 d) than after any of the other procedures (^aP < 0.0001) and was significantly longer than after the modified procedure for prolapse and hemorrhoids (7.24 ± 1.30 d) and after the procedure for prolapse and hemorrhoids (6.13 ± 1.93 d) (^bP < 0.0001); B: Mean operating time was significantly greater in Milligan-Morgan hemorrhoidectomy (19.98 ± 4.21 min) than in any of the other procedures (^cP < 0.0001) and was significantly shorter in the procedure for prolapse and hemorrhoids (13.30 ± 2.74 min) than in the modified procedure for prolapse and hemorrhoids (15.55 ± 3.27 min) (^dP < 0.0001). MMH: Milligan-Morgan hemorrhoidectomy; M-PPH: Modified procedure for prolapse and hemorrhoids; PPH: Procedure for prolapse and hemorrhoids.

Figure 3

Early postoperative complications. A: Postoperative anastomotic bleeding rate after the modified procedure for prolapse and hemorrhoids (M-PPH) was significantly lower than that after the procedure for prolapse and hemorrhoids (^aP < 0.0001); B: Sensation of rectal tenesmus rate after procedure for prolapse and hemorrhoids was significantly higher than that after the Milligan-Morgan hemorrhoidectomy (^bP = 0.005). The rate after the modified procedure for prolapse and hemorrhoids was significantly higher than that after the procedure for prolapse and hemorrhoids (^cP = 0.008) or Milligan-Morgan hemorrhoidectomy (^dP < 0.0001). MMH: Milligan-Morgan hemorrhoidectomy; M-PPH: Modified procedure for prolapse and hemorrhoids; PPH: Procedure for prolapse and hemorrhoids.

Figure 4

The rate of postoperative recurrence. The rate after the procedure for prolapse and hemorrhoids was significantly higher than that after the modified procedure for prolapse and hemorrhoids (^aP < 0.0001) or the Milligan-Morgan hemorrhoidectomy (^bP < 0.0001). MMH: Milligan-Morgan hemorrhoidectomy; M-PPH: Modified procedure for prolapse and hemorrhoids; PPH: Procedure for prolapse and hemorrhoids.

Figure 5

Further postoperative anal dysfunction. A: The incidence of postoperative anal discharge in the Milligan-Morgan hemorrhoidectomy, procedure for prolapse and hemorrhoids and modified procedure for prolapse and hemorrhoids group was 3.7%, 6.2% and 5.6%, respectively; B: The rate of postoperative anal incontinence after the modified procedure for prolapse and hemorrhoids was significantly higher than that after the Milligan-Morgan hemorrhoidectomy (^aP = 0.001); C: The postoperative anal stenosis rate after Milligan-Morgan hemorrhoidectomy was significantly higher than that after the procedure for prolapse and hemorrhoids (^bP < 0.0001) or the modified procedure for prolapse and hemorrhoids (^cP < 0.0001). MMH: Milligan-Morgan hemorrhoidectomy; M-PPH: Modified procedure for prolapse and hemorrhoids; PPH: Procedure for prolapse and hemorrhoids.