Enton Bollano¹*, Krenar Lila¹, Dariel Thereska¹, and Ina Kola², Blina Abdullahu³, Jyotsna MMBS⁴, Wern Lynn⁵, Naglaa Ghobriel MBBS¹, FNU Deepali MMBS⁷, Fjolla Hyseni⁸, Abdallah al-madani⁹ Valon Vokshi¹⁰, Jacklyn Tan Wohlers¹¹ and Arben Gjata¹

¹Departament of Surgery, Faculty of Medicine, University of Medicine, Tirana, University Hospital Center “Mother Theresa”, Tirana, Albania
²Department of Burns and Plastic Surgery, University Hospital Center “Mother Theresa”, Tirana, Albania
³MD, Faculty of Medicine, University of Medicine, Tirana, University Hospital Center “Mother Theresa”, Tirana, Albania
⁴Jyotsna MBBS MBBS AMBEDKAR MEDICAL COLLEGE BANGALORE KARNATAKA INDIA jyotsna1011@hotmail.com
⁵Department of Internal Medicine,UPMC HARRISBURG USA
⁶MBBS, FACULTY OF MEDICINE ALWEXANDRIA UNIVERISTY, EGYPT
⁷MBBS, Department of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
⁸MD, PhD candidate, Research scientist/Sonographer, NYU Langone Health, New York, USA
⁹King Hussein Medical Center Jordan AMMAN
¹⁰Valon Vokshi Department of Anesthesiology university clinical center, Kosovo
¹¹Department of Laboratory Medicine and Pathology, Mayo Clinic Rocester MN, USA

*Corresponding Author: Enton Bollano, Departament of Surgery, Faculty of Medicine, University of Medicine, Tirana, University Hospital Center “Mother Theresa”, Tirana, Albania.

Received: July 12, 2023; Published: July 24, 2023

Abstract

Introduction: The "Milligan-Morgan" technique is considered as the golden standard for the surgical treatment of hemorrhoid disease [1]. However, modification aim to improve patient’s outcome and reduce the number of postoperative complications and faster rehabilitation of patients has been and remains subject to many studies. The choice of technique depends on various factors, including the severity of hemorrhoids, the surgeons expertise, and the individual patients needs and preferences.

Aim: The study aimed to compare the outcomes of patients who underwent the Milligan-Morgan technique alone versus those who had the Milligan-Morgan technique combined with left lateral sphincterotomy. The researchers likely evaluated several factors, including postoperative pain, wound healing, complications, recurrence rates, and patient satisfaction. By comparing the two groups, the study aimed to determine whether the addition of left lateral sphincterotomy provided any additional benefits in terms of improved outcomes, reduced postoperative pain, or better overall patient satisfaction compared to the Milligan-Morgan technique alone.

Material and Methods: In this study, 152 patients diagnosed with hemorrhoidal prolapse were divided into two groups: Group A, consisting of 92 patients who underwent the "Milligan-Morgan" technique without left lateral sphincterotomy (MM), and Group B, consisting of 60 patients who underwent the "Milligan-Morgan" technique with left lateral sphincterotomy (MMS). We compared the data related to pain level and complications, including postoperative pain, wound healing, complications, recurrence rates, and patient satisfaction, during the hospitalization period and six months after surgery between the two groups.

Results: The study indicated several findings regarding the comparison of the "Milligan-Morgan" technique without left lateral sphincterotomy (Group A) and with left lateral sphincterotomy (Group B) for patients with hemorrhoidal prolapse. Here is a summary of the findings:

1. The average pain level was 4.96 for Group A and 5.26 for Group B. These results suggest that patients in Group B (MMS) had slightly higher pain levels but showed better tolerance during the postoperative period compared to Group A (MM).
2. Group A had a 43% wound closure rate, while Group B had a significantly higher closure rate of 9%. This indicates that wounds in Group B closed relatively faster compared to Group A.
3. Urinary retention was compared between the two groups, resulting in 33% in Group A and 4% in Group B. The statistical significance of P = 0.0001 indicates that Group B had a significantly lower incidence of urinary retention compared to Group A.
4. Incontinence: both groups had similar rates of incontinence at the six-month mark.

Complications: Up to six months after surgery, there were 8 patients with anal stricture, which did not reach statistical significance (P = 0.14). However, Group A had a higher number of complications, including: postoperative pain, wound healing issues, complications, and recurrence rates compared to Group B. Group B had a lower incidence of complications (14%) compared to Group A (37%).

Conclusion: The addition of left lateral sphincterotomy to open hemorrhoidectomy in patients with prolapsed hemorrhoids offers several benefits: postoperative pain reduction, faster wound healing, preserved urinary continence, reduction in postoperative complications.

 Keywords: Open Hemorrhoidectomy; Pain; Sphincterotomy; Hemorrhoids; Hemorrhoidal Prolapse

References

1. Perry WB., et al. “Standard Practice Task Force of The American of Colon and Rectal Surgeons. Practice parameters for the management of anal fissures (3^rd revision)”. Diseases of the Colon and Rectum 53 (2010): 1110-1115.
2. London NJ., et al. “Effect of four days of preoperative lactulose on post haemorrhoidectomy pain: results of placebo controlled trial”. British Medical Journal 295 (1987): 363-364.
3. McRae HM and McLeod RS. “Comparison of haemorrhoidal treatment modalities. A meta analysis”. Diseases of the Colon and Rectum 38 (1995): 687-694.
4. Corman ML. “Anal fissure”. In: Corman ML editor. Colon and rectal surgery. Lippincott Raven, Philadephia (1998): 4206-4223.
5. Pavlidis T., et al. “Modern stapled Longo procedure vs. conventional Milligan-Morgan hemorhoidectomy randomized controlled trial”. The International Journal of Colorectal Disease 17 (2002): 503.
6. Harbour R and Miller J. “A new system for grading recommendations in evidence based guidelines”. BMJ 323 (2001): 334-336.
7. Mousavi SR., et al. “A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure”. Journal of Gastrointestinal Surgery 13 (2009): 1279-1282.
8. Knowles CH., et al. “Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS)”. Diseases of the Colon and Rectum 43 (2000): 1419-1426.
9. Pelta AE., et al. “Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-anus: a review of 109 cases”. Diseases of the Colon and Rectum 50 (2007): 1662-1667.
10. Vaizey CJ. “Faecal incontinence: standardizing outcome measures”. Colorectal Disease 16 (2014): 156-158.
11. Melenhorst J., et al. “Sacral neuromodulation in patients with faecal incontinence: results of the first 100 permanent implantations”. Colorectal Disease 9 (2007): 725-730.
12. Metzer FM., et al. “Stapled versus excision hemorrhoidectomy: long term results of a prospective randomized trial”. Archives of Surgery 137 (2002): 337-340.
13. Altomare DF., et al. “Ligasure for Hemorrhoids Study Group. Ligasure Precise vs. conventional diathermy for Milligan-Morgan hemorrhoidectomy: a prospective, randomized, multicenter trial”. Diseases of the Colon and Rectum5 (2008): 514-519.
14. Khubchandani IT. “Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study”. Diseases of the Colon and Rectum11 (2002): 1452-1457.
15. Milligan ETC., et al. “Surgical anatomy of the anal canal, and the operative treatment of haemorrhoids”. Lancet 3 (1937): 1119-1124.
16. Melenhorst J., et al. “Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?” Colorectal Disease 10 (2008): 257-262.
17. Abramowitz L., et al. “Anal fissure and thrombosed external hemorrhoids before and after delivery”. Diseases of the Colon and Rectum 45 (2002): 650-655.
18. Damon H., et al. “Prevalence of anal incontinence in adults and impact on quality-of-life”. Gastroentérologie Clinique et Biologique 30 (2006): 37-43.

Citation

Citation: Enton Bollano., et al. “Combining Milligan-Morgan Technique with Left Lateral Sphincterotomy for Better Outcomes in Prolapsed Hemorrhoids”.Acta Scientific Medical Sciences 7.8 (2023): 176-181.

Copyright

Copyright: © 2023 Enton Bollano., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.