VM39 - Treatment of Mixed Hemorrhoids with Milligan-Morgan Hemorrhoidectomy Combined with Sclerotherapy with 3% Polidocanol Foam : A Case Report

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Purpose/Background: The aim of this video abstract is to show the case report of a patient with mild anemia who undergone a combined procedure of Milligan-Morgan Hemorrhoidectomy combined with Sclerotherapy with 3% Polidocanol Foam.
The Milligan-Morgan (open) Hemorrhoidectomy is one of the representative techniques for the III-IV internal hemorrhoids or mixed hemorrhoids. But when the patient has more than three or four hemorrhoids’ piles, the surgeon cannot completely remove them, because this will incur a very high risk of anal stenosis and postoperative bleeding. In the begin of 2024, Prof.Gallo and his colleagues innovatively proposed using 3% polidocanol foam sclerotherapy to the mucocutaneous bridge and residual hemorrhoids after excisional hemorrhoidectomy and got good clinical results. Inspired by this study, our center tried to practice this combined procedure in patients and gained more clinical experience.

Methods/Interventions: A 35-year-old male patient presented with recurrent hematochezia following prolapse requiring manual retraction more than 2 years.
Digital anal examination showed no blood staining on the fingertips. Anoscope showed that the mucosa was prominent hyperemic in bulging at the lithotomy position 3, 5, 7 and 11 o'clock. The preoperative hemoglobin of the patient was 120 gram per liter which was mild anemia.The Hemorrhoidal Disease Symptom Score (HDSS) was 12, and the Short Health Scale for Hemorrhoidal Disease Scores (SHS-HD) was 14. And Visual Analogue Scale (VAS) was described as 1.
The patient underwent Milligan-Morgan hemorrhoidectomy under general anesthesia in the operating room. TTo prevent postoperative stenosis, Lateral internal sphincterotomy was performed. The Polidocanol Foam was performed above the dentate line in the residual piles with mucocutaneous bridges function. And also, the injection was performed around the base of the ligation point.

Results/Outcomes: The patient was discharged from the hospital 7 days after surgery and followed up once a week. The wound healed well; the hemorrhoids fell off within one week. No significant bleeding happened; only minor oozing of blood could be found on the toilet paper. Postoperative pain was mild, with a mean VAS of 3 (low pain) and a maximum pain score of 6 in the first 2 weeks after surgery. For 15 days after the surgery, the patient was able to return to work and resume social activities.
Patient’s 1-month-follow-up shows that his HDSS score is 5, SHS-HD score is 6 and VAS is 0.

Conclusion/Discussion: In general, the combined procedure showed good results. The patient was able to quickly return to work and daily life after the surgery, experienced mild postoperative pain, and had a positive recovery experience.
The following is an explanation of this combined procedure from the surgical team, intended to serve as a reference for clinical practice. In this video, Polidocanol foam injection has two main injection points. The purpose of injecting in the residual piles is to protect the function of the mucocutaneous bridge, thereby reducing the risk of anal stenosis. And when we inject the Polidocanol foam around the base of the ligation point, by the spreading of a considerable volume of foam along the interstitial space, it may cause the obliteration of the vascular bed in and near the ligation point. That will help to cut off the blood supply and prevent patient from postoperative bleeding.
In conclusion, this combined procedure has the potential to balance symptom relief and postoperative recovery, improving patient outcomes in the treatment of complex hemorrhoidal conditions.