After being diagnosed with ‘hemorrhoidal pathology” (3rd degree hemorrhoids, polyp in the anal canal), the 37 year-old male patient consulted various medical services and specialists, who each suggested different medical treatment methods:
1. Rubber band ligation;
2. Milligan-Morgan technique;
3. Cryotherapy;
4. Stapler.

The patient specified that each specialist consulted only practices the technique that he personally deems most efficient. The problem raised, therefore, is that each specialist believes his technique (stapler, cryotherapy, ligation, etc.) to be the best, strongly advising against other techniques (without, however, clarifying the reasons for this). Purely based on acquaintances’ experiences with the treatment, and the excellent results obtained, the patient would tend towards opting for cryotherapy (which would appear to be the least invasive, cheapest, and simplest technique, as it is generally carried out as an outpatient, with no particular preparation or hospital stay required).

Online Doctor Consultation – Medical Questions:
1) Will any of the techniques mentioned provide a definitive solution to the medical problem?
2) If so, which of the previously specified techniques can be considered best in terms of least sufferance during and post surgery? And which technique would allow the patient to return to normal activity (including non-competitive sports) the quickest?

The expert´s opinion

First of all I must emphasis that I have some doubt concerning the medical diagnosis and that some important details are missing. The medical report did not describe the physical rectal examination regarding the external anal component. This is important for choosing the best surgical technique and I will assume that there is no external component.

Options of treatment

Cryotherapy: (the option the patient mentioned he was leaning toward) this is a painful procedure, frequently associated with a profuse discharge and at least a week off work. Only about 50% of patients are well satisfied with the treatment. In terms of morbidity and time off work it is slightly better than hemorrhoidectomy, but the long term results are less predictable. It has more complications than does rubber-band ligation. Most proctologists have abandoned this technique.

Rubber-band ligation: complications are infrequent with rubber-band ligation. Pain is usually mild and can be managed with analgesics. Return to work can be immediately or the day after treatment. The results of rubber-band ligation have been excellent with patient satisfaction of 80 to 91%. It must be emphasized that optimal treatment consist of 2-4 sessions with at least two weeks interval and depends on the number of hemorrhoids to be treated.

Milligan-Morgan operation: This is one of the most frequent techniques practiced. The operation is usually performed under general anesthesia, but spinal anesthesia can be used. The long term results are over 90% patient satisfaction. Pain is considered to be the main reason that patients resist the operation. It is evident that pain experienced after the operation is patient dependent. Hospital stay is about 1-2 days, but return to work is not for at least two weeks.

Stapled hemorrhoidectomy: This is relatively a new technique and is in practice for ten years. In all aspects it is an operation and must take place in the hospital. Patients report on less post operative pain compared to Milligan-Morgan operation and hospital stay is usually 1 day. The success rate is about the same as the former but there is one exception: the stapler technique is not effective for treatment of Hemorrhoids with an external component.

Conclusion: according to the information provided by the patient the most suitable technique of treatment is stapled hemorrhoidectomy since it is most effective and less painful than Milligan-Morgan operation. Rubber-band ligation, though excellent, is not indicated in this case. The rectal polyp should be excised in any case.