title: Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients.
abstract: BACKGROUND
  Surgery is the only curative method of hemorrhoidal disease. Currently the Milligan-Morgan hemorrhoidectomy is still considered the "gold standard", since it is the best performing technique. However, postoperative pain remains a major problem. We analize the postoperative analgesic requirements for this procedure in 117 patients.
  
  
  METHODS
  Between 2012 and 2013, 117 consecutive patients undergoing Milligan-Morgan hemorroidectomy, with an analysis of sex, age, total vascular anal cushions removed, hospital stay, complications, and relation with postoperative analgesic requirements. Patients with documented allergy to NSAIDs or pyrazolones were excluded. Additionally 23 patients undergoing Milligan-Morgan hemorrhoidectomy associated to internal lateral sphincterotomy were also analyzed.
  
  
  RESULTS
  The mean age of patients was 51.7 years. The 50.8% were women and 49.2% men. In 33.3% of cases, one vascular anal cushion was removed, 2 in 39.3%, and 3 in 27.4%. The average stay for the 3 groups was 2.0days. An analgesic dose average of 4.1 by day was given, with opioid requirements in 22.2% of cases. It was statistically significant that as more anal cushions were eliminated was higher the opioids need. No significant difference of opioids use was found regarding patients undergoing sphincterotomy as additional procedure.
  
  
  CONCLUSIONS
  Postoperative pain after a Milligan-Morgan hemorrhoidectomy currently remains a problem for colorectal surgery teams. This involves the use of opioids comparable to other major surgeries, finally causing not negligible days of admission charge. A protocolized analgesic treatment, as we actually do in our center, should be implemented after a Milligan-Morgan hemorrhoidectomy for improving the postoperative period pain management.
authors.affiliation: Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain.
authors.forename: Adrian
authors.initials: A
authors.lastname: Medina-Gallardo
authors.affiliation: Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain. Electronic address: layuha@hotmail.com.
authors.forename: Yuhamy
authors.initials: Y
authors.lastname: Curbelo-Peña
authors.affiliation: Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain. Electronic address: jdecastro@chv.cat.
authors.forename: Xavier
authors.initials: X
authors.lastname: De Castro
authors.affiliation: Department of Epidemiology, Vic University Hospital, Barcelona, Vic, Spain. Electronic address: proura@chv.cat.
authors.forename: Pere
authors.initials: P
authors.lastname: Roura-Poch
authors.affiliation: Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain. Electronic address: jroca@chv.cat.
authors.forename: Josep
authors.initials: J
authors.lastname: Roca-Closa
authors.affiliation: Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain. Electronic address: edecaralt@chv.cat.
authors.forename: Enric
authors.initials: E
authors.lastname: De Caralt-Mestres
keywords: Analgesia; Hemorrhoids; Milligan-Morgan hemorrhoidectomy; Opioids; Severe postoperative pain