Outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation on patients with circumferential mixed hemorrhoids

Outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation on patients with circumferential mixed hemorrhoids | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation on patients with circumferential mixed hemorrhoids Shengze Li, Chunbao Zhai, Bo Shi, Gangjie Qiao, Jin Tang, Yongquan Wu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7462451/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: We propose a novel nonexcisional technique for circumferential mixed hemorrhoids. This procedure, namely AL,involves combining Aluminum potassium sulfate and tannic acid (ALTA) therapy with ligation. This study aimed to compare the efficacy and safety of this novel procedure over Milligan-Morgan hemorrhoidectomy (MM) in patients with circumferential mixed hemorrhoids. Methods: This multicenter retrospective study conducted at three hospitals in China included 514 patients with circumferential mixed hemorrhoids who 224underwent AL and 290 underwent MM. Primary endpoints were symptom resolution and recurrence rate. Secondary endpoints were intraoperative outcomes, postoperative pain, complications, anal function and cosmetic outcome. Results: The complete symptom resolution rate in both groups showed no statistically significant difference. Recurrence rates in the AL and MM groups were 2.2% and 12.4%, respectively ( R < 0.001 ). Mean operative time was significantly shorter in AL group ( P < 0.001 ). Anal cosmetic outcome in AL group was superior to the MM group ( R < 0.001 ). Subgroup analysis showed higher complete symptom resolution rate with grade Ⅳ hemorrhoidal patients in the AL group ( R < 0.001 ). No anal dysfunction occurred in both groups. Conclusions: AL is safe and noninferior to MM in the treatment of grade Ⅲ circumferential mixed hemorrhoids, and it is more effective in the treatment of grade Ⅳ. It shows promising results as a minimally invasive technique compared with MM, with lower recurrence rate, shorter operative time and favorable cosmetic outcome. Health sciences/Diseases Health sciences/Gastroenterology Health sciences/Medical research Hemorrhoids Milligan-Morgan hemorrhoidectomy Efficiency Anal cosmesis Minimally invasive treatment Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Hemorrhoidal disease (HD) manifests as lower gastrointestinal bleeding and prolapse of the inflamed and vascular tissues of the anal canal 1 . It often requires surgical intervention in advanced stages 2 . Circumferential mixed hemorrhoids are the terminal stage in the development of HD 3 , characterized by their circumferential arrangement around the anal canal. Clinical symptoms typically comprise circumferential prolapse, repeated bleeding, local dampness and pruritus, often with progressive aggravation, which seriously impair patients’ quality of life 4 . Previous studies have shown that conservative treatment is often inadequate in alleviating the symptoms, with the majority of patients require surgical intervention 5,6 . The basic principle of surgical treatment is to solve the symptoms. However, circumferential mixed hemorrhoids are different from other types of hemorrhoids. If partial hemorrhoids are residual after surgery, symptoms of bleeding and prolapse are difficult to achieve complete resolution. This type of prolapsed hemorrhoids is often large and there is no clear boundary among them 7 , making it difficult to balance the complete removal of the diseased tissue with the protection of anal function. Therefore, it is imperative to explore the optimal surgical procedure for its complete resolution as well as maintenance of normal anal anatomy and physiological function. Surgical procedures for treating circumferential mixed hemorrhoids include Excisional hemorrhoidectomy, procedure for prolapse and hemorrhoids（PPH）,and tissue-selecting therapystapler（TST） 8,9 . Excisional hemorrhoidectomy remains the gold standard in the surgical management of grades III-IV circumferential mixed hemorrhoids for reasons that it has excellent results, minimal recurrence rates, few complications 10-12 . According to the different treatment methods of the surgical wound, it is divided into Ferguson hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy (MM) 13 . Compared to the Ferguson hemorrhoidectomy, MM is the traditional and currently most common procedure for the treatment of circumferential mixed hemorrhoids 14,15 . However, the presence of postoperative scarring and persistent anal edema compromise perianal cosmesis, which affects patient satisfaction and causes anxiety in some patients 16 . Some patients have a strong desire for anal aesthetics 17 . Furthermore, MM is not ideal for large circumferential mixed hemorrhoids which the main symptom is bleeding 18 . The modern management of hemorrhoids has altered, with an increasing ethos to tailor treatment according to patient wishes and the severity of disease 19 . With the development of minimally invasive surgery，the treatment for advanced hemorrhoids is gradually shifting toward minimally invasive procedures that target hemorrhoidal blood flow reduction 20 . In this study, we introduce a novel nonexcisional procedure for circumferential mixed hemorrhoids, namely AL, and discuss its clinical efficacy and advantages. This procedure involves separating the symptomatic hemorrhoid columns into groups, ligating both the internal and external components separately, injecting a sclerosing agent called Aluminum potassium sulfate and tannic acid (ALTA) into the internal component, and waiting for tissue to necrose and slough. ALTA is an effective sclerosing agent for the treatment of internal hemorrhoids 21 , which is proven to safe and effective as a local injection for the treatment of hemorrhoids in Asian countries 22-24 . Therefore, the aim of this study is to introduce the surgical process and postoperative efficacy in detail, compare the efficacy and safety of this novel procedure over traditional Milligan-Morgan hemorrhoidectomy (MM) in patients with circumferential mixed hemorrhoids and provide a new choice for the treatment of circumferential mixed hemorrhoids. Materials and methods Ethical approval We conducted a multicenter retrospective observational study at 3 institutions in China. This study was reviewed and approved by the ethics committee of the second Hospital of Shanxi Medical University (Approval No.2025-269) and each participating institution. The study was undertaken with the understanding and appropriate informed consent of patients. Written consent was obtained from the patients. This research was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki of 1964 and its later amendments or comparable ethical standards. Patients gave consent for their photographic material to publication of information relating to them. Study design and populations The multicenter retrospective observational study was conducted at 3 institutions in China, including The second Hospital of Shanxi Medical University, The Fifth Clinical Medical College of Shanxi Medical University and Taiyuan Seventh People's Hospital. We included 514 consecutive and eligible patients who underwent AL or MM from January 2019 to June 2022. The decision between AL and MM was dictated largely by the attending surgeon and patient's willingness. The two groups received the same preoperative and postoperative care. The AL was performed by surgeons all experienced in the new method and trained by the same specialist. Inclusion criteria: (i)Diagnosed with circumferential mixed hemorrhoids with internal hemorrhoids at grade Ⅲ or Ⅳ 25 .(ii) Aged 18-75 years. (iii) underwent AL or MM. (iv) Agreed and signed the informed consent voluntarily. Exclusion criteria: (i) With history of previous hemorrhoid surgery or receiving other surgical procedures. (ii) With other anorectal diseases (fistula, abscess, rectal carcinoma, etc.). (iii) With severe digestive, renal and circular system health conditions. (iv) With being Pregnant or experiencing a breastfeeding period. Procedures Modified ligation combining injection operation With complete exposure after anal dilatation, each external hemorrhoid was slightly pulled towards the outside with Allis forceps. Divided naturally internal hemorrhoids and corresponding external hemorrhoids into a group according to the o'clock position of the hemorrhoids. Tissue scissors radially incised the connected hemorrhoidal bodies from the middle and ligated on each side. The incision extended upward to 0.5 cm above the dentate line. The lower incision extended outward to the distal end of the external hemorrhoids at a depth of 0.5-1 cm. The depth of which was to the surface of the sphincter muscle. Usually muscle was not touched for patients with normal anal pressure. Depending on the tension of the anal canal, the lower edge of the internal sphincter was divided and cut off at the interscalene in the 6 o’clock position appropriately for these specific patients with internal anal sphincter spasm due to high anal canal pressure. Ligated blood vessels and nucleus propria of internal hemorrhoids with a 1-0（the USP definition） silk suture from submucosa, the ligation was 0.5~1.0cm away from the dentate line. The corresponding external hemorrhoid was lifted with Allis forceps and the external hemorrhoids at the base were ligated using the same silk in the same way which a V-shape was made. Ligated other groups with the same method and kept the ligated bodies at different levels of the anal canal to prevent postoperative anal stenosis. The hemorrhoidal nucleus was injected with Aluminum potassium sulfate and tannic acid (ALTA) injection（Jilin Ji'an Yisheng Pharmaceutical Co., Ltd, China）and saline 1:1 mixed liquid, showing a half-full state (Figs. 1 and 2). The silk sutures fell off alone after necrosing the hemorrhoid. (see Supplementary Material AL Surgical Videos). The procedures of MM were carried out by following the surgical technique previously described 15 . Each symptomatic column was excised in each patient with circumferential mixed hemorrhoids. Data collection Authors screened hospital medical records and database to extract the following data for each patient: age, sex, body mass index (BMI), personal and family history, symptoms, grade of HD, procedural and in-hospital characteristics. Postoperative data and short- and long-term results were evaluated by Follow-up. Follow-up was conducted weekly by outpatient visit until healing and then every 1 month by telephone follow-up survey and periodic reexamination. Each patient was followed up for three years after surgery. The final deadline for follow-up was June 2025.Readmission were required if patients have complications needed to deal with, such as heavy bleeding, anal stenosis leading to difficulty in defecation, etc. Outcomes and clinical variables The primary endpoint parameter of this study was symptom resolution and recurrence. Resolution of symptoms and hemorrhoids was considered complete symptom resolution which was evaluated at 3 months. Recurrences were determined by anoscopy and self-report based on the findings of the surgeon’s examination and patient’s complaint，which was assessed within 3 years after surgery. Pain was assessed using a visual analog scale (VAS), with zero equivalent to “no pain” and 10 to “maximum pain”, which was assessed at 1 day and 14 days 26 . Symptoms of incontinence were evaluated by Wexner incontinence score(WIS) 27 at 4 weeks and 1 year. Postoperative perianal edema is referring to severe perianal edema that anal marginal edema occupies more than 1/2 circle perianal, which was evaluated at 7 days. Anal cosmetic outcome 3 months post-operatively was evaluated according to Vancouver Scar Scale (VSS) 28 ,which included scar color, thickness, vascular distribution, and softness and scores. The VSS had a total score of 15 points, with more severe scars receiving higher scores 29 . Statistical analysis SPSS(version 25.0) was used for statistical analyses. Continuous variables are presented as mean±standard deviation ( ±s) or median (interquartile range, IQR) and were compared using Student’s t test or the Mann–Whitney U test, depending on their distribution. Categorical variables are shown as n(%). Association of categorical variables was assessed using the c 2 test or Fisher’s exact test. The operation time, the pain scores after two weeks，intraoperative blood loss and anal function of the two groups were compared by using Graphpad Prism(version 9.5.0). The anal cosmetic outcome and recurrence-free probability of the two groups were compared by using R software(version 4.4.2). A two-tailed P-value <0.05 was considered statistically significant. Results Patient characteristics A total of 778 consecutive patients were identified. 264 patients were excluded from the study due to receiving a previous hemorrhoid surgery, being lost to follow-up or other reasons. Of whom the remaining 514 eligible patients, 224 patients were included in the AL group while 290 patients comprised the MM group in this study for analysis. The study flow chart is showed in Fig. 3. The baseline characteristics are outlined in Table 1. Table 1. Baseline characteristics and postoperative results of study subjects. Variable s AL (n=224) MM(n=290) Statistic P Sex 0.668 0.414 male 137（61.2） 167（57.6） female 87（38.8） 123（42.4） Age, years 49.62±14.56 50.94±13.87 1.049 0.295 Course, years 6（2,10） 5（2,10） 0.228 0.774 BMI, kg/m 2 23.24±3.27 23.64±2.99 1.421 0.156 Goligher classification 0.010 0.920 Ⅲ 128（57.1） 167（57.6） Ⅳ 96（42.9） 123（42.4） Piles a 1.937 0.164 ＜5 127(56.7) 182(62.8) ≥5 97(43.3) 108(37.2) Complete symptom resolution 0.901 0.320 Yes 207(92.4) 261(90.0) No 17(7.6) 29(10.0) Complications 0.128 0.721 bleeding 5（2.2） 12（4.1） dysuria 15（6.7） 11（3.8） infection 1（0.4） 2（0.7） anal stenosis 1（0.4） 1（0.4） perianal edema 23（10.3） 36（12.4） total 45（20.1） 62（21.3） Vancouver Scar Scale 5（4,7） 1（1,2） 17.994 ＜0.001 a The internal hemorrhoids of circumferential mixed hemorrhoids commonly occur above the dentate line, with the hemorrhoids located at the 3, 7, and 11 o'clock positions, among others. Circumferential mixed hemorrhoids can be classified into several piles based on their specific locations. Primary outcomes There was no significant difference in the complete symptom resolution rate between the AL group [92.4% (207/224) vs. 90.0% (261/290)] and the MM group( R ＞0.05 ). At a follow up of 36 months, we registered 5(2.2%) recurrence in the AL group and 36(12.4%) in the MM one. The recurrence-free probability in AL group was significantly higher than that in MM group ( R < 0.0 01 ). （Fig. 4F） Secondary outcomes Comparison of intraoperative and postoperative results between the two groups The operative time in AL group was significantly shorter than that in MM group（21.04 ± 3.58 vs. 36.39 ± 4.99 min; t ＝40.665, R ＜ 0.001 ）, There was no significant difference in intraoperative blood loss between the two groups（10.28 ± 3.29 vs. 10.77 ± 3.45 ml; t ＝1.160, R ＝ 0.108 ）.（Fig. 4A and 4B） There were not differences concerning pain postoperative days 1 to 7 including during defecation. Pain during postoperative days 7 to 14 was lower in the MM group but there were not statistically significant differences（ R ＞ 0.05 ）. （Fig. 4D） Five (2.2%) of the 224 patients in the AL group needed a reoperation because of bleeding fifteen (7.4%) had dysuria, one had infection (0.4%) one had anal stenosis (0.4%) and twenty-three (10.3%) had postoperative perianal edema. The corresponding values for the 290 patients in the MM group were twelve (4.1%) for bleeding, eleven (3.8%) for dysuria, two had infection (0.7%), one had anal stenosis (0.8%), and thirty-six (12.4%) for postoperative perianal edema. There was no significant difference between the groups in the total incidence of complications (Table 1). Comparison of anal cosmetic outcome and anal function between the two groups At 4 weeks, the incontinence score in the AL group was significantly lower in the MM group (1.31 ± 0.80 vs. 1.80 ± 0.89, P ＜ 0.001 ). （Fig. 4C）.During the follow-up, the intermittent gas leakage resolved spontaneously in all patients. No incontinence for liquid or solid stools occurred during follow up. No patients of both groups developed anal incontinence after 1 year. Anal cosmetic outcome in AL group was superior to the MM group. (Fig. 2F and 4E). Subgroup analysis We assessed the consistency of the treatment effect on the primary outcome in subgroups. Compared to the MM group, the AL technique showed higher complete symptom resolution with grade Ⅳ hemorrhoidal patients (90/96 vs. 103/123, P ＜ 0.001 ). No statistically significant differences were found between the two groups with grade Ⅲ hemorrhoidal patients in terms of complete symptom resolution rate（ R ＞ 0.05 ）.（Fig. 5）.The treatment effect on the primary outcome was consistent in other subgroups. There was no appreciable difference in benefit among patients in other subgroups. Discussion We conducted a multicenter, retrospective study comparing a promising technique named AL for the severest circumferential hemorrhoids to the gold-standard Milligan-Morgan hemorrhoidectomy. Our study demonstrated a high recurrence-free rate of 97.8% after a AL procedure for grade Ⅲ to Ⅳ circumferential mixed hemorrhoids. We founded that AL was associated with shorter operative time and better anal cosmetic outcome. MM is a conventional surgical procedure for mixed hemorrhoids, but it is commonly accompanied by adverse postoperative prognostic outcomes, such as anal stenosis, severe edema, and residual skin tag when implemented on patients with circumferential mixed hemorrhoids 30 . Additionally, it leaves behind some internal hemorrhoidal tissue and skin tags, which are the main complaints of patients with severe hemorrhoids as incomplete resection or recurrence 31 . Some of these patients experienced recurrence and symptoms after MM when faced with advanced stages hemorrhoids. Our study supported that the procedure of AL was safe and effective in obtaining anatomical repair and relieving symptoms. Furthermore, it represents a valid procedure for the surgical management of this severe condition. Generally, the volume of grade Ⅳ hemorrhoids is larger and more severe than grade Ⅲ hemorrhoids based on the Goligher classification 32 . Wang et al. 33 proposed that the excision of the internal hemorrhoids and redundant anoderm (part of external hemorrhoids) must be complete when circumferential mixed hemorrhoids is performed. Abe et al. 24 reported that the effects of ALTA for hemorrhoids were almost same to those of excisional hemorrhoidectomy. It was observed that more tissue in the AL group was removed than in a standard hemorrhoidectomy. This led to the conclusion that the AL technique showed higher complete symptom resolution with grade Ⅳ hemorrhoidal patients compared to the MM group. Another obvious advantage of the AL is anal cosmetic outcome. It is a cosmetic feature that is rarely reported in series of hemorrhoid operations, except in the study by Huang et al. 34 and Wu et al. 17 . The reason for including this outcome is that patients have higher requirements for postoperative anal appearance. Low anal smoothness has an impact on mental health and quality of sexual life in these patients. By preserving the maintenance of normal anal anatomy and avoiding perineal incisions, the of AL technique reduces surgical trauma and promotes favorable aesthetic outcome. These improved results are also explained by improved knowledge of the anatomy of the anal region and a more accurate surgical technique, such as with adequate blood supply and proper recreation of the mucocutaneous junction above the level of the dentate line. The rectal mucosa is closely connected to the skin after necrosing the hemorrhoids. Therefore, AL showed a better cosmetic result. Recurrence rates have been evaluated in some studies. In most reports the recurrence rate after MM was stated to be low 35 , but was usually evaluated after only a short follow-up or excluding circumferential mixed hemorrhoids. Genova et al. 36 suggested that in grade IV hemorrhoids treated with MM no recurrence occurred during the three-year follow-up. A tendency towards a higher recurrence rate was reported in patients with grade Ⅳ hemorrhoids in long-term follow-up, irrespective of the technique used 37,38 .Kim et al. 39 reported the cumulative recurrence rates with circumferential third-degree hemorrhoids after 5 years were 23 % (14/61) in the MM group. The recurrence may be attributable to fail to completely remove the hemorrhoid nucleus propria which has undergone pathological changes or insufficient removal capacity of the instruments. Removing more prolapsed tissue to reduce the recurrence is believed to benefit patients with more severe prolapsed hemorrhoids 40 . Huang et al. 34 reported recurrence rates of grade Ⅲ to Ⅳ circumferential mixed hemorrhoids at 1 year of 0.65% in the M-TST-CACP group, compared to 5.88% in PPH group. Consistent data were limited on the epidemiology of HD recurrence 41 . The incidence and prevalence of recurrence reported across geographies were impacted by differences in definition data collection. In our study, the recurrence rate in MM group was significantly higher than that in AL group during the 36-month follow-up after surgery, due to residual tissue when treating grade IV circumferential mixed hemorrhoids. The complication rates were similar in the both groups. In this study, there was no statistically significant difference in the assessment of postoperative pain, although there was a trend towards more pain in the AL group from day 7 after operation because hemorrhoid tissue dropped from day 7 to 14(Fig. 2C-2E). It was essential to note that long effect of local anesthetic bupivacaine and ropivacaine, local application of postoperative oxybuprocaine and oral analgesia agents celecoxib was used in the study, and this may have minimized possible differences between the two groups. Novel innovations are rife and driven by the fact that industry recognizes a common condition with outcomes, particularly pain that can be improved 19 . The goal for the majority of patients who underwent AL was to remove the hemorrhoidal tissue from the sphincter and maintain the integrity of the sphincter. Partial internal sphincter resection was performed only for some specific patients so that the anus retained sufficient aperture after surgery to decrease the risk of anal stenosis and relieve pain caused by spasm of the internal anal sphincter, which has been proven to be effective by other studies on hemorrhoids 15,17 . All ligature points were not in the same plane while in a jagged arrangement. It was important for these patients, which can account for the low morbidity of anal stenosis after AL. The superficial and deep parts of the external anal sphincter are involved in the formation of the anorectal ring, which plays an important role in anal continence 42 . If they are cut carelessly during surgery, it can cause fecal incontinence 43 .AL and MM did not damage them, so a minority of fecal incontinence was not caused by them but may be anal cushions which were believed to contribute to the anal continence mechanism. Impairment of the anal cushion function may lead to anal incontinence 44 . However, the role of physiologic and pathological anal cushions in anal continence is less studied. Hemorrhoids are physiologic vascular cushions underlying the distal rectal mucosa and they can become pathological being the most common cause of painless rectal bleeding during defecation with prolapsing anal tissue 45 . Patients with grades Ⅲ and Ⅳ hemorrhoids present with a pathologically abnormal cushion which usually appears as a “mosaic pattern” in sonography, which is in accord with an arteriovenous fistula in pathology 46 . Inflammation of the anal cushion remains major pathogenesis for the development of hemorrhoids 47 .For circumferential mixed hemorrhoids, pathological anal cushions are massively enlarged and prolapsing circumferentially through the anal canal and fails to perform function to anal continence well 48 . Miyamoto et al. 49 found that blood flow significantly increased following advancement of the grade of hemorrhoid. After 4 weeks, Wexner incontinence score in AL group was lower than MM group, which could be explained by the hypothesis that AL directly reduced blood flow in the hemorrhoidal plexus through removing most of the pathological anal cushions, better fixed the physiological anal cushion in the anal canal and prevented the hemorrhoidal supporting tissue from being further weakened, resulting that the remaining physiologic anal cushion returned to the normal anatomical position and truly enhanced anal continence. Although some patients experienced temporary sensory anal incontinence due to the removal of most of the pathological anal cushions, the 1-year follow-up showed no significant impact on anal continence. Our findings supported the idea that the removal of most of the pathological anal cushions had no effect on long-term anal continence. The study has some limitations. The study is not randomized, introducing potentially bias. Dekker et al. 32 proposed that a more reliable and international new classification for the evaluation of the severity of HD is needed. Future multicenter randomized controlled trials (RCTs) studies may include populations with more diverse races and cultural backgrounds. Further studies with longer follow-up and comparison with other procedures are suggested. In addition, its applicability in patients with special types of hemorrhoids will be also explored in the future. Conclusion AL shows promising results as a minimally invasive technique for treating circumferential mixed hemorrhoids compared with Milligan-Morgan hemorrhoidectomy, with lower recurrence rate, shorter operative time and favorable cosmetic outcome. The procedure provides a new choice for these patients with a need for an anal cosmetic outcome. AL is safe and noninferior to MM in the treatment of grade Ⅲ circumferential mixed hemorrhoids and is more effective in the treatment of grade Ⅳ. Further studies and long-term follow-ups are required to confirm its effectiveness and to establish its broader applicability. Declarations Acknowledgments The authors are grateful to all patients and relatives who made valuable contributions to the data collection process. Author contributions Conceptualization, L. SZ., Z. CB. and L. WX.；Project administration, L. SZ., Z.CB and L.WX；Data curation, L. SZ., S.B, Q.GJ, T.J and R.YZ; Formal analysis, L. SZ., S.B, Q.GJ, T.J ,W.YQ, S.ZZ; Investigation, L. 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The efficiency and safety of modified tissue-selecting therapy stapler combined with complete anal canal epithelial preservation operation in circumferential mixed hemorrhoids: a randomized controlled trial. Langenbeck's archives of surgery 408 , 332, doi:10.1007/s00423-023-03081-2 (2023). Mott, T., Latimer, K. & Edwards, C. Hemorrhoids: Diagnosis and Treatment Options. American family physician 97 , 172-179 (2018). Genova, P., Damiano, G., Lo Monte, A. I. & Genova, G. Transanal hemorrhoidal dearterialization versus Milligan-Morgan hemorrhoidectomy in grade III/IV hemorrhoids. Annali italiani di chirurgia 90 , 145-151 (2019). Ganio, E., Altomare, D. F., Milito, G., Gabrielli, F. & Canuti, S. Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy. The British journal of surgery 94 , 1033-1037, doi:10.1002/bjs.5677 (2007). Jee, J., O'Connell, L. V., Kaur, I. & Sahebally, S. M. Conventional Excisional Haemorrhoidectomy versus Transanal Haemorrhoidal Dearterialization for Haemorrhoids: A Systematic Review and Meta-Analysis. Digestive surgery 41 , 204-212, doi:10.1159/000540256 (2024). Kim, J. S. et al. Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 17 , 1292-1298, doi:10.1007/s11605-013-2220-7 (2013). Wei, J., Ding, X., Jiang, J., Ji, L. & Huang, H. Indications, Feasibility, and Safety of TST STARR Plus Stapler for Degree III Hemorrhoids: A Retrospective Study of 125 Hemorrhoids Patients. Frontiers in surgery 9 , 860150, doi:10.3389/fsurg.2022.860150 (2022). Lohsiriwat, V. et al. Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review. Advances in therapy 40 , 117-132, doi:10.1007/s12325-022-02351-7 (2023). Bharucha, A. E. et al. Faecal incontinence in adults. Nature reviews. Disease primers 8 , 53, doi:10.1038/s41572-022-00381-7 (2022). Varghese, C. et al. Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 25 , 2257-2265, doi:10.1111/codi.16753 (2023). Thekkinkattil, D. K. et al. Measurement of anal cushions in idiopathic faecal incontinence. The British journal of surgery 96 , 680-684, doi:10.1002/bjs.6597 (2009). Stratta, E., Gallo, G. & Trompetto, M. Conservative Treatment of Hemorrhoidal Disease. Reviews on recent clinical trials 16 , 87-90, doi:10.2174/1574887115666201021150144 (2021). Aimaiti, A. et al. Sonographic appearance of anal cushions of hemorrhoids. World journal of gastroenterology 23 , 3664-3674, doi:10.3748/wjg.v23.i20.3664 (2017). Nallajerla, S. K. & Ganta, S. Evaluation Of Anti-inflammatory Mediated Anti-hemorrhoidal Activity of Lawsonia inermis on Croton Oil Induced Hemorrhoidal Rats. Anti-inflammatory & anti-allergy agents in medicinal chemistry 21 , 62-73, doi:10.2174/1871523021666220330143845 (2022). Ke, M. H. et al. Single-nucleus RNA sequencing and spatial transcriptomics reveal the mechanism by which Xiaozhiling injection treats internal hemorrhoids. World journal of gastrointestinal surgery 17 , 103494, doi:10.4240/wjgs.v17.i4.103494 (2025). Miyamoto, H. et al. Visualization and hypervascularization of the haemorrhoidal plexus in vivo using power Doppler imaging transanal ultrasonography and three-dimensional power Doppler angiography. Colorectal disease 15 , e686-691, doi:10.1111/codi.12406 (2013). Additional Declarations No competing interests reported. Supplementary Files ALSurgicalVideos.zip ALSurgicalVideos.mp4 Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 30 Dec, 2025 Editor invited by journal 02 Sep, 2025 Submission checks completed at journal 29 Aug, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7462451","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":581676590,"identity":"af11c09a-fa69-41bd-b538-e0669a8d3deb","order_by":0,"name":"Shengze Li","email":"","orcid":"","institution":"The second Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shengze","middleName":"","lastName":"Li","suffix":""},{"id":581676593,"identity":"6f8a9fe5-4487-43c1-b21c-0f73bf8391c0","order_by":1,"name":"Chunbao Zhai","email":"","orcid":"","institution":"The Fifth Clinical Medical College of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chunbao","middleName":"","lastName":"Zhai","suffix":""},{"id":581676594,"identity":"752f7cd7-82ca-496d-a5a9-6da11558a3db","order_by":2,"name":"Bo Shi","email":"","orcid":"","institution":"Taiyuan Seventh People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Shi","suffix":""},{"id":581676595,"identity":"2bdb539c-3ee9-487b-9703-63f5c1c11a6a","order_by":3,"name":"Gangjie Qiao","email":"","orcid":"","institution":"The Fifth Clinical Medical College of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gangjie","middleName":"","lastName":"Qiao","suffix":""},{"id":581676596,"identity":"e0041db7-b27d-4d51-884a-407fd72d7ef5","order_by":4,"name":"Jin Tang","email":"","orcid":"","institution":"The Fifth Clinical Medical College of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Tang","suffix":""},{"id":581676597,"identity":"b0711d84-e1db-450e-8f5e-0584a3894558","order_by":5,"name":"Yongquan Wu","email":"","orcid":"","institution":"Taiyuan Seventh People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongquan","middleName":"","lastName":"Wu","suffix":""},{"id":581676598,"identity":"ab6bdacc-e538-4af4-863b-8ddd5275cd6e","order_by":6,"name":"Zhenzhen Shi","email":"","orcid":"","institution":"Taiyuan Seventh People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhenzhen","middleName":"","lastName":"Shi","suffix":""},{"id":581676599,"identity":"d819b640-90e4-43f6-8e8e-f4dbcd282a5f","order_by":7,"name":"Jiming Duan","email":"","orcid":"","institution":"The second Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiming","middleName":"","lastName":"Duan","suffix":""},{"id":581676600,"identity":"00dbedbc-1a97-47f1-a83d-4cbe4f142339","order_by":8,"name":"Yingzheng Ren","email":"","orcid":"","institution":"Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yingzheng","middleName":"","lastName":"Ren","suffix":""},{"id":581676601,"identity":"0f1b302b-0287-45be-9012-8a33e0bebf89","order_by":9,"name":"Wenxing Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIie3RsQ4BMRjA8TZNrkvpSvoSH5eIRONZKpd0MpjEpiI5Bg9w3kLiBdBguZglDCzms0kYiMUiymbob+4/X/sVIc/7Q3mCDaiOJAEdzA8ZyLozCQgxrSzVlLM0KiUtHbkTRM15HFteTFRFsGyBjTOhuDfNxVrAVmkhYUYQtcvJ54vhfsg2MoT0aGtN2OcR03rrSOKQtXUEa9XYNeFEUIFVXMngygLbncwUiCpYbL5ITCmJLSkOVVmgbxN4LJk8lzwCHQWut3C+Pry+8nKTdU7t6mPyZu5vxz3P87x37rRjSnZbB6yJAAAAAElFTkSuQmCC","orcid":"","institution":"The second Hospital of Shanxi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Wenxing","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-08-26 11:23:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7462451/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7462451/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101497919,"identity":"3e56772f-6c28-4141-a8b8-7b7f52038f54","added_by":"auto","created_at":"2026-01-30 12:58:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":837914,"visible":true,"origin":"","legend":"\u003cp\u003eApplication of the Aluminum potassium sulfate and tannic acid (ALTA) therapy with ligation for grade Ⅲ circumferential mixed hemorrhoids as illustrated schematically. A. Circumferential mixed hemorrhoids exposure completely. B. Each external hemorrhoid was slightly pulled towards the outside with Allis forceps. C. Treatment of posterior anal. D. Using tissue scissors to divide naturally internal hemorrhoids and corresponding external hemorrhoids into a group. E. Ligate blood vessels and nucleus propria of internal hemorrhoids. F. The ligation was 0.5~1.0cm away from the dentate line. G. The corresponding external hemorrhoid was lifted with Allis forceps. H. The external hemorrhoids at the base were ligated using the same silk in the same way. I. The hemorrhoidal nucleus was injected with ALTA injection and saline 1:1 mixed liquid.\u003c/p\u003e","description":"","filename":"Fig.1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/ffac76e090cbf13ff512fd36.jpg"},{"id":101942732,"identity":"7a9d67c1-f94b-4f35-9af4-393e7582a82b","added_by":"auto","created_at":"2026-02-05 09:36:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":492675,"visible":true,"origin":"","legend":"\u003cp\u003eAnal appearance of grade Ⅳ circumferential mixed hemorrhoids after Aluminum potassium sulfate and tannic acid (ALTA) therapy with ligation. A. Preoperative circumferential mixed hemorrhoids with skin tags. B. grouped hemorrhoids naturally during operation. C. Postoperative hemorrhoids with a half-full state. D. After 3 days, most of the hemorrhoids were atrophied and necrotic. E. All ligature points were not in the same plane while in a jagged arrangement. After 14 days, all hemorrhoids necrosis and shedding, the rectal mucosa is closely connected to the skin. F. Healed wound and good anal cosmetic outcome.\u003c/p\u003e","description":"","filename":"Fig.2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/92527d0e963f3fb39a82f1c1.jpg"},{"id":101497921,"identity":"1cc42ce1-aaec-45d9-a3e4-f70cb329bff1","added_by":"auto","created_at":"2026-01-30 12:58:49","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":341311,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the study. AL: aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation; MM: Milligan-Morgan hemorrhoidectomy.\u003c/p\u003e","description":"","filename":"Fig.3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/e3ad427bcde9122d07da34ec.jpg"},{"id":101752400,"identity":"b17ea112-37ad-4ffb-b9f7-b24e1e148c28","added_by":"auto","created_at":"2026-02-03 10:27:16","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":545977,"visible":true,"origin":"","legend":"\u003cp\u003eComparisons between two groups of patients. A. operative time; B. intraoperative blood loss；C. anal incontinence scores after 4 weeks. D. postoperative VAS pain scores the first 14 days. E. anal cosmetic outcome. F. recurrence-free probability.\u003c/p\u003e","description":"","filename":"Fig.4.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/c4608e3f91d8d9e9893951ce.jpg"},{"id":101497922,"identity":"39347a6f-ec1b-4c96-aa8a-182b7f279810","added_by":"auto","created_at":"2026-01-30 12:58:49","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":265392,"visible":true,"origin":"","legend":"\u003cp\u003ePrimary outcome in prespecified subgroups. The primary outcome was the complete symptom resolution, which was defined as resolution of symptoms and hemorrhoids. The body-mass index(BMI) is the weight in kilograms divided by the square of the height in meters. The age and course are measured in years.\u003c/p\u003e","description":"","filename":"Fig.5.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/3aa33026478c768e50c6a83c.jpg"},{"id":101943987,"identity":"087b1301-5ff1-499e-a9ae-16ea89baf805","added_by":"auto","created_at":"2026-02-05 09:46:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3343127,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/9152f272-7b9d-44d3-a3cc-46aa5ac460bf.pdf"},{"id":101497941,"identity":"7aaa5a0b-29ab-4bed-9895-217384e71c0e","added_by":"auto","created_at":"2026-01-30 12:58:56","extension":"zip","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":218968850,"visible":true,"origin":"","legend":"","description":"","filename":"ALSurgicalVideos.zip","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/57f69a3f1e271a5eaa1b1931.zip"},{"id":101497925,"identity":"60275e1c-1168-4d4f-a09d-717f87b132e1","added_by":"auto","created_at":"2026-01-30 12:58:51","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":49875018,"visible":true,"origin":"","legend":"","description":"","filename":"ALSurgicalVideos.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7462451/v1/ef2bd801be889b848db6c68d.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation on patients with circumferential mixed hemorrhoids","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHemorrhoidal disease (HD) manifests as lower gastrointestinal bleeding and prolapse of the inflamed and vascular tissues of the anal canal\u003csup\u003e1\u003c/sup\u003e. It often requires surgical intervention in advanced stages\u003csup\u003e2\u003c/sup\u003e. Circumferential mixed hemorrhoids are the terminal stage in the development of HD\u003csup\u003e3\u003c/sup\u003e, characterized by their circumferential arrangement around the anal canal. Clinical symptoms typically comprise circumferential prolapse, repeated bleeding, local dampness and pruritus, often with progressive aggravation, which seriously impair patients\u0026rsquo; quality of life \u003csup\u003e4\u003c/sup\u003e. Previous studies have shown that conservative treatment is often inadequate in alleviating the symptoms, with the majority of patients require surgical intervention\u003csup\u003e5,6\u003c/sup\u003e. The basic principle of surgical treatment is to solve the symptoms. However, circumferential mixed hemorrhoids are different from other types of hemorrhoids. If partial hemorrhoids are residual after surgery, symptoms of bleeding and prolapse are difficult to achieve complete resolution. This type of prolapsed hemorrhoids is often large and there is no clear boundary among them\u003csup\u003e7\u003c/sup\u003e, making it difficult to balance the complete removal of the diseased tissue with the protection of anal function.\u0026nbsp;Therefore, it is imperative to explore the optimal surgical procedure for its complete resolution as well as maintenance of normal anal anatomy and physiological function.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Surgical procedures for treating circumferential mixed hemorrhoids include Excisional hemorrhoidectomy,\u0026nbsp;procedure for prolapse and hemorrhoids（PPH）,and tissue-selecting therapystapler（TST）\u003csup\u003e8,9\u003c/sup\u003e. Excisional hemorrhoidectomy remains the gold standard in the surgical management of grades III-IV circumferential mixed hemorrhoids\u0026nbsp;for reasons that it has excellent results, minimal recurrence rates, few complications\u003csup\u003e10-12\u003c/sup\u003e. According to the different treatment\u0026nbsp;methods\u0026nbsp;of the surgical wound, it is divided into Ferguson hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy (MM)\u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;Compared to\u0026nbsp;the\u0026nbsp;Ferguson hemorrhoidectomy, MM is the traditional and currently most common procedure for the treatment of circumferential mixed hemorrhoids\u003csup\u003e14,15\u003c/sup\u003e.\u0026nbsp;However, the presence of postoperative scarring and persistent anal edema compromise perianal cosmesis,\u0026nbsp;which affects patient satisfaction and causes anxiety in some patients\u003csup\u003e16\u003c/sup\u003e.\u0026nbsp;Some patients have a strong desire for anal aesthetics\u003csup\u003e17\u003c/sup\u003e. Furthermore,\u0026nbsp;MM is not ideal for large circumferential mixed hemorrhoids\u0026nbsp;which the main symptom is bleeding\u003csup\u003e18\u003c/sup\u003e. The\u0026nbsp;modern\u0026nbsp;management of\u0026nbsp;hemorrhoids has altered,\u0026nbsp;with an increasing ethos to tailor treatment according to patient wishes and the severity of disease\u003csup\u003e19\u003c/sup\u003e.\u0026nbsp;With the development of minimally invasive surgery，the treatment for advanced hemorrhoids is gradually shifting toward minimally invasive procedures that target hemorrhoidal blood flow reduction\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this study, we introduce a novel nonexcisional procedure for circumferential mixed hemorrhoids, namely AL, and discuss its clinical efficacy and advantages. This procedure involves separating the symptomatic hemorrhoid columns into groups, ligating both the internal and external components separately, injecting a sclerosing agent called Aluminum potassium sulfate and tannic acid (ALTA)\u0026nbsp;into the internal component, and waiting for tissue to necrose and slough. ALTA is an effective sclerosing agent for the treatment of internal hemorrhoids\u003csup\u003e21\u003c/sup\u003e, which is proven to safe and effective as a local injection for the treatment of hemorrhoids in Asian countries\u003csup\u003e22-24\u003c/sup\u003e. Therefore, the aim of this study is to introduce the surgical process and postoperative efficacy in detail, compare the efficacy and safety of this novel procedure over traditional Milligan-Morgan hemorrhoidectomy (MM) in patients with circumferential mixed hemorrhoids and provide a new choice for the treatment of circumferential mixed hemorrhoids.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a multicenter retrospective observational study at 3 institutions in China. This study was reviewed and approved by the ethics committee of the second Hospital of Shanxi Medical University (Approval No.2025-269) and each participating institution. The study was undertaken with the understanding and appropriate informed consent of patients. Written consent was obtained from the patients. This research was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki of 1964 and its later amendments or comparable ethical standards. Patients gave consent for their photographic material to publication of information relating to them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and populations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe multicenter retrospective observational study was conducted at 3 institutions in China, including The second Hospital of Shanxi Medical University, The Fifth Clinical Medical College of Shanxi Medical University and Taiyuan Seventh People\u0026apos;s Hospital. We included 514 consecutive and eligible patients who underwent AL or MM from January 2019 to June 2022. The decision between AL and MM was dictated largely by the attending surgeon and patient\u0026apos;s willingness. The two groups received the same preoperative and postoperative care. The AL was performed by surgeons all experienced in the new method and trained by the same specialist. Inclusion criteria: (i)Diagnosed with circumferential mixed hemorrhoids with internal hemorrhoids at grade Ⅲ or Ⅳ\u003csup\u003e25\u003c/sup\u003e.(ii)\u0026nbsp;Aged 18-75 years.\u0026nbsp;(iii)\u0026nbsp;underwent\u0026nbsp;AL\u0026nbsp;or MM.\u0026nbsp;(iv)\u0026nbsp;Agreed\u0026nbsp;and signed\u0026nbsp;the informed consent voluntarily.\u0026nbsp;Exclusion criteria:\u0026nbsp;(i)\u0026nbsp;With\u0026nbsp;history of previous hemorrhoid surgery or receiving other surgical procedures. (ii)\u0026nbsp;With other\u0026nbsp;anorectal diseases (fistula, abscess, rectal carcinoma, etc.).\u0026nbsp;(iii)\u0026nbsp;With severe\u0026nbsp;digestive, renal and circular system health conditions. (iv) With being Pregnant or experiencing a breastfeeding period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eModified ligation\u0026nbsp;combining\u0026nbsp;injection\u0026nbsp;operation\u003c/p\u003e\n\u003cp\u003eWith complete exposure after anal dilatation, each external hemorrhoid was slightly pulled towards the outside with Allis forceps. Divided naturally internal hemorrhoids and corresponding external hemorrhoids into a group according to the o\u0026apos;clock position of the hemorrhoids. Tissue scissors radially incised the connected hemorrhoidal bodies from the middle and ligated on each side. The incision extended upward to 0.5 cm above the dentate line. The lower incision extended outward to the distal end of the external hemorrhoids at a depth of 0.5-1 cm. The depth of which was to the surface of the sphincter muscle. Usually muscle was not touched for patients with normal anal pressure. Depending on the tension of the anal canal, the lower edge of the internal sphincter was divided and cut off at the interscalene in the 6 o\u0026rsquo;clock position appropriately for these specific patients with internal anal sphincter spasm due to high anal canal pressure. Ligated blood vessels and nucleus propria of internal hemorrhoids with a 1-0（the USP definition） silk suture from submucosa, the ligation was 0.5~1.0cm away from the dentate line. The corresponding external hemorrhoid was lifted with Allis forceps and the external hemorrhoids at the base were ligated using the same silk in the same way which a V-shape was made. Ligated other groups with the same method and kept the ligated bodies at different levels of the anal canal to prevent postoperative anal stenosis. The hemorrhoidal nucleus was injected with Aluminum potassium sulfate and tannic acid (ALTA) \u0026nbsp;injection（Jilin Ji\u0026apos;an Yisheng Pharmaceutical Co., Ltd, China）and saline 1:1 mixed liquid, showing a half-full state (Figs. 1 and 2). The silk sutures fell off alone after necrosing the hemorrhoid. (see Supplementary Material AL Surgical Videos).\u003c/p\u003e\n\u003cp\u003eThe procedures of MM were carried out by following the surgical technique previously described\u003csup\u003e15\u003c/sup\u003e. Each symptomatic column was excised in each patient with circumferential mixed hemorrhoids.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAuthors screened hospital medical records and database to extract the following data for each patient: age, sex, body mass index (BMI), personal and family history, symptoms, grade of HD, procedural and in-hospital characteristics. Postoperative data and short- and long-term results were evaluated by Follow-up. Follow-up was conducted weekly by outpatient visit until healing and then every 1 month by telephone follow-up survey and periodic reexamination. Each patient was followed up for three years after surgery. The final deadline for follow-up was June 2025.Readmission were required if patients have complications needed to deal with, such as heavy bleeding, anal stenosis leading to difficulty in defecation, etc.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and clinical variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary endpoint parameter of this study was symptom resolution and recurrence. Resolution of symptoms and hemorrhoids was considered complete symptom resolution which was evaluated at 3 months. Recurrences were determined by anoscopy and self-report based on the findings of the surgeon\u0026rsquo;s examination and patient\u0026rsquo;s complaint，which was\u0026nbsp;assessed\u0026nbsp;within\u0026nbsp;3\u0026nbsp;years after surgery. Pain was assessed using a visual analog scale (VAS), with zero equivalent to \u0026ldquo;no pain\u0026rdquo; and 10 to \u0026ldquo;maximum pain\u0026rdquo;, which was assessed at 1 day and 14 days\u003csup\u003e26\u003c/sup\u003e . Symptoms of incontinence were evaluated by Wexner\u0026nbsp;incontinence score(WIS)\u003csup\u003e27\u003c/sup\u003e at 4 weeks and 1 year. Postoperative perianal edema is referring to severe perianal edema that anal marginal edema occupies more than 1/2 circle perianal,\u0026nbsp;which\u0026nbsp;was\u0026nbsp;evaluated at 7 days.\u0026nbsp;Anal cosmetic outcome\u0026nbsp;3\u0026nbsp;months post-operatively\u0026nbsp;was evaluated according to\u0026nbsp;Vancouver Scar Scale (VSS)\u003csup\u003e28\u003c/sup\u003e,which included\u0026nbsp;scar color, thickness, vascular distribution, and softness\u0026nbsp;and\u0026nbsp;scores. The VSS \u0026nbsp;had\u0026nbsp;a total score of 15 points, with more severe scars receiving higher scores\u003csup\u003e29\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eanalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS(version 25.0) was used for statistical analyses. Continuous variables are presented as mean\u0026plusmn;standard deviation (\u0026nbsp;\u0026plusmn;s) or median (interquartile range, IQR) and were compared using Student\u0026rsquo;s t test or the Mann\u0026ndash;Whitney U test, depending on their distribution. Categorical variables are shown as n(%).\u0026nbsp;Association of categorical variables was assessed using the\u0026nbsp;c\u003csup\u003e2\u003c/sup\u003e test or\u0026nbsp;Fisher\u0026rsquo;s\u0026nbsp;exact\u0026nbsp;test. The operation time, the pain scores\u0026nbsp;after two weeks，intraoperative blood loss and anal function of the two groups were compared by\u0026nbsp;using\u0026nbsp;Graphpad Prism(version 9.5.0). The anal cosmetic outcome\u0026nbsp;and\u0026nbsp;recurrence-free probability\u0026nbsp;of the two groups were compared by\u0026nbsp;using R software(version\u0026nbsp;4.4.2). \u0026nbsp;A two-tailed \u003cstrong\u003e\u003cem\u003eP-value\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 778 consecutive patients were identified. 264 patients were excluded from the study due to receiving a previous hemorrhoid surgery, being lost to follow-up or other reasons. Of whom the remaining 514 eligible patients, 224 patients were included in the AL group while 290 patients comprised the MM group in this study for analysis. The study flow chart is showed in Fig. 3. The baseline characteristics are outlined in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBaseline characteristics and postoperative results of study subjects.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"109%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAL (n=224)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMM(n=290)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistic\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e137（61.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e167（57.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87（38.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e123（42.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.62\u0026plusmn;14.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.94\u0026plusmn;13.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCourse, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6（2,10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5（2,10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.24\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.64\u0026plusmn;2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGoligher classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.920\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eⅢ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e128（57.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e167（57.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eⅣ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e96（42.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e123（42.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePiles\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e＜5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e127(56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e182(62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e97(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108(37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eComplete symptom resolution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.901\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e207(92.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e261(90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17(7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29(10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.721\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ebleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5（2.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12（4.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003edysuria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15（6.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11（3.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003einfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（0.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2（0.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eanal stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（0.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（0.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eperianal \u0026nbsp; edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23（10.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36（12.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003etotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45（20.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62（21.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVancouver Scar Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5（4,7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（1,2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The internal hemorrhoids of circumferential mixed hemorrhoids commonly occur above the dentate line, with the hemorrhoids located at the 3, 7, and 11 o\u0026apos;clock positions, among others. Circumferential mixed hemorrhoids can be classified into several piles based on their specific locations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; There was no significant difference in the complete symptom resolution rate between the AL group [92.4% (207/224) vs. 90.0% (261/290)] and the MM group(\u003cstrong\u003e\u003cem\u003eR\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＞0.05\u003c/strong\u003e). At a follow up of 36 months, we registered 5(2.2%) recurrence in the AL group and 36(12.4%) in the MM one. The recurrence-free probability in AL group was significantly higher than that in MM group (\u003cstrong\u003e\u003cem\u003eR \u0026lt; 0.0\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e01\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;（Fig. 4F）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of intraoperative and postoperative results between the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe operative time in AL group was significantly shorter than that in MM group（21.04 \u0026plusmn; 3.58 vs. 36.39 \u0026plusmn; 4.99 min; \u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e＝40.665, \u003cstrong\u003e\u003cem\u003eR\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e）, There was no significant difference in intraoperative blood loss between the two groups（10.28 \u0026plusmn; 3.29 vs. 10.77 \u0026plusmn; 3.45 ml; \u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e＝1.160,\u0026nbsp;\u003cstrong\u003e\u003cem\u003eR\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＝\u003c/strong\u003e\u003cstrong\u003e0.108\u003c/strong\u003e）.（Fig. 4A\u0026nbsp;and 4B）\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; There were not differences concerning pain postoperative days 1 to 7 including during defecation. Pain during postoperative days 7 to 14 was lower in the MM group but there were not statistically significant differences（\u003cstrong\u003e\u003cem\u003eR\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＞\u003c/strong\u003e\u003cstrong\u003e0.05\u003c/strong\u003e）.\u0026nbsp;（Fig. 4D）\u003c/p\u003e\n\u003cp\u003eFive (2.2%) of the 224 patients in the AL group needed a reoperation because of bleeding fifteen (7.4%) had dysuria, one had infection (0.4%) one had anal stenosis (0.4%)\u0026nbsp;and twenty-three (10.3%) had postoperative perianal edema. The corresponding values for the 290 patients in the MM group were twelve (4.1%) for bleeding, eleven (3.8%) for dysuria, two had infection (0.7%), one had anal stenosis (0.8%), and thirty-six (12.4%) for postoperative perianal edema. There was no significant difference between the groups in the total incidence of complications (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;anal cosmetic outcome and anal function\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ebetween the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; At 4 weeks, the incontinence score in the AL group was significantly lower in the MM group (1.31 \u0026plusmn; 0.80 vs. 1.80 \u0026plusmn; 0.89, \u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e). （Fig. 4C）.During the follow-up, the intermittent gas leakage resolved spontaneously in all patients. No incontinence for liquid or solid stools occurred during follow up. No patients of both groups developed anal incontinence after 1 year. Anal cosmetic outcome in AL group was superior to the MM group. (Fig. 2F and 4E).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe assessed the consistency of the treatment effect on the primary outcome in subgroups. Compared to the MM group, the AL technique showed\u0026nbsp;higher complete symptom resolution with grade Ⅳ hemorrhoidal patients (90/96 vs. 103/123, \u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e). No statistically significant differences were found between the two groups with grade Ⅲ hemorrhoidal patients in terms of complete symptom resolution rate（\u003cstrong\u003e\u003cem\u003eR\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e＞\u003c/strong\u003e\u003cstrong\u003e0.05\u003c/strong\u003e）.（Fig. 5）.The treatment effect on the primary outcome was consistent in other subgroups. There was no appreciable difference in benefit among patients in other subgroups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe conducted a multicenter,\u0026nbsp;retrospective study comparing a promising technique named AL for the severest circumferential hemorrhoids to the gold-standard Milligan-Morgan hemorrhoidectomy. Our study demonstrated a high recurrence-free rate of 97.8% after a AL procedure for grade Ⅲ to Ⅳ circumferential mixed hemorrhoids. We founded that AL was associated with shorter operative time and better anal cosmetic outcome.\u003c/p\u003e\n\u003cp\u003eMM is a conventional surgical procedure for mixed hemorrhoids, but it is commonly accompanied by adverse postoperative prognostic outcomes, such as anal stenosis, severe edema, and residual skin tag when implemented on patients with circumferential mixed hemorrhoids\u003csup\u003e30\u003c/sup\u003e. Additionally, it leaves behind some internal hemorrhoidal tissue and skin tags, which are the main complaints of patients with severe hemorrhoids as incomplete resection or recurrence\u003csup\u003e31\u003c/sup\u003e. Some of these patients experienced recurrence and symptoms after MM when faced with advanced stages hemorrhoids. Our study supported that the procedure of AL was safe and effective in obtaining anatomical repair and relieving symptoms. Furthermore, it represents a valid procedure for the surgical management of this severe condition. Generally, the volume of grade Ⅳ hemorrhoids is larger and more severe than grade Ⅲ hemorrhoids based on the Goligher classification\u003csup\u003e32\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;Wang et al.\u0026nbsp;\u003csup\u003e33\u003c/sup\u003e proposed that the excision of the internal hemorrhoids and redundant anoderm (part of external hemorrhoids) must be complete when circumferential mixed hemorrhoids is performed.\u0026nbsp;Abe et al.\u003csup\u003e24\u003c/sup\u003e reported that the effects of ALTA for hemorrhoids were almost same to those of excisional hemorrhoidectomy. It was observed that more tissue in the AL group was removed than in a standard hemorrhoidectomy. This led to the conclusion that the AL technique showed higher complete symptom resolution with grade Ⅳ hemorrhoidal patients compared to the MM group.\u003c/p\u003e\n\u003cp\u003eAnother obvious advantage of the AL is anal cosmetic outcome. It is a cosmetic feature that is rarely reported in series of hemorrhoid operations, except in the study by Huang et al.\u003csup\u003e34\u003c/sup\u003e and Wu et al. \u003csup\u003e17\u003c/sup\u003e. The reason for including this outcome is that patients have higher requirements for postoperative anal appearance. Low anal smoothness has an impact on mental health and quality of sexual life in these patients. By preserving the maintenance of normal anal anatomy and avoiding perineal incisions, the of AL technique reduces surgical trauma and promotes favorable aesthetic outcome. These improved results are also explained by improved knowledge of the anatomy of the anal region and a more accurate surgical technique, such as with adequate blood supply and proper recreation of the mucocutaneous junction above the level of the dentate line. The rectal mucosa is closely connected to the skin after necrosing the hemorrhoids. Therefore, AL showed a better cosmetic result.\u003c/p\u003e\n\u003cp\u003eRecurrence rates have been evaluated in some studies. In most reports the recurrence rate\u003c/p\u003e\n\u003cp\u003eafter MM was stated to be low\u003csup\u003e35\u003c/sup\u003e, but was usually evaluated after only a short follow-up or excluding circumferential mixed hemorrhoids. Genova et al. \u003csup\u003e36\u003c/sup\u003e suggested that in grade IV hemorrhoids treated with MM no recurrence occurred during the three-year follow-up. A tendency towards a higher recurrence rate was reported in patients with grade Ⅳ hemorrhoids in long-term follow-up, irrespective of the technique used\u003csup\u003e37,38\u003c/sup\u003e.Kim et al. \u003csup\u003e39\u003c/sup\u003e reported the cumulative recurrence rates with circumferential third-degree hemorrhoids after 5 years were 23 % (14/61) in the MM group. The recurrence may be attributable to fail to completely remove the hemorrhoid nucleus propria which has undergone pathological changes or insufficient removal capacity of the instruments.\u0026nbsp;Removing more prolapsed tissue to reduce the recurrence is believed to benefit patients with more severe prolapsed hemorrhoids\u003csup\u003e40\u003c/sup\u003e. Huang et al. \u003csup\u003e34\u003c/sup\u003e reported recurrence rates of grade Ⅲ to Ⅳ circumferential mixed hemorrhoids at 1 year of 0.65% in the M-TST-CACP group, compared to 5.88% in PPH group. Consistent data were limited on the epidemiology of HD recurrence\u003csup\u003e41\u003c/sup\u003e. The incidence and prevalence of recurrence reported across geographies were impacted by differences in definition data collection. In our study, the recurrence rate in MM group was significantly higher than that in AL group during the 36-month follow-up after surgery, due to residual tissue when treating grade IV circumferential mixed hemorrhoids.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;The complication rates were similar in the both groups. In this study, there was no statistically significant difference in the assessment of postoperative pain, although there was a trend towards more pain in the AL group from day 7 after operation because hemorrhoid tissue dropped from day 7 to 14(Fig. 2C-2E).\u0026nbsp;It was essential to note that long effect of local anesthetic bupivacaine and ropivacaine, local application of postoperative oxybuprocaine and oral analgesia agents celecoxib was used in the study, and this may have minimized possible differences between the two groups. Novel innovations are rife and driven by the fact that industry recognizes a common condition with outcomes, particularly pain that can be improved\u003csup\u003e19\u003c/sup\u003e. The goal for the majority of patients who underwent AL was to remove the hemorrhoidal tissue from the sphincter and maintain the integrity of the sphincter. Partial internal sphincter resection was performed only for some specific patients so that the anus retained sufficient aperture after surgery to decrease the risk of anal stenosis and relieve pain caused by spasm of the internal anal sphincter, which has been proven to be effective by other studies on hemorrhoids\u003csup\u003e15,17\u003c/sup\u003e. All ligature points were not in the same plane while in a jagged arrangement. It was important for these patients, which can account for the low morbidity of anal stenosis after AL.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; The superficial and deep parts of the external anal sphincter are involved in the formation of the anorectal ring, which plays an important role in anal continence\u003csup\u003e42\u003c/sup\u003e. If they are cut carelessly during surgery, it can cause fecal incontinence\u003csup\u003e43\u003c/sup\u003e.AL and MM did not damage them, so a minority of fecal incontinence was not caused by them but may be anal cushions which were believed to contribute to the anal continence mechanism. Impairment of the anal cushion function may lead to anal incontinence\u003csup\u003e44\u003c/sup\u003e. However,\u0026nbsp;the role of physiologic and pathological anal cushions in anal continence is less studied.\u0026nbsp;Hemorrhoids are physiologic vascular cushions underlying the distal rectal mucosa and they can become pathological being the most common cause of painless rectal bleeding during defecation with prolapsing anal tissue\u003csup\u003e45\u003c/sup\u003e. Patients with grades Ⅲ and Ⅳ hemorrhoids present with a pathologically abnormal cushion which usually appears as a \u0026ldquo;mosaic pattern\u0026rdquo; in sonography, which is in accord with an arteriovenous fistula in pathology\u003csup\u003e46\u003c/sup\u003e.\u0026nbsp;Inflammation of the anal cushion remains major pathogenesis for the development of hemorrhoids\u003csup\u003e47\u003c/sup\u003e.For circumferential mixed hemorrhoids, pathological anal cushions are massively enlarged and prolapsing circumferentially through the anal canal and fails to perform function to anal continence well\u003csup\u003e48\u003c/sup\u003e. Miyamoto et al.\u0026nbsp;\u003csup\u003e49\u003c/sup\u003e found that blood flow significantly increased following advancement of the grade of hemorrhoid. After 4 weeks, Wexner incontinence score in AL group was lower than MM group, which could be explained by the hypothesis that AL directly reduced blood flow in the hemorrhoidal plexus through removing most of the pathological anal cushions, better fixed the physiological anal cushion in the anal canal and prevented the hemorrhoidal supporting tissue from being further weakened, resulting that the remaining physiologic anal cushion returned to the normal anatomical position and truly enhanced anal continence. Although some patients experienced temporary sensory anal incontinence due to the removal of most of the pathological anal cushions, the 1-year follow-up showed no significant impact on anal continence. Our findings supported the idea that the removal of most of the pathological anal cushions had no effect on long-term anal continence.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; The study has some limitations. The study is not randomized, introducing potentially bias. Dekker et al.\u003csup\u003e32\u003c/sup\u003e proposed that a more reliable and international new classification for the evaluation of the severity of HD is needed. Future multicenter randomized controlled trials (RCTs) studies may include populations with more diverse races and cultural backgrounds. Further studies with longer follow-up and comparison with other procedures are suggested. In addition, its applicability in patients with special types of hemorrhoids will be also explored in the future.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAL shows promising results as a minimally invasive technique for treating circumferential mixed hemorrhoids compared with Milligan-Morgan hemorrhoidectomy, with lower recurrence rate, shorter operative time and favorable cosmetic outcome. The procedure provides a new choice for these patients with a need for an anal cosmetic outcome. AL is safe and noninferior to MM in the treatment of grade Ⅲ circumferential mixed hemorrhoids and is more effective in the treatment of grade Ⅳ. Further studies and long-term follow-ups are required to confirm its effectiveness and to establish its broader applicability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all patients and relatives who made valuable contributions to the data collection process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, L. SZ., Z. CB. and L. WX.；Project administration, L. SZ.,\u0026nbsp;Z.CB and\u0026nbsp;L.WX；Data curation, L.\u0026nbsp;SZ., S.B,\u0026nbsp;Q.GJ, T.J and R.YZ;\u0026nbsp;Formal analysis, L.\u0026nbsp;SZ., S.B, Q.GJ, T.J ,W.YQ, S.ZZ;\u0026nbsp;Investigation,\u0026nbsp;L.\u0026nbsp;SZ.,\u0026nbsp;Z.\u0026nbsp;CB.\u0026nbsp;and\u0026nbsp;L. WX.;\u0026nbsp;Methodology, L.\u0026nbsp;SZ.,\u0026nbsp;T.J ,W.YQ, S.ZZ;\u0026nbsp;Software,\u0026nbsp;L.\u0026nbsp;SZ.;\u0026nbsp;Resources, Z.\u0026nbsp;CB.,\u0026nbsp;L. WX.,D.JM.,R.YZ;\u0026nbsp;Writing\u0026mdash;original draft, L.\u0026nbsp;SZ.\u0026nbsp;;\u0026nbsp;Supervision, Z.\u0026nbsp;CB.\u0026nbsp;and\u0026nbsp;L. WX.；Writing\u0026mdash;review \u0026amp; editing, L. WX.\u0026nbsp;All authors\u0026nbsp;reviewed\u0026nbsp;the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article. And the primary data could be achieved from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Natural Science Foundation of Shanxi Province(Grant numbers [20210302123261]) and the Hubei Chen Xiaoping Science and Technology Development Foundation (Grant numbers[CXPJJH122002-099]).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOmori, J.\u003cem\u003e et al.\u003c/em\u003e Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases. \u003cem\u003eJournal of gastroenterology\u003c/em\u003e \u003cstrong\u003e59\u003c/strong\u003e, 24-33, doi:10.1007/s00535-023-02057-9 (2024).\u003c/li\u003e\n\u003cli\u003eGrossi, U., Santoro, G. 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H.\u003cem\u003e et al.\u003c/em\u003e Single-nucleus RNA sequencing and spatial transcriptomics reveal the mechanism by which Xiaozhiling injection treats internal hemorrhoids. \u003cem\u003eWorld journal of gastrointestinal surgery\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, 103494, doi:10.4240/wjgs.v17.i4.103494 (2025).\u003c/li\u003e\n\u003cli\u003eMiyamoto, H.\u003cem\u003e et al.\u003c/em\u003e Visualization and hypervascularization of the haemorrhoidal plexus in vivo using power Doppler imaging transanal ultrasonography and three-dimensional power Doppler angiography. \u003cem\u003eColorectal disease\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, e686-691, doi:10.1111/codi.12406 (2013).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hemorrhoids, Milligan-Morgan hemorrhoidectomy, Efficiency, Anal cosmesis, Minimally invasive treatment","lastPublishedDoi":"10.21203/rs.3.rs-7462451/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7462451/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: We propose a novel nonexcisional technique for circumferential mixed hemorrhoids. This procedure, namely AL,involves combining Aluminum potassium sulfate and tannic acid (ALTA) therapy with ligation. This study aimed to compare the efficacy and safety of this novel procedure over Milligan-Morgan hemorrhoidectomy (MM) in patients with circumferential mixed hemorrhoids.\u003c/p\u003e\n\u003cp\u003eMethods: This multicenter retrospective study conducted at three hospitals in China included 514 patients with circumferential mixed hemorrhoids who 224underwent AL and 290 underwent MM. Primary endpoints were symptom resolution and recurrence rate. Secondary endpoints were intraoperative outcomes, postoperative pain, complications, anal function and cosmetic outcome.\u003c/p\u003e\n\u003cp\u003eResults: The complete symptom resolution rate in both groups showed no statistically significant difference. Recurrence rates in the AL and MM groups were 2.2% and 12.4%, respectively (\u003cem\u003e\u003cstrong\u003eR \u0026lt; 0.001\u003c/strong\u003e\u003c/em\u003e). Mean operative time was significantly shorter in AL group (\u003cem\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e). Anal cosmetic outcome in AL group was superior to the MM group (\u003cem\u003e\u003cstrong\u003eR \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e). Subgroup analysis showed higher complete symptom resolution rate with grade Ⅳ hemorrhoidal patients in the AL group (\u003cem\u003e\u003cstrong\u003eR \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e). No anal dysfunction occurred in both groups.\u003c/p\u003e\n\u003cp\u003eConclusions: AL is safe and noninferior to MM in the treatment of grade Ⅲ circumferential mixed hemorrhoids, and it is more effective in the treatment of grade Ⅳ. It shows promising results as a minimally invasive technique compared with MM, with lower recurrence rate, shorter operative time and favorable cosmetic outcome.\u003c/p\u003e","manuscriptTitle":"Outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid(ALTA) sclerotherapy with ligation on patients with circumferential mixed hemorrhoids","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 12:58:45","doi":"10.21203/rs.3.rs-7462451/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-28T08:47:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T10:56:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-02T11:05:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-29T09:08:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-08-29T09:03:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"397184fc-0fbd-4cc9-8c4e-f2492a7a26d4","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61880122,"name":"Health sciences/Diseases"},{"id":61880123,"name":"Health sciences/Gastroenterology"},{"id":61880124,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-01-30T12:58:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 12:58:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7462451","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7462451","identity":"rs-7462451","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}