Review for 10.1186/s12876-025-03963-3 (2025)

Title: Milligan–Morgan hemorrhoidectomy combined with rubber band ligation and
polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: A
retrospective study
Version: 0 Date: 05 Apr 2025
Reviewer's report:
The manuscript highlights improved patient outcomes, including lower recurrence rates, reduced
postoperative pain, faster recovery, and fewer complications, offering a promising alternative for
the treatment of grade III/IV hemorrhoids. However, several aspects require further clarification:
Abstract:
• The recurrence rate is one of the primary outcomes and should be explicitly mentioned with
numerical data in the abstract.
• It would be beneficial to provide the proportion of patients with anal stenosis rather than
mentioning a number.
Introduction:
• It would be helpful to mention previously studied combinations, such as sclerobanding
(sclerotherapy + band ligation) or Milligan–Morgan hemorrhoidectomy combined with non-
doppler hemorrhoidal artery ligation, to provide context.
• Clarify the rationale behind this combination of techniques and explain how it may reduce
postoperative adverse outcomes.
Methodology:
• It should be explicitly stated that this is a retrospective cohort study.
• To minimize selection bias, it would be helpful to describe the criteria used to choose between
the two surgical techniques.
• Consider performing a post hoc power analysis to validate the sample size.
• Clarify why no valid incontinence score was used to assess this outcome if presented.
• The definition of recurrence seems misleading, as it includes prolapse as a criterion. Bleeding
alone, without prolapse, should also be considered a recurrence.
• It would be helpful to specify the types of data collected during clinic visits versus those
collected by telephone.
• Regarding PFS, how much was injected into each ligated nodule? Is there a marker indicating
sufficient injection?
• The term "residual hemorrhoids" needs clarification—does it refer to other existing
hemorrhoids or the distal tissue of the same hemorrhoids?
o If it's other hemorrhoids, what criteria determined whether sclerobanding or excision was
performed?
o What is the minimum distance the excision can approach the sclerobanding?
o If the residual hemorrhoids refer to the distal tissue of the same hemorrhoid, what was the
extent of excision, and did any excisions require suture ligation at the feeding vessels?
Results:
• It would be helpful to provide a flow diagram to outline the number of patients assessed for
eligibility, those excluded, and the reasons for exclusion.
• There was no significant difference in operative time between the two groups. However,
the case group involved three techniques, meaning that the control group (MMH alone) likely
included more complex cases. The greater number of incisions in the control group (p < 0.001)
confirms such idea and indicates a risk of bias.
• Additionally, it would be beneficial to include the median number of hemorrhoids treated in
each group and to estimate the mean wound areas in both groups.
Discussion:
• Justifying why combined techniques could reduce postoperative adverse outcomes would
strengthen this section. Please include any theoretical or personal assumptions you have about
this effect.
• Although healing time was significantly shorter in the case group, it would be helpful to
discuss the clinical relevance of a difference of just one day and whether this small difference
is meaningful in practice.
• How did lower pain scores in the case group impact other outcomes, such as healing time and
patient satisfaction?
• The comparable HSS scores between both groups need further explanation—why is this
important, and how does it reflect the effectiveness of the techniques?