INTRODUCTION
Hemorrhoids are the most frequent benign anal disorder experienced by medical doctors and surgeons. It is calculated that the lifelong risk of developing hemorrhoids in the general population may be as high as 75%[1]. Mixed hemorrhoids often occur at the same position above and below the dentate line of the anus. The main clinical symptoms include rectal bleeding, anal mass, swelling, sensation of foreign body, pain, local discharge and pruritus[2]. Most hemorrhoid patients are treated conservatively at first. If medical treatment is ineffective, non-surgical outpatient procedure might be more appropriate. Surgical treatment is only performed on patients whose symptoms persist after conservative or outpatient treatment[3]. Traditional hemorrhoidectomy procedures, involving the Milligan-Morgan hemorrhoidectomy (M-MMH) method and the Ferguson procedure, have problems of postoperative pain, bleeding, urinary retention and long-term complications[4]. Therefore, this study modified the M-MMH procedure by combining techniques such as “V” incision and “8” figure ligation to optimize wound repair and support combined acupuncture treatment.
Acupuncture is among the oldest treatments in conventional Chinese medicine. The main stimulation methods include manual acupuncture, electroacupuncture and transcutaneous acupoint electrostimulation[5]. Research has revealed that acupuncture promotes wound healing by anti-inflammatory actions and promotes re-epithelialization and angiogenesis[6]. In addition, another study reported that acupoint application was more useful than other treatments for post-operative pain in mixed blood hemorrhoids[7]. However, research on the combined effects of systemic acupuncture protocols with the M-MMH techniques on pain control and wound healing is still insufficient.
Accordingly, the present research is intended to assess the impact of combining acupuncture therapy on the basis of M-MMH surgery on the postoperative pain level and wound healing process with mixed hemorrhoids through retrospective analysis, with a view to providing clinical data reference for the construction of an accelerated perioperative rehabilitation program combining traditional Chinese and Western medicines.
MATERIALS AND METHODS
General information about patients
Reviewed and gathered clinical data of patients with mixed hemorrhoids diagnosed in our anorectal department from January 2023 to December 2024. Inclusion criteria: (1) Meeting the diagnostic criteria for mixed hemorrhoids[8] and having internal hemorrhoids graded as III to IV[9]; (2) Aged 18 years to 75 years; (3) Having no contraindications to surgery and being willing to undergo surgical treatment; (4) Having no contraindications to acupuncture; and (5) Having complete clinical data. Exclusion criteria: (1) Having severe heart, liver, kidney and other major organ failure; (2) Having coagulation disorders or immune system diseases; (3) Having other anorectal illnesses like anal fistula or perianal abscess; and (4) Having allergies to acupuncture or postoperative medication.
Based on the above criteria, a series of 80 patients were included and categorized into a control group (n = 40) and a combination group (n = 40) by treatment method.
Sample size estimation
The sample size was calculated using G*Power 3.1 software. Based on a pilot study of 10 patients per group, the mean postoperative day 3 VAS score in the control group was 3.5 ± 0.6, and in the combined group was 2.2 ± 0.5. To detect this difference with a two-sided α = 0.05 and power (1 - β) = 0.90, a minimum of 34 patients per group was required. Accounting for a 15% potential dropout rate, 40 patients per group were enrolled.
Group allocation
This was a retrospective cohort study, and group allocation was determined by actual treatment received rather than random assignment. The patient selection and grouping process followed a sequential screening procedure: First, all potentially eligible patients who met the inclusion criteria were identified from the electronic medical record system of our Anorectal Department; second, patients were divided according to whether they had received postoperative acupuncture treatment as documented in their treatment records; third, patients with incomplete clinical data or those meeting any exclusion criteria were excluded; finally, all eligible patients identified during the study period were included in the analysis, resulting in 40 patients in the control group (those who did not receive postoperative acupuncture) and 40 patients in the combined group (those who did receive acupuncture), based on their actual treatment allocation.
Treatment methods
Both groups of patients underwent the M-MMH procedure upon admission. All patients were placed at the folding knife and underwent sacral anesthesia. A “V”-shaped radial incision was made in the external hemorrhoid portion, and the venous plexus was stripped to the dentate line of about 0.5 cm, and the base of the internal hemorrhoid was clamped with a curved vascular forceps, and the distal hemorrhoidal tissues were excised with a No. 7 silk thread in an “8” through suture. During the procedure, sufficient skin and mucosal bridges were preserved. Postoperatively, the anal canal was packed with Vaseline gauze and pressure bandaged.
Control group
The patient received routine basic treatment after surgery. The specific contents included: Intravenous infusion of antibiotics (cefotaxime sodium, 2.0 g, twice a day) to prevent infection for 24-48 hours. The patient could start a liquid diet 6 hours after operation, then switch to a semi-liquid diet the next day, and then gradually transition to a regular diet. The patient was also given oral lactulose solution (15 mL, once a day) to keep the bowels open. From the second day after surgery, the patient was given a warm sitz bath with 1:5000 potassium permanganate solution for 15 minutes each time, twice a day. The dressing was changed once a day, and the wound was covered with Vaseline gauze. If the patient complained of unbearable pain [visual analog scale (VAS) ≥ 4 points], oral loxoprofen sodium tablets (60 mg/time) were given as needed as a rescue analgesia[10].
Combined group
On the basis of postoperative basic treatment, the acupuncture operation was performed by two licensed acupuncturists with over 5 years of clinical experience, who had undergone unified training on the study protocol, including point location, needling techniques, and communication with patients to ensure consistency. The training involved 5 supervised sessions on non-study volunteers until an inter-operator agreement of > 90% on point location and needling depth was achieved. The main acupoints were Changqiang (the center line of the tip of the tailbone and the anus), Chengshan (the depression under the gastrocnemius muscle belly), and Erbai (4 cun over the transverse carpal stripe, on each of the radial flexor carpi radialis tendon sides). The patients were lying on their sides. after the local skin was regularly sterilized, 0.30 mm × 40 mm disposable sterile stainless steel acupuncture needles (Suzhou Medical Appliance Factory, China) were used for needling. Changqiang was obliquely stabbed 0.5-1 cun towards the direction of the anus close to the front edge of the coccyx, Chengshan was punctured 1-1.5 cun until the patient felt soreness, numbness, distension, and heaviness (Qi acquisition), and Erbai was pricked 0.5-0.8 cun straight. After obtaining the Qi, the even tonifying and reducing technique was applied, with a fixed rotation amplitude of 180° (± 10°) and a fixed frequency of 60 times/minute (± 5 times/minute). The needle was left in place for 30 minutes (± 1 minute), during which the needle was performed once every 10 minutes (± 1 minute) for 30 seconds to maintain needle sensation. The treatment was performed once a day, starting 6 hours (± 30 minutes) after the operation, for 7 consecutive days as one course of treatment[11].
Observation indicators
Pain level: The VAS evaluation of pain was adopted. The pain scores of patients were recorded at 6 hours, 1 day, 3 days and 7 days postoperatively. A 10 cm long ruler was used, with “0” (no pain) and “10” (the most intense pain that can be imagined) marked at the two ends. Patients marked the corresponding position on the ruler according to the average pain intensity experienced in the past 24 hours. The distance (cm) from the “0” point to the marked point was the pain score. Higher scores mean more severe pain[12].
Wound recovery status: A senior physician who was unaware of the grouping retrospectively scored the wound recovery status on the 1st, 3rd and 7th days after the operation based on the postoperative dressing record. All scores were negative indicators (the higher the score, the worse the recovery). Specifically, the scores included: Wound edema score (0: No oedema; 1: Mild oedema, skin lines present; 2: Medium oedema, skin lines disappear; 3: Serious oedema, skin tight and shiny)[13]; wound exudate score (0 points: Dry dressing; 1 point: Small amount of exudate, wetted area < 25%; 2 points: Moderate amount of exudate, wetted area 25%-75%; 3 points: Large amount of exudate, wetted area > 75%)[14] and poor granulation tissue score (0 points: Bright red and dense granulation tissue, nearly healed; 1 point: Bright red granulation tissue, good growth; 2 points: Pale red granulation tissue, slow growth; 3 points: Pale wound, no granulation tissue growth)[15].
Postoperative recovery related indicators: (1) Time to disappearance of wound secretions: Defined as the first postoperative day when the wound exudate score was 0 for two consecutive days (e.g., if scores were 1, 0, 0 on days 4, 5, and 6, day 5 was recorded as the disappearance time); (2) Time to disappearance of edema in the surgical area: Defined as the first postoperative day when the wound edema score was 0 for two consecutive days; (3) Time to complete wound healing: Defined as the day when the wound was completely epithelialized with no exudate or secretions, as confirmed by a senior anorectal surgeon during dressing change. To minimize inter-observer variability, all final healing assessments were independently reviewed and confirmed by two senior physicians who were blinded to the group allocation, and any disagreements were resolved by consensus. All assessments were uniformly conducted during the morning dressing change (between 8:00 am and 10:00 am) to control for circadian influences; and (4) Postoperative complications: Record the number of cases of complications like anal stenosis, urine trapping and anal discharge in both groups during the treatment period.
Statistical analysis
Data was implemented utilizing SPSS 21.0 software. The measured data were presented as mean ± SD. The normality of distribution was assessed using the Shapiro-Wilk test. Intergroup comparisons for normally distributed data were performed using independent samples t-tests; for non-normally distributed data, the Mann-Whitney U test was applied. All continuous variables in this study were normally distributed, thus t-tests were used. Count data were presented as percentages (%), and the χ2 tests when all expected cell counts were ≥ 5; otherwise, Fisher's exact test was used. For multiple comparisons of VAS scores and wound recovery scores at different time points (6 hours, day 1, days 3, days 7), a Bonferroni correction was applied to adjust the significance level, with a corrected α’ = 0.05/4 = 0.0125 considered statistically significant for these repeated measures. There were no missing data in this study as only patients with complete medical records were included. The difference was regarded as clinically meaningful at P < 0.05.
DISCUSSION
Hemorrhoids are the most prevalent anorectal disease throughout the world, with clinical manifestations including rectal bleeding, anal swelling, a feeling of a foreign body feeling or pain, local secretions or itchiness, prolapse of hemorrhoidal pads or protruding lumps[16]. Hemorrhoids may appear up or down the anal canal; the upper part is known as internal hemorrhoids and the lower part is known as external hemorrhoids[17]. Internal hemorrhoids often cause painless rectal bleeding during defecation, while external hemorrhoids are often accompanied by pain due to thrombosis and involvement of perianal nerves[18]. Although not life-threatening, complaints of bleeding, pain and itching markedly influence quality of life and increase the socioeconomic burden due to absenteeism and frequent treatment needs[19]. Mixed hemorrhoids are among the most prevalent forms of hemorrhoids, manifesting as internal and external hemorrhoidal nuclear blood vessel plexuses fusing with each other at corresponding sites[20]. Mixed hemorrhoids are vulnerable to recurring bleeds, which can cause serious anemia. The core treatments for hemorrhoids include conservative treatment and surgical treatment. Hemorrhoids are categorized as grades I to IV under the Gölih Clinical Classification System. Mildly symptoms hemorrhoids (grades I and II) are often manageable with conservative therapy, while symptoms grade III to IV hemorrhoids normally need surgical intervention[21]. Clinical studies have revealed that patients with grade III/IV mixed hemorrhoids may develop complications such as anemia and anal stenosis if they are not treated in time, which may further increase the physical and emotional load of the patients[22].
The M-MMH procedure is still a very preferred treatment for III to IV degrees hemorrhoids owing to its high cost- effective and excellent long-term outcome[23]. Its core principle is to dissect the internal hemorrhoid attachment tissue to the dentate line and ligate it through the fibrovascular pedicle, while removing excess perianal skin and hemorrhoid tissue[24]. However, this traditional surgical method is often accompanied by complications linked to postoperative pain, bleeding delays and delayed healing of the wound[25,26]. Therefore, this study, based on the M-MMH procedure, constructed a more favorable surgical basis for recovery through modifications such as “V” shaped incision, preservation of skin bridge and mucosal bridge, and “8” figure suture ligation, creating conditions for combined acupuncture therapy.
According to traditional Chinese medicine theory, acupuncture stimulates different meridians by “activating qi” and “promoting blood circulation”, thereby regulating distal organs and relieving pain[27]. From the perspective of traditional Chinese medicine, the anal swelling and pain after hemorrhoidal surgery is mostly due to the prolonged course of the disease, the deficiency of qi and blood, and damp-heat betting[28]. Studies have revealed the benefits of acupuncture in relieving postoperative pain from hemorrhoid surgery[29]. It has been reported that electroacupuncture at the Bajiao point alleviates short-term anal pain and swollenness after hemorrhoid surgery, decreases the rate of urine retention, and reduce the need for postoperative analgesic medication[30]. Changqiang is located midway between the coccyx tip and anus, Chengshan lies in the depression of the gastrocnemius muscle, and Erbai is situated 4 cun proximal to the wrist transverse crease[31]. In study, bowel incision at Changqiang and bilateral purple border points showed excellent analgesia and safety of postoperative pain administration of mixed hemorrhoidectomy[32]. Meanwhile, studies have assessed the effects of electroacupuncture at Chengshan and Erbai acupoints on postoperative complications of mixed testicular swelling, along with the clinical benefits of electroacupuncture at Changqiang and Chengshan acupoints on postoperative pain and discomfort in patients with mixed testicular swelling. The results showed that electroacupuncture at Chengshan alleviates postoperative anal pain by suppressing the muscarinic acetylcholine receptors/inositol trisphosphate-calmodulin2+-calmodulin signaling pathway[33].
The M-MMH technique reduces surgical trauma through precise operation, creating a foundation for postoperative recovery. However, it cannot completely avoid problems such as pain and edema caused by traumatic inflammatory reactions and nerve stimulation. Acupuncture therapy, on the other hand, can relieve pain by stimulating the meridians. The significant reduction in postoperative VAS scores can be attributed to acupuncture’s analgesic effects mediated by endogenous opioid peptides (β-endorphins, enkephalins) released from immune cells at inflammatory sites, which act on μ- and δ-opioid receptors on peripheral sensory nerve endings to inhibit nociceptive transmission[34]. Additionally, acupuncture promotes adenosine release at acupoints by activating mast cell transient receptor potential vanilloid 2 channels, with adenosine A1 receptor activation further suppressing substance P expression in dorsal root ganglia neurons[34]. The observed reductions in wound edema and exudate scores reflect acupuncture’s anti-inflammatory properties. Mechanistically, acupuncture inhibits the NOD-like receptor family pyrin domain containing 3 inflammasome activation in macrophages through cannabinoid CB2 receptor signaling[34], while promoting the balance between pro-inflammatory M1 and anti-inflammatory M2 macrophages via peroxisome proliferator-activated receptor gamma (PPARγ) upregulation[35]. This macrophage polarization shift increases interleukin (IL)-10 production and decreases tumor necrosis factor α (TNF-α) and IL-1β release, thereby attenuating local inflammatory responses[34]. The enhanced granulation tissue formation and accelerated wound healing align with acupuncture’s ability to promote angiogenesis and tissue regeneration. Transcutaneous electrical stimulation upregulates VEGF-A, transforming growth factor β, and Wnt3a expression while activating the phosphoinositide 3-kinases/protein kinase B signaling pathway, which collectively stimulate endothelial cell proliferation and collagen synthesis[36]. Furthermore, acupuncture optimizes mitochondrial dynamics by promoting fusion (mitofusin 1 upregulation) while inhibiting excessive fission (mitochondrial fission 1 protein downregulation), and enhances mitochondrial oxidative phosphorylation through sulfur cluster assembly enzyme-mediated iron-sulfur cluster assembly, meeting the high energy demands of proliferating cells during wound repair[36]. The involvement of PPARγ in regulating biotin metabolism - by reducing excess linoleic acid and increasing L-lysine levels - provides a metabolic basis for M2 macrophage polarization and subsequent tissue regeneration[35]. Collectively, these findings indicate that the observed clinical benefits of combined M-MMH and acupuncture are associated with integrated “analgesia-anti-inflammation-promoting healing” correlations, rather than definitive causal relationships. The “analgesia-anti-inflammation-promoting healing” mechanisms: Surgical excision removes the pathological nidus, while acupuncture activates endogenous opioid analgesia, regulates neuroimmune interactions, optimizes mitochondrial bioenergetics, and reprograms macrophage metabolism via PPARγ, creating a coordinated biological environment for accelerated wound recovery.
This study retrospectively analyzed clinical data from 80 cases to further validate the value of this combined regimen clinically. Prior to therapy, there were no clinical findings between the two groups of baseline data such as age, gender, disease duration, and hemorrhoid severity (all P > 0.05), ensuring intergroup comparison. Post-treatment data showed that, in terms of pain control, the combined treatment group had considerably lower VAS scores than those of the control group at 6 hours post-surgery and on day 1, days 3, and days 7 (all P < 0.05), especially showing a faster trend of pain relief on day 3 post-surgery (2.19 ± 0.44: 3.44 ± 0.61). Regarding wound healing, the combined therapy group showed significantly lower scores on postoperative days 3 and days 7 compared to the control group (days 7: 0.47 ± 0.07: 0.91 ± 0.12), exudation score (days 7: 0.38 ± 0.05: 0.56 ± 0.08), and poor granulation tissue score (days 7: 0.53 ± 0.06: 0.74 ± 0.07) (all P < 0.001). This significant reduction in scores reveals the advantages of the combined therapy in reducing inflammatory edema, decreasing wound exudation, and promoting high-quality granulation tissue growth. This advantage further translated into improvements in key clinical endpoints: The time to disappearance of wound secretions (5.50 ± 0.70 days: 7.55 ± 1.29 days), the time to disappearance of surgical edema (4.52 ± 0.16 days: 6.83 ± 0.45 days), and the time to complete wound healing (30.06 ± 1.81 days: 35.28 ± 1.12 days) were all significantly shorter in the combined group than in the control group (all P < 0.001). Ultimately, the overall rate of postoperative complications in the combined group (10.00%) was considerably lower than that in the control group (27.50%). These results corroborate each other, suggesting that acupuncture, as an adjunct therapy, may be associated with improved postoperative pain control and accelerated wound healing. However, given the retrospective non-randomized design, these findings should be interpreted as observed associations rather than proven causal effects. The possibility of selection bias - whereby patients who opted for acupuncture may have had different pain tolerance, recovery expectations, or health awareness - cannot be excluded. Prospective randomized controlled trials are warranted to confirm these preliminary observations and establish causality.
While this study clarified the clinical value of the M-MMH combined with acupuncture, certain limitations remain. First, regarding study design: The non-randomized, single-center, retrospective design inherently carries risks of selection bias and unmeasured confounding. Despite comparable baseline data, patient preference for acupuncture and physician recommendation could introduce systematic differences in unmeasured factors like pain tolerance and recovery expectations, potentially overestimating the intervention’s effect. Second, concerning sample size: Although the sample (n = 80) was adequately powered to detect differences in primary outcomes (VAS scores), it may lack statistical power for secondary outcomes like individual complication rates, increasing the risk of type II error. Third, regarding outcome assessment: Reliance on retrospective chart review introduces potential measurement bias. Despite using standardized scales and blinded assessors, original medical records may have inter-observer variability in describing wound characteristics, and complete blinding of outcome assessors during the data extraction phase could not be fully achieved. Fourth, related to follow-up duration: Our follow-up was limited to the acute postoperative period (7 days) and short-term healing, lacking long-term assessments of anal function (e.g., anorectal manometry), quality of life (e.g., short form-36 health survey scale), and hemorrhoid recurrence rates at 6 months or 1 year. Fifth, regarding mechanistic insights: This study focused on clinical outcomes and did not include serological or histological biomarkers (such as IL-6, TNF-α, β-endorphin, or VEGF levels), limiting objective mechanistic support. Based on these limitations, future research should be advanced in several directions. First, large-sample, multicenter, prospective randomized double-blind placebo-controlled trials (randomized controlled trials) are urgently needed. Such trials should include a sham acupuncture control group (e.g., superficial needling at non-acupoints) to minimize placebo effects and ensure true blinding. Second, embedded mechanistic studies within randomized controlled trials should utilize enzyme-linked immunosorbent assay, polymerase chain reaction, and proteomic technologies to dynamically track changes in neuropeptides (substance P, β-endorphin), inflammatory cytokines (IL-1β, IL-6, TNF-α, IL-10), and growth factors (VEGF, transforming growth factor β1), thereby elucidating the molecular pathways underlying the “analgesia-anti-inflammation-promoting healing” synergy. Third, optimization of the acupuncture protocol through factorial design trials is warranted to compare different acupoint combinations (e.g., adding Zusanli ST36, Sanyinjiao SP6), stimulation parameters (manual vs electroacupuncture, varying frequencies), and treatment timing (preemptive vs postoperative analgesia) to establish an evidence-based optimal regimen. Fourth, extending follow-up periods to 6-12 months with comprehensive assessments including anorectal manometry, endoanal ultrasound, and validated quality of life questionnaires (e.g., Hemorrhoid Symptom Severity Score) will provide crucial data on long-term functional outcomes and recurrence. Fifth, investigating the cost-effectiveness of this combined approach in future healthcare economic analyses will facilitate its broader clinical adoption and integration into enhanced recovery after surgery protocols.
