J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website https://jocmr.elmerjournals.com

Original Article

Volume 18, Number 11, November 2026, pages 835-841

Severe Inpatient Pain After Stapled Hemorrhoidopexy Versus Milligan–Morgan Hemorrhoidectomy: A Multicenter Overlap-Weighted Cohort Study

↓ **Table 1.** Baseline Characteristics Before and After Propensity-Score Overlap Weighting
Characteristic	Milligan–Morgan (n = 193)	Stapled hemorrhoidopexy (n = 321)	Unweighted SMD	Weighted SMD
Data were mean ± standard deviation or number (%). The propensity model also included hospital. The largest absolute hospital-indicator SMD was 0.499 before weighting and 0.008 after weighting. The maximum absolute weighted SMD across all modeled terms was 0.035. SMD: standardized mean difference.
Age, years	43.1 ± 14.3	47.5 ± 14.7	0.303	0.000
Female sex	66 (34.2)	109 (34.0)	−0.005	0.000
Ethnic minority	106 (54.9)	128 (39.9)	−0.305	0.000
Emergency operation	32 (16.6)	34 (10.6)	−0.175	0.000
Preoperative bleeding	135 (69.9)	244 (76.0)	0.137	0.000
Preoperative anal pain	140 (72.5)	216 (67.3)	−0.115	−0.001
Medical comorbidity	20 (10.4)	48 (15.0)	0.138	−0.001
Thrombosis	40 (20.7)	37 (11.5)	−0.252	−0.001
Coexisting anal lesion	12 (6.2)	11 (3.4)	−0.131	0.001
Hemorrhoid grade II	9 (4.7)	12 (3.7)	−0.046	0.000
Hemorrhoid grade III	125 (64.8)	212 (66.0)	0.027	0.000
Hemorrhoid grade IV	59 (30.6)	97 (30.2)	−0.008	0.000
Internal hemorrhoids	65 (33.7)	100 (31.2)	−0.054	0.002
External hemorrhoids	1 (0.5)	0	−0.102	−0.035
Mixed hemorrhoids	127 (65.8)	221 (68.8)	0.065	−0.001

↓ Table 1. Baseline Characteristics Before and After Propensity-Score Overlap Weighting

Characteristic

Milligan–Morgan (n = 193)

Stapled hemorrhoidopexy (n = 321)

Unweighted SMD

Weighted SMD

Data were mean ± standard deviation or number (%). The propensity model also included hospital. The largest absolute hospital-indicator SMD was 0.499 before weighting and 0.008 after weighting. The maximum absolute weighted SMD across all modeled terms was 0.035. SMD: standardized mean difference.

Age, years

43.1 ± 14.3

47.5 ± 14.7

0.303

0.000

Female sex

66 (34.2)

109 (34.0)

−0.005

0.000

Ethnic minority

106 (54.9)

128 (39.9)

−0.305

0.000

Emergency operation

32 (16.6)

34 (10.6)

−0.175

0.000

Preoperative bleeding

135 (69.9)

244 (76.0)

0.137

0.000

Preoperative anal pain

140 (72.5)

216 (67.3)

−0.115

−0.001

Medical comorbidity

20 (10.4)

48 (15.0)

0.138

−0.001

Thrombosis

40 (20.7)

37 (11.5)

−0.252

−0.001

Coexisting anal lesion

12 (6.2)

11 (3.4)

−0.131

0.001

Hemorrhoid grade II

9 (4.7)

12 (3.7)

−0.046

0.000

Hemorrhoid grade III

125 (64.8)

212 (66.0)

0.027

0.000

Hemorrhoid grade IV

59 (30.6)

97 (30.2)

−0.008

0.000

Internal hemorrhoids

65 (33.7)

100 (31.2)

−0.054

0.002

External hemorrhoids

1 (0.5)

−0.102

−0.035

Mixed hemorrhoids

127 (65.8)

221 (68.8)

0.065

−0.001

↓ **Table 2.** Unadjusted Early Postoperative Outcomes
Outcome	Milligan–Morgan (n = 193)	Stapled hemorrhoidopexy (n = 321)
Data were number (%) unless otherwise indicated. IQR: interquartile range.
Pain grade A: no pain	6 (3.1)	41 (12.8)
Pain grade B: routine regimen only	41 (21.2)	187 (58.3)
Pain grade C: 1 additional dose	107 (55.4)	88 (27.4)
Pain grade D: 2 additional doses	35 (18.1)	4 (1.2)
Pain grade E: ≥ 3 additional doses	4 (2.1)	1 (0.3)
Severe pain (grade D or E)	39 (20.2)	5 (1.6)
Operative time > 60 min	28 (14.5)	22 (6.9)
Urinary retention requiring catheterization	55 (28.5)	103 (32.1)
Postoperative bleeding	5 (2.6)	4 (1.2)
Length of stay, days	9.79 ± 4.50	8.24 ± 3.60
Length of stay, median (IQR), days	9 (7–13)	7 (6–10)
Length of stay > 10 days	76 (39.4)	66 (20.6)

↓ Table 2. Unadjusted Early Postoperative Outcomes

Outcome

Milligan–Morgan (n = 193)

Stapled hemorrhoidopexy (n = 321)

Data were number (%) unless otherwise indicated. IQR: interquartile range.

Pain grade A: no pain

6 (3.1)

41 (12.8)

Pain grade B: routine regimen only

41 (21.2)

187 (58.3)

Pain grade C: 1 additional dose

107 (55.4)

88 (27.4)

Pain grade D: 2 additional doses

35 (18.1)

4 (1.2)

Pain grade E: ≥ 3 additional doses

4 (2.1)

1 (0.3)

Severe pain (grade D or E)

39 (20.2)

5 (1.6)

Operative time > 60 min

28 (14.5)

22 (6.9)

Urinary retention requiring catheterization

55 (28.5)

103 (32.1)

Postoperative bleeding

5 (2.6)

4 (1.2)

Length of stay, days

9.79 ± 4.50

8.24 ± 3.60

Length of stay, median (IQR), days

9 (7–13)

7 (6–10)

Length of stay > 10 days

76 (39.4)

66 (20.6)

↓ **Table 3.** Propensity Score–Overlap Weighted Treatment-Effect Estimates
Outcome	Weighted Milligan–Morgan	Weighted stapled hemorrhoidopexy	Difference, stapled hemorrhoidopexy–MM (95% CI)^a	Risk ratio (95% CI)	P
^aDifferences for binary outcomes are percentage points. ^bMean difference in days for length of stay. Inference used hospital-clustered sandwich variances and a t distribution with 12 degrees of freedom. P values correspond to the difference scale; risk-ratio intervals were estimated separately. Effective sample sizes were 147.3 for Milligan–Morgan and 194.6 for stapled hemorrhoidopexy. CI: confidence interval; MM: Milligan–Morgan hemorrhoidectomy.
Severe pain	17.4%	0.8%	−16.5 (−24.1 to −9.0)	0.05 (0.01–0.23)	< 0.001
Operative time > 60 min	11.6%	10.5%	−1.0 (−7.8 to 5.7)	0.91 (0.47–1.76)	0.743
Urinary retention	26.1%	34.1%	8.0 (−0.4 to 16.4)	1.31 (0.99–1.72)	0.061
Postoperative bleeding	3.0%	1.4%	−1.6 (−5.4 to 2.3)	0.48 (0.09–2.66)	0.398
Length of stay > 10 days	36.0%	24.1%	−11.9 (−23.3 to −0.4)	0.670 (0.449–1.001)	0.044
Length of stay, days	9.36	8.45	−0.92 (−2.11 to 0.28)^b	-	0.121

↓ Table 3. Propensity Score–Overlap Weighted Treatment-Effect Estimates

Outcome

Weighted Milligan–Morgan

Weighted stapled hemorrhoidopexy

Difference, stapled hemorrhoidopexy–MM (95% CI)^a

Risk ratio (95% CI)

^aDifferences for binary outcomes are percentage points. ^bMean difference in days for length of stay. Inference used hospital-clustered sandwich variances and a t distribution with 12 degrees of freedom. P values correspond to the difference scale; risk-ratio intervals were estimated separately. Effective sample sizes were 147.3 for Milligan–Morgan and 194.6 for stapled hemorrhoidopexy. CI: confidence interval; MM: Milligan–Morgan hemorrhoidectomy.

Severe pain

17.4%

0.8%

−16.5 (−24.1 to −9.0)

0.05 (0.01–0.23)

< 0.001

Operative time > 60 min

11.6%

10.5%

−1.0 (−7.8 to 5.7)

0.91 (0.47–1.76)

0.743

Urinary retention

26.1%

34.1%

8.0 (−0.4 to 16.4)

1.31 (0.99–1.72)

0.061

Postoperative bleeding

3.0%

1.4%

−1.6 (−5.4 to 2.3)

0.48 (0.09–2.66)

0.398

Length of stay > 10 days

36.0%

24.1%

−11.9 (−23.3 to −0.4)

0.670 (0.449–1.001)

0.044

Length of stay, days

9.36

8.45

−0.92 (−2.11 to 0.28)^b

0.121

↓ **Table 4.** Sensitivity Analyses
Analysis	Sample	Outcome	Stapled hemorrhoidopexy–MM estimate	95% CI	P
The concordant-indicator analysis excluded seven records classified from procedure-specific fields. Matched binary-outcome P values are exact McNemar tests; the length-of-stay P value is from the paired Wilcoxon test. CI: confidence interval; MM: Milligan–Morgan hemorrhoidectomy.
Primary overlap-weighted cohort	514	Severe pain	−16.5 percentage points	−24.1 to −9.0	< 0.001
Concordant-indicator overlap-weighted cohort	507	Severe pain	−16.0 percentage points	−23.7 to −8.4	< 0.001
Matched cohort	78 pairs	Severe pain	−16.7 percentage points	−25.6 to −7.7	< 0.001
Matched cohort	78 pairs	Length of stay > 10 days	−16.7 percentage points	−29.5 to −3.8	0.019
Matched cohort	78 pairs	Length of stay	−1.26 days	−2.28 to −0.24	0.008

↓ Table 4. Sensitivity Analyses

Analysis

Sample

Outcome

Stapled hemorrhoidopexy–MM estimate

95% CI

The concordant-indicator analysis excluded seven records classified from procedure-specific fields. Matched binary-outcome P values are exact McNemar tests; the length-of-stay P value is from the paired Wilcoxon test. CI: confidence interval; MM: Milligan–Morgan hemorrhoidectomy.

Primary overlap-weighted cohort

514

Severe pain

−16.5 percentage points

−24.1 to −9.0

< 0.001

Concordant-indicator overlap-weighted cohort

507

Severe pain

−16.0 percentage points

−23.7 to −8.4

< 0.001

Matched cohort

78 pairs

Severe pain

−16.7 percentage points

−25.6 to −7.7

< 0.001

Matched cohort

78 pairs

Length of stay > 10 days

−16.7 percentage points

−29.5 to −3.8

0.019

Matched cohort

78 pairs

Length of stay

−1.26 days

−2.28 to −0.24

0.008