Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy

Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial

PURPOSE

Pain and reduced quality of life (QoL) are major subjects of interest after surgery for hemorrhoids. The aim of this study was to find predictive parameters for postoperative pain and QoL after hemorrhoidectomy.

METHODS

This is a follow-up analysis of data derived from a multicenter randomized controlled trial including 770 patients, which examines the usefulness of tamponade after hemorrhoidectomy. Different pre-, intra-, and postoperative parameters were correlated with pain level assessed by NRS and QoL by the EuroQuol.

RESULTS

At univariate analysis, relevant (NRS > 5/10 pts.) early pain within 48 h after surgery was associated with young age (≤ 40 years, p = 0.0072), use of a tamponade (p < 0.0001), relevant preoperative pain (p = 0.0017), pudendal block (p < 0.0001), and duration of surgery (p = 0.0149). At multivariate analysis, not using a pudendal block (OR 2.64), younger age (OR 1.55), use of a tamponade (OR 1.70), and relevant preoperative pain (OR 1.56) were significantly associated with relevant early postoperative pain. Relevant pain on day 7 was significantly associated only with relevant early pain (OR 3.13, p < 0.001). QoL overall remained at the same level. However, n = 229 (33%) patients presented an improvement of QoL and n = 245 (36%) an aggravation. Improvement was associated with a reduction of pain levels after surgery (p < 0.0001) and analgesia with opioids (p < 0.0001).

CONCLUSION

Early relevant pain affects younger patients but can be prevented by avoiding tamponades and using a pudendal block. Relevant pain after 1 week is associated only with early pain. Relief in preexisting pain and opioids improve QoL.

TRIAL REGISTRATION

DRKS00011590 12 April 2017.

Comparison of ointment-based agents after excisional procedures for hemorrhoidal disease: a network meta-analysis of randomized controlled trials

INTRODUCTION

Efficient postoperative pain control is important after hemorrhoidal surgery. Although several locally applied medications have been used, current evidence regarding the optimal strategy is still conflicting. This network meta-analysis assessed analgesic efficacy and safety of the various topical medications in patients submitted to excisional procedures for hemorrhoids.

METHODS

The present study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The last systematic literature screening was performed at 15 June 2023. Comparisons were based on a random effects multivariate network meta-analysis under a Bayesian framework.

RESULTS

Overall, 26 RCTs and 2132 patients were included. Regarding postoperative pain, EMLA cream (surface under the cumulative ranking curve (SUCRA) 80.3%) had the highest ranking at 12-h endpoint, while aloe vera cream (SUCRA 82.36%) scored first at 24 h. Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation. Lidocaine (SUCRA 87.9%) displayed the best performance regarding overall morbidity rates.

CONCLUSIONS

Due to the inconclusive results and several study limitations, further RCTs are required.

Can Targeting Sphincter Spasm Reduce Post-Haemorrhoidectomy Pain? A Systematic Review and Meta-Analysis

BACKGROUND

Haemorrhoidectomy is often complicated by significant post-operative pain, to which spasm of the internal anal sphincter is thought to be a contributing factor. This study appraises the evidence behind interventions aimed at lowering sphincter spasm to relieve post-haemorrhoidectomy pain.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-analyses compliant systematic review was conducted. Medline, EMBASE, and CENTRAL databases were systematically searched. All RCTs which compared interventions targeting the internal anal sphincter to relieve pain post excisional haemorrhoidectomy were included. The primary outcome measure was pain on the visual analogue scale.

RESULTS

Of the initial 10,221 search results, 39 articles were included in a qualitative synthesis, and 33 studies were included in a meta-analysis. Topical glyceryl trinitrate (GTN) reduced pain on day 7 (7 studies, 485 participants), with a mean difference and 95% confidence interval (MD, 95% CI) of -1.34 (-2.31; -0.37), I² = 91%. Diltiazem reduced pain on day 3 on the VAS, and the MD was -2.75 (-398; -1.51) shown in five studies (n = 227). Botulinum toxin reduced pain on day 7, in four studies with 178 participants, MD -1.43 (-2.50; -0.35) I² = 62%. The addition of Lateral Internal Sphincterotomy to haemorrhoidectomy reduced pain on day 2 in three studies with 275 participants, MD of -2.13 (-3.49; -0.77) I² = 92%. The results were limited by high heterogeneity and risk of bias.

CONCLUSION

Evidence suggests that lateral sphincterotomy, administration of botulinum toxin and the application of topical diltiazem or GTN can reduce post-operative pain after haemorrhoidectomy. Lateral sphincterotomy should not be routinely used due to the risk of incontinence.

Efficacy of postoperative oral metronidazole for haemorrhoidectomy pain: a randomized double-blind, placebo-controlled trial

AIM

The aim of this work was to examine the efficacy of oral metronidazole in reducing posthaemorrhoidectomy pain versus placebo.

METHOD

Forty patients were randomized to either metronidazole and standard care or placebo and standard care (21 metronidazole, 19 placebo) in a double-blinded, randomized controlled trial. The main outcome measure was posthaemorrhoidectomy pain scores over 21 days, measured on a 10-point Likert scale.

RESULTS

There were no significant differences between groups with regards to age, gender, smoking status, self-reported general health or quality of life, haemorrhoid-related pain, haemorrhoid-related impact on quality of life, reported satisfaction with surgery, experience of surgery, median overall pain score or likelihood of recommending surgery to others. For reported median worst pain scores and defaecation-related pain, a trend to significance was identified between groups on days 16 and 18-21, with the metronidazole group reporting less pain. However, these differences were not significant when prespecified Bonferroni correction criteria were used. Using multilevel mixed effects modelling, the impact of time on median worst pain score was identified to be highly significant (P < 0.0001) whereas treatment allocation (placebo versus metronidazole) did not significantly affect the improvement in patients' reported pain (P = 0.8837).

CONCLUSION

Our data do not support the hypothesis that postoperative metronidazole has a clinically meaningful effect on posthaemorrhoidectomy pain. This study adds to the previous literature, and implies that it should not be routinely used as an adjunct to analgesia.

Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

Post-operative pain following excisional haemorrhoidectomy poses a particular challenge for patient recovery, as well as a burden on hospital resources. There appears to be an increasing role for topical agents to improve this pain, but their efficacy and safety have not been fully assessed. This systematic review aims to assess all topical agents used for pain following excisional haemorrhoidectomy.

METHODS

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently assessed MEDLINE, EMBASE, and CENTRAL databases to 27 June 2019. All randomised controlled trials (RCTs) in English that investigated topical agents following excisional haemorrhoidectomy were included. Meta-analysis was performed using Review Manager, version 5.3.

RESULTS

A total of 3639 records were identified. A final 32 RCTs were included in the qualitative analysis. Meta-analysis was performed on 9 RCTs that investigated glyceryl trinitrate (GTN) (5 for diltiazem, 2 for metronidazole and 2 for sucralfate). There were mixed significant changes in pain for GTN compared with placebo. Diltiazem resulted in significant reduction of pain on post-operative days 1, 2, 3 and 7 (p < 0.00001). Metronidazole resulted in significant reduction of pain on days 1 (p = 0.009), 7 (p = 0.002) and 14 (p < 0.00001). Sucralfate resulted in signification reduction of pain on days 7 and 14 (both p < 0.00001).

CONCLUSION

Topical diltiazem, metronidazole and sucralfate appear to significantly reduce pain at various timepoints following excisional haemorrhoidectomy. GTN had mixed evidence. Several single trials identified other promising topical analgesics.

Randomized clinical trial with topical diltiazem for post-hemorrhoidectomy wound healing

Anal sphincter spasm contributes to the delay in surgical wound healing after hemorrhoidectomy. A prospective, experimental, randomized, double-blind trial was conducted on two groups of patients that underwent closed hemorrhoidectomy. There were 26 patients in each group. Group A received topical diltiazem in the anal region three times a day. Group B received a placebo. Cicatrization time was documented for 6 weeks through digital photography. Mean healing time for the group treated with diltiazem was 3.19 weeks (22.33±0.884 days) and 3.92 weeks (27.44±1.130 days) for the control group (p=0.012 95% CI). At week three, the wounds in 73.07% of the patients in the diltiazem group had healed, compared with 46.15% of the patients in the control group.

Nitrates for the prevention of cardiac morbidity and mortality in patients undergoing non-cardiac surgery

BACKGROUND

Cardiac complications are not uncommon in patients undergoing non-cardiac surgery, especially in patients with coronary artery disease (CAD) or at high risk of CAD. Perioperative cardiac complications can lead to mortality and morbidity, as well as higher costs for patient care. Nitrates, which are among the most commonly used cardiovascular drugs, perform the function of decreasing cardiac preload while improving cardiac blood perfusion. Sometimes, nitrates are administered to patients undergoing non-cardiac surgery to reduce the incidence of cardiac complications, especially for patients with CAD. However, their effects on patients' relevant outcomes remain controversial.

OBJECTIVES

• To assess effects of nitrates as compared with other interventions or placebo in reducing cardiac risk (such as death caused by cardiac factors, angina pectoris, acute myocardial infarction, acute heart failure and cardiac arrhythmia) in patients undergoing non-cardiac surgery.• To identify the influence of different routes and dosages of nitrates on patient outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Chinese BioMedical Database until June 2014. We also searched relevant conference abstracts of important anaesthesiology or cardiology scientific meetings, the database of ongoing trials and Google Scholar.We reran the search in January 2016. We added three potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into our formal review findings for the review update.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing nitrates versus no treatment, placebo or other pharmacological interventions in participants (15 years of age and older) undergoing non-cardiac surgery under any type of anaesthesia.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. Two review authors selected trials, extracted data from included studies and assessed risk of bias. We resolved differences by discussion and, when necessary, sought help and suggestions from a third review author. We used a random-effects model for data analysis.

MAIN RESULTS

We included 27 randomized controlled trials (RCTs) (8244 participants analysed). Investigators reported 12 different comparisons of three different nitrates (nitroglycerin, isosorbide dinitrate and nicorandil) versus no treatment, placebo or other pharmacological interventions. All participants were older than 15 years of age. More than half of the trials used general anaesthesia. Surgical procedures in most trials were at low to moderate risk for perioperative cardiac complications. Only two comparisons including three studies reported the primary outcome - all-cause mortality up to 30 days post operation. Researchers reported other morbidity outcomes and adverse events in a variable and heterogeneous way, resulting in limited available data for inclusion in the meta-analysis. We determined that the overall methodological quality of included studies was fair to low, in accordance with risk of bias in most domains.In summary, we found no difference in the primary outcome - all-cause mortality up to 30 days post operation - when nitroglycerin was compared with no treatment (one study, 60 participants, 0/30 vs 1/30; (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.87, very low-quality evidence based on GRADE criteria) or with placebo (two studies, 89 participants, 1/45 vs 0/44; RR 2.81, 95% CI 0.12 to 63.83, very low-quality evidence). Regarding our secondary outcomes, we noted no statistically significant differences in angina pectoris, acute myocardial infarction, acute heart failure, cardiac arrhythmia or cardiac arrest in any comparisons. In comparisons versus nitroglycerin, although more events of cardiac ischaemia were observed in participants receiving no treatment or placebo, we found no statistically significant differences in any comparisons, except the comparison of nicorandil versus placebo. One study revealed a potential dose-dependent protective effect of nicorandil for cardiac ischaemia.Adverse events were reported in a heterogeneous way among the comparisons. In general, more participants treated with nitrates had hypotension, tachycardia and headache, but investigators reported no statistically significant differences between groups in any comparisons.

AUTHORS' CONCLUSIONS

This systematic review suggests that nitroglycerin or isosorbide dinitrate is not associated with improvement in mortality and cardiac complications among patients undergoing non-cardiac surgery. Limited evidence suggests that nicorandil may reduce the risk of cardiac ischaemia in participants undergoing non-cardiac surgery. Additional studies are needed to consolidate the evidence.However, the data included in many of the analyses in this review are sparse - that is, adequate data are few - resulting in very low power to detect differences between nitrates and comparators. Thus, a more objective conclusion would state that available evidence is insufficient to show whether nitrates are associated with improvement in mortality and cardiac complications among patients undergoing non-cardiac surgery.Over the past decade, no high-quality studies have focused on association of cardiac mortality and morbidity with use of nitrates during non-cardiac surgery. This review underlines the need for well-designed trials in this field.

Hemorrhoidectomy - making sense of the surgical options

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Randomized single-blind clinical trial of intradermal methylene blue on pain reduction after open diathermy haemorrhoidectomy

BACKGROUND

Open haemorrhoidectomy has been associated with considerable postoperative pain and discomfort. Perianal intradermal injection of methylene blue has been shown to ablate perianal nerve endings and may bring about temporary pain relief after haemorrhoidectomy. We hypothesized that the administration of intradermal methylene blue would reduce postoperative pain during the initial period after surgery.

METHOD

A randomized, prospective, single-blind placebo-controlled trial was conducted. Patients were randomized to intradermal injection at haemorrhoidectomy of either 4 ml 1% methylene blue and 16 ml 0.5% marcaine or of 16 ml 0.5% marcaine and 4 ml saline prior to surgical dissection. Patients were asked to fill in a pain diary with a visual analogue scale. The primary outcome measure was pain score and analgesic use. Secondary outcomes were complications.

RESULTS

There were 37 patients in the methylene blue arm and 30 patients in the placebo arm. There were no statistically significant differences in the sex, type of haemorrhoid, number of haemorrhoids excised, duration of surgery or hospital stay. The mean pain scores were significantly lower and the use of paracetamol was also significantly less in the methylene blue group during the first three postoperative days. The risk ratio of acute urinary retention occurring when methylene blue was not used was 2.320 (95% CI 1.754-3.067). Other complication rates were not significantly different.

CONCLUSION

Perianal intradermal injection of methylene blue was useful in reducing the initial postoperative pain of open haemorrhoidectomy.

Glyceryl trinitrate ointment did not reduce pain after stapled hemorrhoidectomy: a randomized controlled trial

Medications, including topical 0.2% glyceryl trinitrate (GTN), can reduce anal spasm and pain after excisional hemorrhoidectomy. GTN after stapled hemorrhoidopexy was compared with routine postoperative management. Patients with symptomatic grade 3/4 hemorrhoids were recruited. After stapled hemorrhoidopexy, residual perianal skin tags were excised as appropriate. Those requiring double purse-string mucosectomy were excluded. Postoperative pain, pain duration, and complications were assessed. One hundred ten patients (74 men; mean age 50.6 years) were enrolled in the control group and 100 patients (57 men; mean age 49.8 years) in the GTN group. Maximum pain was higher in the GTN group (P  =  0.015). There were no differences between the two groups in residual perianal skin tags requiring excision, postoperative complications, recurrence rates, follow-up period, average pain, duration of pain, or satisfaction scores. Sixteen GTN patients were noncompliant due to side effects. None had persistent perianal skin tags. GTN did not reduce postoperative pain after stapled hemorrhoidectomy.

Spasmolysis therapy after Milligan-Morgan haemorrhoidectomy

Pain after hemorrhoid surgery is the most common postoperative complication, significantly influencing patients' quality of life. Severe postoperative pain may still occur and continues to be the major concern of patients who are unwilling to undergo the surgery. Anal sphincter hypertonicity has been identified as a major influencing factor for increased pain after surgery. Since persistent internal anal sphincter spasm is a major factor responsible for the genesis of pain, relieving internal anal sphincter spasm is considered to be an effective method to ease the pain. Currently, multiple treatments have been used to manage pain after haemorrhoidal surgery, including sphincterotomy, botulinum toxin, glyceryl trinitrate, and calcium channel blockers. Haemorrhoidectomy coupled with spasmolysis therapy can significantly reduce the incidence of postoperative complications and improve the quality of life.

Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study

INTRODUCTION

Conventional haemorrhoidectomy (CH) is well known to cause significant post-operative pain and delayed return to daily activities. Both surgical wounds and sphincterial apparatus spasms are likely responsible for the pain. In this study, we evaluated the role of glyceryl trinitrate ointment (GTN) in reducing post-operative pain, ameliorating wound healing and recovery after CH.

PATIENTS AND METHODS

Between 01/08 and 12/11, 203 patients with symptomatic haemorrhoids were enrolled in the study and received (103 patients) or not (100 patients) 0.4 % GTN ointment for 6 weeks after surgery. Pain was assessed using a 10-cm linear visual analogue scale (VAS). Data on post-operative pain, wound secretion and bleeding, return to normal activities and complications were recorded. Data were analysed using Fisher's exact and Mann-Whitney tests.

RESULTS

GTN-treated group experienced significantly less pain during the first week after surgery (p < 0.0001). This difference was more evident starting from post-operative day 4 (p < 0.0001). A significant higher percentage of untreated patients experienced severe pain (mean VAS score > 7) (10 % vs 31 %). There were significant differences in terms of secretion time (p = 0.0052) and bleeding time (p = 0.02) in favor of GTN. In addition, the duration of itching was less in the GTN group (p = 0.0145). Patients treated with GTN were able to an early return to daily activities compared to untreated (p < 0.0001). Fifteen GTN-treated patients (14.6 %) discontinued the application because of local discomfort and headache.

CONCLUSIONS

GTN ointment enhances significantly post-operative recovery, reducing pain in terms of duration and intensity. This effect might be secondary to a faster wound healing expressed by reduced secretion, bleeding and itching time.

[Pain management after hemorrhoidectomy. Patient-controlled analgesia vs conventional pain therapy]

PURPOSE

The aim of this randomized non-blinded study was to assess the pain management after hemorrhoidectomy using patient-controlled analgesia (PCA).

PATIENTS AND METHODS

In this study following Ferguson hemorrhoidectomy 38 patients were administered either standard pain management with oral non-steroidal analgesics (control n = 18) or additional PCA with piritramid intravenously by infusion pump within the first 24 h (PCA n = 19).

RESULTS

The pain score within the first 24 h after surgery was significantly lower in patients with PCA compared to control patients (maximum pain within 12 h postoperatively: mean PCA 2.6 versus control 5.7). During the first 24 h postoperatively, patients with PCA were significantly more satisfied with the pain management than the control patients.

CONCLUSIONS

Pain after hemorrhoidectomy can be reduced within the first 24 h using PCA. Patients are significantly more satisfied with PCA than with standard medication.

Phlebotonics for haemorrhoids

BACKGROUND

Haemorrhoids are variceal dilatations of the anal and perianal venous plexus and often develop secondary to the persistently elevated venous pressure within the haemorrhoidal plexus (Kumar 2005). Phlebotonics are a heterogenous class of drugs consisting of plant extracts (i.e. flavonoids) and synthetic compounds (i.e. calcium dobesilate). Although their precise mechanism of action has not been fully established, they are known to improve venous tone, stabilize capillary permeability and increase lymphatic drainage. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphoedema and haemorrhoids.Numerous trials assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease suggest that there is a potential benefit.

OBJECTIVES

The aim of this review was to investigate the efficacy of phlebotonics in alleviating the signs, symptoms and severity of haemorrhoidal disease and verify their effect post-haemorrhoidectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 2011 issue 9 , MEDLINE (1950 to September 2011) and EMBASE (1974 to September 2011).

SELECTION CRITERIA

Only randomised controlled trials evaluating the use of phlebotonics in treating haemorrhoidal disease were used. No cross-over or cluster-randomized trials were included for analysis and any trial which had a quasi-random method of allocation was excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and analysed the eligibility of the data for inclusion. Disagreements were resolved by meaningful discussion.

MAIN RESULTS

We considered twenty-four studies for inclusion in the final analysis. Twenty of these studies (enrolling a total of 2344 participants) evaluated the use of phlebotonics versus a control intervention. One of these twenty studies evaluated the use of phlebotonics with a medical intervention and another study with rubber band ligation.The remaining four studies included two which compared different forms of phlebotonics with each other, one study which evaluated phlebotonics with a medical intervention and one study which compared the use of phlebotonics with infrared photocoagulation. Eight studies were excluded for various reasons including poor methodological quality.Phlebotonics demonstrated a statistically significant beneficial effect for the outcomes of  pruritus (OR 0.23; 95% CI 0.07 to 0.79) (P=0.02), bleeding (OR 0.12; 95% CI 0.04 to 0.37) (P=0.0002), bleeding post-haemorrhoidectomy (OR 0.18; 95% 0.06 to 0.58)(P=0.004), discharge and leakage (OR 0.12; 95% CI 0.04 to 0.42) (P=0.0008) and overall symptom improvement (OR 15.99 95% CI 5.97 to 42.84) (P< 0.00001), in comparison with a control intervention. Although beneficial they did not show a statistically significant effect compared with a control intervention for pain (OR 0.11; 95% CI 0.01 to 1.11) (P=0.06), pain scores post-haemorrhoidectomy (SMD -1.04; 95% CI -3.21 to 1.12 ) (P= 0.35) or post-operative analgesic consumption (OR 0.54; 95% CI 0.30 to 0.99)(P=0.05).

AUTHORS' CONCLUSIONS

The evidence suggests that there is a potential benefit in using phlebotonics in treating haemorrhoidal disease as well as a benefit in alleviating post-haemorrhoidectomy symptoms. Outcomes such as bleeding and overall symptom improvement show a statistically significant beneficial effect and there were few concerns regarding their overall safety from the evidence presented in the clinical trials.However methodological limitations were encountered. In order to enhance our conclusion further, more robust clinical trials which take into account these limitations will need to be performed in the future.

A literature review on the role of chemical sphincterotomy after Milligan-Morgan hemorrhoidectomy

OBJECTIVE

A literature review of agents used to induce chemical sphincterotomy after hemorrhoidectomy.

METHODS

Electronic databases were searched from January 1935 to August 2010.

RESULTS

Two randomized controlled trials compared calcium channel blockers (Ca2) with placebo. Pain appeared to be less for up to 7 days, and its side-effect profile was comparable to the control group. Four randomized controlled trials examined the role of glyceryl trinitrate (GTN). GTN may be used up to 6 weeks to aid healing. Pain may be slightly less during its use and potentially offers less pain during defecation in the first 48 h. Its side-effect profile including headache appears comparable to placebo. Three randomized controlled trials investigated botulinum toxin A (BTX). BTX may be used to aid healing after hemorrhoidectomy. Pain may be less for up to a week after surgery. Its side-effect profile including incontinence to flatus appears comparable to placebo. It would be especially useful in cases where poor patient compliance is envisaged. Only one paper was found comparing BTX with GTN. BTX may be preferred over GTN due to better pain control and fewer side effects.

CONCLUSION

BTX, Ca2, and GTN may give effective pain relief for a week after hemorrhoidectomy. Their side-effect profiles are comparable to placebo.

A randomized, prospective, double-blind, placebo-controlled trial of the effect of topical diltiazem on posthaemorrhoidectomy pain

AIM

Spasm of the internal anal sphincter plays a role in haemorrhoidal disease and may be a source of anal pain after haemorrhoid surgery. In this study, we investigated the effect of topical diltiazem (DTZ) on postoperative pain following Milligan-Morgan haemorrhoidectomy.

METHOD

After haemorrhoidectomy, 33 patients were randomly assigned to receive DTZ ointment (2%; n = 16) or a placebo ointment (n = 17). Ointments were applied to the perianal region three times daily for 7 days. A Visual Analogue Scale was used to assess postoperative pain. The primary end-point was reduction in postoperative pain.

RESULTS

Patients using the DTZ cream had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week, and total and daily narcotic analgesic use was higher in the placebo group. There were no differences in morbidity between the two groups.

CONCLUSION

Perianal application of DTZ cream after haemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity.

Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing

INTRODUCTION

Glyceryl Trinitrate (GTN) ointment has been used to treat anal fissure and pain relief in haemorrhoids, but the value of its use post-haemorrhoidectomy as an analgesic and in wound healing is unclear. The side effect of headache has often been an associated problem. Therefore, a meta-analysis of randomised controlled trials was carried out investigating the role of GTN post-haemorrhoidectomy as an analgesic, its role in would healing and the unwanted incidence of headache.

METHOD

A structured literature search from 1966 to 2009, both paper and online, with no language barrier was carried out. 760 papers were identified and 5 randomised control trials which met the entry criteria were included in this study.

RESULTS

A total of 333 patients were included in the meta-analysis. The results revealed that GTN ointment was statistically significant in reducing pain on Day 3 and 7 compared to the placebo group. Day 3 shows a pain score of - 1.51 (p value of 0.029) and Day 7 by - 1.66 (p value of 0.014) respectively. However, it was not significant in reducing pain on Day 1. The Odds ratio for wound healing after GTN treatment at 3 weeks was 3.57 (P < 0.0001) when compared to the placebo group. Side effect of headache was not statistically significant.

CONCLUSION

This meta-analysis has shown that GTN ointment used post-haemorrhoidectomy has a significant analgesic effect in the intermediate time period (ie. Days 3-7). It also significantly improved wound healing at 3 weeks.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial

BACKGROUND

The present study was conducted to compare operative time, postoperative course and outcome of LigaSure hemorrhoidectomy (LH), and conventional open hemorrhoidectomy (OH) for prolapsed hemorrhoids.

METHODS

Eighty-four patients with grade III and IV hemorrhoids were randomized into two groups of 42 patients each; group 1 patients underwent LH whereas group 2 patients underwent OH. Data regarding patient demographics, operative details, postoperative pain score, amount of parenteral analgesics required, length of hospital stay, and time until return to work or normal physical activity were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. All patients had regular follow-ups every 2 weeks for the first 8 weeks postoperatively, and at 2-month intervals thereafter, for a total period of 12 months.

RESULTS

Patient demographics, clinical characteristics, and length of hospital stay were similar in both groups (P > 0.05). The mean operative time, postoperative pain score (up to 48 h), amount of parenteral analgesics required, time off work, and time needed for complete wound healing were significantly less in patients who underwent LH (P < 0.001). Both groups had similar postoperative complications except for delayed wound healing that was observed at 4 weeks postoperatively, in seven patients (16.67%) in the LH group compared to 17 patients (40.48%) in the OH group (chi(2) = 5.83, P = 0.016). Although hemorrhoid recurrence, at 1 year, was also lower among the LH group compared to the OH group (2.38 vs. 9.14%, respectively), the difference was not statistically significant (P = 0.167).

CONCLUSIONS

LH is a better alternative than conventional OH in treating prolapsed hemorrhoids (grades III and IV) since it reduces operating time, postoperative pain, and time off work, and allows surgical wounds to heal faster, with minimal comparable side effects and a low recurrence rate.

The effect of glyceryl trinitrate ointment on posthemorrhoidectomy pain and wound healing: results of a randomized, double-blind, placebo-controlled study

PURPOSE

Spasm of the internal sphincter may be a source of anal pain and delayed healing after hemorrhoidectomy. This study assessed whether glyceryl trinitrate (GTN) ointment reduces pain and promotes wound healing after hemorrhoidectomy.

METHODS

A prospective, randomized, double-blind, placebo-controlled trial was conducted comparing effects of an ointment containing GTN (0.2 percent) vs. a placebo ointment. The study preparations were self-applied by the patient to the surgical site twice per day for two weeks after the hemorrhoidectomy. Pain was assessed with a visual analog scale, and 24-hour analgesic use was recorded on postoperative days 1, 3, and 7. Complete healing was defined as complete epithelialization and evaluated at the end of the third postoperative week.

RESULTS

Sixty-nine patients were randomly assigned to receive topical 0.2 percent GTN group or placebo. Data from 30 patients in each group were available for analyses. Patients in the GTN group experienced significantly less postoperative pain than those with placebo on days 1, 3, and 7 (P < 0.05). Use of prescribed analgesics (metamizole and acetaminophen) was significantly greater for the placebo group on days 1 and 3. Wound healing at the end of the third postoperative week was significantly greater with GTN compared with placebo (76.7 percent vs. 46.7 percent, P = 0.02).

CONCLUSIONS

Compared with placebo, perianal application of 0.2 percent GTN ointment significantly decreases postoperative pain after hemorrhoidectomy and reduces analgesic requirements in the immediate postoperative period. GTN ointment also achieves more rapid healing of wounds.

Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy

BACKGROUND

Milligan-Morgan excision haem-orrhoidectomy remains a very popular treatment modality for third and fourth degree haemorrhoids due to its cost effectiveness and good long-term results. The LigaSure tissue-sealing device is an alternative technique used in haemorrhoidectomy that has been shown to produce favourable results. The aim of this study was to assess the effectiveness of the LigaSure tissue sealing device in comparison with conventional diathermy haemorrhoidectomy.

METHODS

A prospective clinical trial was conducted. Patients with newly diagnosed haemorrhoids requiring haemorrhoidectomy were randomized to either LigaSure haemorrhoidectomy or diathermy haemorrhoidectomy. Surgical technique and postoperative care was standardized. Outcome measures were operative time and bleeding, postoperative pain (measured on a visual analogue scale) and rate of wound healing.

RESULTS

We randomized 44 patients, 22 to LigaSure and 22 to diathermy; 43 patients were evaluated. They were aged between 19 and 71 years. There were no differences in patient demographics or type of haemorrhoid being operated on. LigaSure haemorrhoidectomy had a significantly lower mean operative time and intraoperative bleeding. At 3 weeks after surgery, haemorrhoidectomy performed with LigaSure had an odds ratio for complete epithelialization of 3.1 over diathermy (95% CI 1.2-8.2). There was no difference in postoperative pain.

CONCLUSION

LigaSure haemorrhoidectomy is superior to diathermy for open haemorrhoidectomy.