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

Efficacy of metronidazole in reducing pain after hemorrhoidectomy: a meta-analysis of randomized controlled trials

OBJECTIVE

Pain is a significant issue in post-hemorrhoidectomy. Metronidazole is being explored as an adjunctive pain management option. This meta-analysis of randomized controlled trials (RCTs) assesses metronidazole's effectiveness and safety compared to a placebo post-hemorrhoidectomy, aiming to provide evidence-based pain management guidance.

METHOD

We conducted a systematic search of the Cochrane Library, Embase, PubMed, Web of Science, and ClinicalTrials.gov for RCTs comparing metronidazole to placebo after hemorrhoidectomy, covering the period from database inception to July 21, 2024. After screening per inclusion/exclusion criteria, study quality was assessed using Cochrane Handbook's risk of bias tool (version 5.1.0). The meta-analysis was conducted using RevMan 5.3 software, the quality of outcome indicators was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and trial sequential analysis (TSA) was employed to verify the adequacy of the sample size.

RESULTS

A total of 9 RCTs were included. The meta-analysis results showed that the pain scores on the first day post-operation [MD=-1.07, 95% CI (-1.85, -0.30), P = 0.006], the second day post-operation [MD=-1.72, 95% CI (-2.62, -0.81), P = 0.0002], the seventh day post-operation [MD=-1.73, 95% CI (-2.70, -0.76), P = 0.0005], and the fourteenth day post-operation [MD=-1.80, 95% CI (-2.67, -0.94), P < 0.0001] in the metronidazole group were lower than those in the placebo group. Additionally, the rate of additional analgesia was reduced [RR = 0.48, 95% CI (0.27, 0.84), P = 0.01]. No statistically significant differences were found between the metronidazole and placebo groups in terms of the overall incidence of complications [RR = 0.69, 95% CI (0.41, 1.16), P = 0.16] and time to return to normal activities [MD=-1.69, 95% CI (-6.58, 3.20), P = 0.50]. Sensitivity analysis indicated that the results for pain scores on the first day post-operation were unstable. High heterogeneity was observed in pain scores on the first, second, seventh, and fourteenth days post-operation, as well as in the time to return to normal activities. The TSA indicated that the sample size for the primary outcome measures had achieved the required information size (RIS), supporting the strength and dependability of the meta-analysis findings.

CONCLUSION

Metronidazole may be effective and safe in reducing postoperative pain in patients undergoing hemorrhoidectomy. However, due to the limitations of this study, further verification is needed from future large-sample, multi-center, well-designed high-quality RCTs.

CLINICAL TRIAL NUMBER

Not applicable.

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.

Chemical sphincterotomy in posthemorrhoidectomy pain relief: a meta-analysis

PURPOSE

This study aims to evaluate the pain relief function of chemical sphincterotomy in patients undergoing haemorrhoid surgery and compare, through a meta-analysis, the different drugs used to treat this condition.

METHODS

We conducted a search in databases including PubMed, EMBASE and Web of Science. The methodological quality was evaluated using the Revised Cochrane risk-of-bias tool for randomized trials (ROB2). The pain score was assessed using a visual analogue scale (VAS) on day 1, day 2, and day 7, and a meta-analysis was conducted based on the use of random effects models. In addition, the subgroup analysis was evaluated based on the kind of experimental drugs. Heterogeneity and publication bias were assessed.

RESULTS

Fourteen studies with a total of 681 patients were included in this meta-analysis, and all studies were randomized controlled trials RCTs. Chemical sphincterotomy showed better pain relief function than placebo on day 1 (SMD: 1.16, 95% CI 0.52 to 1.80), day 2 (SMD: 2.12, 95% CI 1.37 to 2.87) and day 7 (SMD: 1.97, 95% CI 1.17 to 2.77) after surgery. In the subgroup meta-analysis, we found that different drugs for chemical sphincterotomy provided different pain relief.

CONCLUSION

Chemical sphincterotomy effectively relieves pain after haemorrhoidectomy, and calcium channel blockers have the best effect.

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 hyaluronic acid film on perianal wound healing in a rat model

Purpose

Postoperative pain and delayed wound healing are the main complications following anal surgery associated with poor quality of life. Hyaluronic acid (HA) supports tissue regeneration and rapid wound healing by promoting cell proliferation and migration. We investigated the effects of HA on perianal wound healing in a rat model.

Methods

Forty-eight 8-week-old Sprague-Dawley rats with perianal wounds created by biopsy punch were divided into 3 groups: simple dressing with gauze (control), dressing with topical HA film, and dressing with topical HA gel. HA agents were not reapplied postoperatively. Wound healing was evaluated by measuring the healed area, and histological analyses were randomly performed using hematoxylin and eosin and Masson trichrome staining.

Results

Fewer mean days were required for complete wound healing in the HA film and HA gel groups than in the control group (11.6 vs. 11.9 vs. 13.8 days, respectively; P = 0.010). The healed area in the HA film group on day 11 was larger than that in the HA gel and control groups (80.2% vs. 61.9% vs. 53.2%, respectively; P < 0.001). Histologically, the HA film group showed accelerated reepithelialization, a rapid transition to lymphocyte-predominant inflammation, and increased fibroblastic proliferation and collagen deposition compared to the other groups. There was no treatment-related toxicity in the HA application groups.

Conclusion

Topical application of HA film to perianal wounds improves the wound healing rate in a rat model. This finding suggests a potential benefit of HA film application in promoting wound healing after anal surgery in humans.

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.

A prospective randomized double-blind study of pain control by topical calcium channel blockers versus placebo after Milligan-Morgan hemorrhoidectomy

INTRODUCTION

Post-hemorrhoidectomy pain is significantly associated with a hypertonicity of the internal anal sphincter. We evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. Purpose of our study was to determine difference in extent of pain control by application of topical calcium channel blocker (diltiazem 2%) versus placebo ointment.

METHODS

This was a prospective randomized double-blind clinical study conducted at Sawai Man Singh Hospital, Jaipur, from May 2016 to May 2017. Sixty patients, who had undergone hemorrhoid, were randomly assigned to receive 2% diltiazem ointment (n = 30) or a placebo ointment (n = 30) postoperatively. Ointments were applied to the perianal region three times daily for 7 days. Pain scores were recorded using visual analog scale at 6, 24, and 48 h and seventh day postoperatively and number of analgesic doses consumed by patients in the first 3 days.

RESULTS

Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week (p < 0.001) except for reading at 6 h. Also, there was significantly less number of analgesic doses consumed in the diltiazem group compared to the placebo group.

CONCLUSION

Perianal application of 2% diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial.

Efficacy of Mesoglycan in Pain Control after Excisional Hemorrhoidectomy: A Pilot Comparative Prospective Multicenter Study

INTRODUCTION

Various pain management strategies for patients undergoing open excisional hemorrhoidectomy have been proposed, yet postoperative pain remains a frequent complaint.

OBJECTIVE

To determine whether mesoglycan (30 mg two vials i.m. once/day for the first 5 days postoperative, followed by 50 mg 1 oral tablet twice/day for 30 days) would reduce the edema of the mucocutaneous bridges and thus improve postoperative pain symptoms.

PATIENTS AND METHODS

For this prospective observational multicenter study, 101 patients undergoing excisional diathermy hemorrhoidectomy for III-IV degree hemorrhoidal disease were enrolled at 5 colorectal referral centers. Patients were assigned to receive either mesoglycan (study group SG) or a recommended oral dose of ketorolac tromethamine of 10 mg every 4-6 hours, not exceeding 40 mg per day and not exceeding 5 postoperative days according to the indications for short-term management of moderate/severe acute postoperative pain, plus stool softeners (control group CG).

RESULTS

Postoperative thrombosis (SG 1/48 versus CG 5/45) (p < 0.001) and pain after rectal examination (p < 0.001) were significantly reduced at 7-10 days after surgery in the mesoglycan-treated group, permitting a faster return to work (p < 0.001); however, in the same group, the incidence of postoperative bleeding, considered relevant when needing a readmission or an unexpected outpatient visit, was higher, possibly owing to the drug's antithrombotic properties.

CONCLUSIONS

The administration of mesoglycan after an open diathermy excisional hemorrhoidectomy can reduce postoperative thrombosis and pain at 7-10 days after surgery, permitting a faster return to normal activities.

Xiaozhi decoction reduced posthemorrhoidectomy pain and analgesic medication consumption: a prospective study

Objective

The aim of this study was to investigate the effect of Xiaozhi decoction (XZD) on posthemorrhoidectomy pain and analgesic medication consumption.

Methods

From May 2013 to March 2015, 315 patients who underwent open hemorrhoidectomy in our hospital were enrolled in this study, of whom, 160 patients were randomly assigned to accept sitz bath with warm water after hemorrhoidectomy (control group) and 155 patients were randomly assigned to accept sitz bath with XZD (XZD group) after hemorrhoidectomy. Postoperative pain at 12 hours after surgery and on postoperative days (PODs) 1, 2, 7, 14 and 28 was evaluated by Visual Analog Scale (VAS). Pain on defecation on PODs 1, 2, 7, 14 and 28 was also recorded using the VAS. The consumption of analgesics was also analyzed.

Results

No significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the XZD group was significantly lower on POD 2 (6.04±1.11 vs 6.33±1.14, P=0.0229), POD 7 (3.35±0.75 vs 4.22±0.87, P=0.0000) and POD 14 (2.87±0.64 vs 3.64±0.77, P=0.0000) than that of the control group. Similarly, patients in the XZD group experienced significantly less pain on defecation on POD 2 (5.02±1.34 vs 5.43±1.56, P=0.0130), POD 7 (3.08±1.17 vs 3.52±1.29, P=0.0017) and POD 14 (2.31±0.85 vs 2.68±0.99, P=0.0004). Patients in the XZD group consumed significantly less analgesic medication on POD 2 (P=0.0136), POD 7 (P=0.0074) and POD 14 (P=0.0046) than the control group.

Conclusion

XZD could effectively relieve postoperative pain and reduce analgesic medication consumption after hemorrhoidectomy.

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.

Topical diltiazem for pain after closed hemorrhoidectomy

BACKGROUND

Anal sphincter spasm contributes to the appearance of postoperative pain following hemorrhoidectomy.

AIM

To determine the efficacy of topical diltiazem in the control of post-hemorrhoidectomy pain.

MATERIAL AND METHODS

A randomized, prospective, experimental, double-blind study was conducted on 2 groups of patients in the postoperative period of closed hemorrhoidectomy. Each group consisted of 17 patients. Group A received topical diltiazem in the anal region 3 times a day and group B received a placebo. Ketorolac was administered to both groups as rescue therapy.

RESULTS

In group A, the mean score on the visual analog scale was 2.97±1.18cm at 24h, 1.51±1.18cm at 48h, and 0.84±0.92cm at 72h. In group B, it was 6.82±1.9cm at 24h, 5.3±1.66cm at 48h, and 4.32±2.13cm at 72h (P<.001, 95% CI). The mean number of analgesic doses in group A was 2.41±0.87 at 24h, 1.11±0.85 at 48h, and 0.94±0.96 at 72h. In group B, it was 3.82±0.52 at 24h, 3.64±0.70 at 48h, and 2.88±1.26 at 72h (P<.001, 95% CI).

CONCLUSIONS

In this study, topical administration of diltiazem resulted in a statistically significant reduction of postoperative pain in patients that underwent closed hemorrhoidectomy.

The Effect of Early Warm Plastic Bag Application on Postoperative Pain after Hemorrhoidectomy: A Prospective Randomized Controlled Trial

Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients were randomly divided into warm plastic bag and control groups by using sealed envelopes, which were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard Milligan-Morgan hemorrhoidectomy using Ligasure™. Although the study group received the warm bag application, the control group did not receive such a treatment. Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation. Additionally, a significant difference existed between the two groups in terms of the need for additional anesthesia. Local thermal application appears to be a safe and effective method for pain relief after hemorrhoidectomy.

Pain management in ambulatory surgery-a review

Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.

Predictors of early postoperative pain after stapled haemorrhoidopexy

AIM

Moderate to severe pain after stapled haemorrhoidopexy (SH) is not uncommon. This study was designed to identify the predictors of postoperative pain after SH in a single centre.

METHOD

Seventy-six patients with Grade II to IV haemorrhoids who underwent SH were selected from a prospectively compiled database. Preoperative data, including patient characteristics, manometry results and surgical data, were documented. Pain was evaluated during the first 24 h after the operation. Its intensity was classified into three grades according to the visual analogue scale (VAS) score: mild (VAS ≤ 3), moderate (VAS >3 to <5) and severe (VAS ≥ 5). Analgesics were not routinely given but were administered if the patient had moderate or severe pain. Both univariate and multivariate analyses were used to determine the predictors of postoperative pain.

RESULTS

Moderate and severe pain was noted in 43 (58.9%) patients. No patient was readmitted due to persistent anal pain during the month following discharge. Postoperative pain was significantly associated with gender (P = 0.017), age (P = 0.014), first initial sensory volume (P = 0.023) and constipation (P = 0.005) in univariate analysis. Multivariate analysis identified male gender as an independent predictor of postoperative moderate to severe pain (P = 0.037, OR = 3.1, 95% CI 1.07-9.09). The initial sensory volume and preoperative coexisting constipation were negative predictors of postoperative moderate to severe pain after SH (P = 0.037, OR = 0.320, 95% CI 0.110-0.934, and P = 0.036, OR = 0.255, 95% CI 0.071-0.913, respectively).

CONCLUSION

Male gender and the initial sensory volume are predictors of postoperative pain after SH. Anal manometry is recommended before the SH procedure. An active analgesia protocol should be considered for male patients with a low initial sensory volume after SH.

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.

Topical glyceryl trinitrate ointment for pain related to anal hypertonia after stapled hemorrhoidopexy: a randomized controlled trial

BACKGROUND

Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles.

OBJECTIVE

We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy.

DESIGN

This was a single-blind, parallel-group, randomized controlled trial.

SETTING

The study was conducted at a university teaching hospital in Rome, Italy.

PATIENTS

Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded.

INTERVENTIONS

Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days.

MAIN OUTCOME MEASURES

Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy.

RESULTS

Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5 ± 1.0 vs 4.0 ± 1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4 ± 7.4 mmHg vs 85.6 ± 7.9 mmHg, p < 0.0001).

LIMITATIONS

GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded.

CONCLUSION

Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

Efficacy of cholestyramine ointment in reduction of postoperative pain and pain during defecation after open hemorrhoidectomy: results of a prospective, single-center, randomized, double-blind, placebo-controlled trial

BACKGROUND

The aim of the present study was to evaluate the efficacy of cholestyramine ointment (15 %) in reducing postoperative pain at rest and during defecation after open hemorrhoidectomy.

METHODS

A total of 91 patients with third and fourth degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either cholestyramine ointment or placebo immediately after surgery, 12 h after surgery, and then every 8 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of tramadol consumption.

RESULTS

The cholestyramine group had less postoperative pain than the placebo group at the 24th hour (1.84 ± 2.54 vs. 4.07 ± 3.35; P = 0.001) and 48th hour (0.18 ± 0.88 vs. 3.57 ± 3.45; P < 0.001) and less pain during defecation starting at the 48th hour (2.28 ± 2.96 vs. 4.77 ± 4.09; P = 0.001). Similarly, the average tramadol consumption at hours 24 and 48 was significantly lower for the cholestyramine group (5.32 ± 21.45 vs. 43.18 ± 61.56 mg at 24 h, and 4.48 ± 16.65 vs. 57.63 ± 65.47 mg at 48 h; P < 0.001). The only adverse event was pruritus, which had a lower frequency in the cholestyramine group but the difference was not significant until postoperative week 4 (P < 0.001).

CONCLUSIONS

Compared with placebo, cholestyramine ointment (15%) reduced postoperative pain at rest and on defecation, and consequently lowered the analgesic requirement after open hemorrhoidectomy.

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.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation

BACKGROUND

In hemorrhoidectomy, pedicle coagulation has been claimed to be associated with less postoperative pain compared with pedicle ligation.

OBJECTIVE

This study was designed to compare the effects of pedicle ligation vs pedicle coagulation on postoperative pain in patients undergoing diathermy excisional hemorrhoidectomy.

DESIGN

The study was conducted as a single-blind prospective randomized clinical trial.

SETTING

Patients were treated at a single tertiary-level teaching hospital (Main University Hospital) in Alexandria, Egypt, from February 2009 to October 2010.

PATIENTS

Patients with symptomatic grade III or IV hemorrhoids were eligible.

INTERVENTION

Patients were randomly allocated to receive either pedicle coagulation or pedicle ligation during 3-quadrant diathermy excision hemorrhoidectomy.

MAIN OUTCOME MEASURES

Patients reported postoperative pain daily on a visual analog scale (0-10, with 10 corresponding to the most severe pain) during the first 10 postoperative days. On-demand parenteral analgesic requirements were recorded during the first 24 hours after surgery. Operative time, postoperative complications, and wound healing rates at 6 weeks postoperatively were also recorded.

LIMITATIONS

No a priori power calculation could be performed, so it was not possible to tell whether nonsignificant differences were real or a result of chance.

RESULTS

A total of 136 patients were randomly assigned, and 120 patients completed the study (60 in each group). The overall median pain score for the first 10 postoperative days was significantly lower in the pedicle coagulation group than in the pedicle ligation group (4.65 vs 6.56, P < .001), and daily median pain scores were significantly lower for pedicle coagulation than for pedicle ligation throughout the first 6 postoperative days (P < .001). Postoperative pain scores followed different courses in the 2 groups. In the coagulation group, pain levels were lowest during the first 3 postoperative days, increasing from day 4 and then falling after day 8. In the ligation group, pain levels were highest during the first 4 postoperative days, then gradually decreased. The median number of analgesic ampoules required during the first 24 hours was also significantly lower for pedicle coagulation than for ligation: 1 (range, 0-3) vs 3 (range, 1-3); P < .001). The median operative time was 15 (range, 14-20) minutes with coagulation and 14.5 (range, 12-18) minutes with ligation (P < .001). No significant differences were observed in the incidence of postoperative complications or wound healing rates at 6 weeks postoperatively. No anal stenoses or recurrences were observed.

CONCLUSIONS

Pedicle coagulation is safe and provides a superior alternative to pedicle ligation by decreasing postoperative pain in the first 6 postoperative days, as well as reducing parenteral analgesic requirements during the first 24 hours postoperatively.

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.

Effects of Aloe vera cream on posthemorrhoidectomy pain and wound healing: results of a randomized, blind, placebo-control study

OBJECTIVE

Aloe vera is an herbal medicine, which has wound healing effects in burn injury. This study assessed the effects of Aloe vera cream in reducing postoperative pain, postdefection pain, and its promotion of wound healing after open hemorrhoidectomy.

DESIGN

A prospective, randomized, double-blind, placebo-controlled trial was conducted comparing the effects of a cream containing Aloe vera versus a placebo cream on posthemorrhoidectomy pain. The study preparations were applied by patients to the surgical site 3 times per day for 4 weeks after hemorrhoidectomy. Pain was assessed with a visual analog scale immediately postoperatively and at hours 12, 24, and 48 after surgery and at weeks 2 and 4. Wound healing was examined and evaluated at the end of 2 and 4 weeks. The use of analgesics was recorded.

RESULTS

Forty-nine (49) patients were randomly assigned to receive aloe (n = 24) or placebo (n = 25). Patients in the topical aloe cream group had significantly less postoperative pain at hours 12, 24, and 48 hours and at 2 weeks. Aloe cream reduced the pain after defecation in 24 and 48 hours postsurgery (p < 0.001). Wound healing at the end of the second postoperative week was significantly greater in the aloe group compared with the placebo group (p < 0.001). Patients required fewer additional analgesics posthemorrhoidectomy (p < 0.001).

CONCLUSIONS

Application of Aloe vera cream on the surgical site is effective in reducing postoperative pain both on resting and during defecation, healing time, and analgesic requirements in the patients compared with the placebo group.

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.