Combination of Topical EMLA With Local Injection of Lidocaine: Superior Pain Relief After Ferguson Hemorrhoidectomy

A Randomized Controlled Trial of Topical Analgesia Posthemorrhoidectomy (TAPH Trial)

BACKGROUND

Postoperative pain remains the greatest problem after hemorrhoidectomy. Pain is hypothesized to arise from bacterial infection, sphincter spasm, and local inflammation.

OBJECTIVE

This trial was conducted to assess the effects of metronidazole, diltiazem, and lidocaine on posthemorrhoidectomy pain.

DESIGN

A double-blinded randomized controlled factorial trial.

SETTINGS

This multicenter trial was conducted in Auckland, New Zealand.

PATIENTS

A total of 192 participants were randomly assigned (1:1:1:1) into 4 parallel arms.

INTERVENTIONS

Participants were randomly assigned into 1 of 4 groups receiving topical treatment with 10% metronidazole, 10% metronidazole + 2% diltiazem, 10% metronidazole + 4% lidocaine, or 10% metronidazole + 2% diltiazem + 4% lidocaine. Participants were instructed to apply treatment to the anal verge 3 times daily for 7 days.

MAIN OUTCOME MEASURES

The primary outcome was pain on the visual analog scale on day 4. The secondary outcomes included analgesia usage, pain during bowel movement, and functional recovery index.

RESULTS

There was no significant difference in the pain and recovery scores when diltiazem or lidocaine was added to metronidazole (score difference between presence and absence of diltiazem in the formulation: -3.69; 95% CI, -13.3 to 5.94; p = 0.46; between presence and absence of lidocaine: -5.67; 95% CI, -15.5 to 3.80; p = 0.24). The combination of metronidazole + diltiazem + lidocaine did not further reduce pain. Secondary analysis revealed a significant difference between the best (metronidazole + lidocaine) and worst (metronidazole + diltiazem + lidocaine) groups in both pain and functional recovery scores. There were no significant differences in analgesic usage, complications, or return to work between the groups. No clinically important adverse events were reported. The adverse event rate did not change in the intervention groups.

LIMITATIONS

Topical metronidazole was used in the control group rather than a pure placebo.

CONCLUSIONS

There was no significant difference in pain when topical diltiazem, lidocaine, or both were added to topical metronidazole. See Video Abstract .

CLINICALTRIALSGOV IDENTIFIER

NCT04276298.

ENSAYO CONTROLADO ALEATORIZADO DE ANALGESIA TPICA POSTERIOR A HEMORROIDECTOMA ENSAYO TAPH

ANTECEDENTES:El dolor postoperatorio sigue siendo el mayor problema tras hemorroidectomía. La hipótesis es que el dolor se debe a infección bacteriana, el espasmo esfínteriano e inflamación local.OBJETIVO:Se realizó un ensayo factorial aleatorizado y controlado para evaluar los efectos del metronidazol, el diltiazem y la lidocaína en el dolor posthemorroidectomía.DISEÑO:Ensayo factorial controlado aleatorizado doble ciego.ESCENARIO:Se realizó un ensayo multicéntrico en Auckland, Nueva Zelanda.PACIENTES:Se aleatorizó a 192 participantes (1:1:1:1) en cuatro brazos paralelos.INTERVENCIONES:Los participantes se asignaron aleatoriamente a uno de los cuatro grupos que recibieron tratamiento tópico con metronidazol al 10% (M), metronidazol al 10% + diltiazem al 2% (MD), metronidazol al 10% + lidocaína al 4% (ML), o metronidazol al 10% + diltiazem al 2% + lidocaína al 4% (MDL). Se indicó a los participantes que lo aplicaran en el margen anal 3 veces al día durante 7 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el dolor en la escala analógica visual en el día 4. Los resultados secundarios incluyeron el uso de analgesia, el dolor al defecar y el índice de recuperación funcional.RESULTADOS:No hubo diferencias significativas en las puntuaciones de dolor y recuperación cuando se añadió diltiazem o lidocaína al metronidazol (diferencia de puntuación entre la presencia y la ausencia de D en la formulación: -3.69; IC del 95%: -13.3; 5.94; p = 0.46; entre la presencia y la ausencia de L: -5.67; IC del 95%: -15.5; 3.80; p = 0.24). La combinación de MDL no redujo más el dolor. El análisis secundario reveló una diferencia significativa entre los grupos mejor (ML) y peor (MDL) tanto en las puntuaciones de dolor como en las de recuperación funcional. No hubo diferencias significativas en el uso de analgésicos, las complicaciones o la reincorporación al trabajo entre los grupos. No se notificaron eventos adversos clínicamente importantes. La tasa de eventosadversos no cambió en los grupos de intervención.LIMITACIONES:Se utilizó metronidazol tópico en el grupo de control, en lugar de un placebo puro.CONCLUSIONES:No hubo diferencias significativas en el dolor cuando se añadió diltiazem tópico o lidocaína, o ambos, al metronidazol tópico. ( Traducción-Dr. Jorge Silva Velazco )Identificador de registro del ensayo clínico:NCT04276298.

Analgesic Efficacy of EMLA Cream Among Patients Undergoing Hemorrhoidectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Post-hemorrhoidectomy pain is a concerning complication for patients and doctors, mainly due to perianal skin dissection and the complex innervation of the area. Therefore, our aim is to explore the analgesic efficacy and safety of EMLA cream among patients undergoing hemorrhoidectomy. We conducted a comprehensive search of five electronic databases (PubMed, Scopus, Web of Science, Embase, Cochrane) from inception until July 6, 2024. A risk of bias assessment was performed using the Risk of Bias Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB-2). Only randomized controlled trials (RCTs) were included. Our outcomes of interest were pain assessment using the Visual Analogue Scale (VAS) score, patient satisfaction, meperidine dosage, frequency of meperidine requests, and single urinary catheterization. We used RevMan software to conduct the statistical analysis. Dichotomous data were pooled as relative risk (RR), while continuous data were pooled as mean difference (MD). Four RCTs were included in our review. Two RCTs showed a low overall risk of bias, while one RCT showed a high risk, and the last one showed some concerns. Our analysis showed a significant difference between the two groups, favoring the EMLA group over the control group, upon arrival at the recovery room and at night on the day of the operation (MD=-1.76, 95% CI (-3.17, -0.36), p=0.01 and MD=-1.65, 95% CI (-2.48, -0.81), p=0.0001, respectively). However, there was no significant difference between the two groups in the morning on the day after the operation (MD=-0.9, 95% CI (-2.02, 0.21), p=0.11). Moreover, patients who used EMLA cream reported increased patient satisfaction compared to those who did not. However, there was no significant difference between both groups in terms of the use of urinary catheterizations. In conclusion, our study showed that applying EMLA cream over the perianal area after hemorrhoidectomy can effectively reduce postoperative pain and decrease the required opioid dosage and patient requests. This ultimately leads to increased patient satisfaction. However, further studies are still required to confirm these findings.

Belgian consensus guideline on the management of anal fissures

Introduction

Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred.

Methods

A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023.

Results

Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks.

Conclusions

The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

Hemoroidlerin Cerrahi Tedavisinde Ferguson Hemoroidektomi

Amaç: Prolabe hemoroidal hastalık nedeniyle ameliyat edilen hastalarımızın ameliyatında geleneksel Ferguson yaklaşımının sonucunu değerlendirmek amaçlanmıştır.Yöntem: Mart 2007-Ocak 2017 tarihleri arasında Ferguson tekniği ile tedavi edilen 769 hasta çalışmaya dahil edildi. Hastaların tıbbi dosyaları değerlendirilerek başvuru şikayetleri, anorektal komorbiditeler, ameliyat bulguları ve postoperatif erken ve geç komplikasyon verileri kaydedildi.Bulgular: Hastaların% 65'i erkekti ve ortalama yaş 39 (18-81) idi. Şikayet süreleri bir hafta ile 5 yıl arasında değişiyordu. Şikayetler sık görülenden az görülene doğru sırasıyla ele gelen pake, kanama ve ağrı idi. Paker'l2r, hastaların %69'unda klasik konumdaydı (saat 3,5,7,11). Vakaların çoğu (% 65) 4. derece hemoroiddi. Hastaların%19'unda anorektal komorbidite olarak anal fissür vardı. Tüm hastalar litotomi pozisyonunda spinal anestezi altında ameliyat edildi. Ferguson tekniği için ameliyat süresi ortalama 20 dakika ve ameliyat sonrası hastanede kalış süresi ortalama bir gündü. Postoperatif dönemde 55 hastada erken komplikasyonlar gelişti. Bunlar 25 hastada (%3-25) şiddetli karın ağrısı, 3 hastada (% 0.4) kanama ve 28 hastada (% 3.60) idrar retansiyonu idi. Yedi hastada geç komplikasyonlar gelişti. 1 hastada anal stenoz, 3 hastada anal fissür ve 2 hastada apse ile fistül gelişti. Hiçbir hastada inkontinans ve nüks görülmedi.Sonuç: Ferguson tekniği halen hemoroid cerrahisinde kullanılmaktadır. Çalışmamızın sonuçları, güvenilir bir tercih yöntemi olarak Ferguson hemoroidektomisini desteklemektedir.

Perianal block with ropivacaine as a supplement to anaesthesia in proctological surgery: double-blind randomized placebo-controlled trial (PERCEPT)

BACKGROUND

The benefit of a perianal block as an adjunct to general or regional anaesthesia is debated. This RCT aimed to compare pain at 24 h and up to 14 days after proctological surgery in patients with and without a perianal block.

METHODS

Between January 2018 and April 2019, patients were allocated to receive a perianal block with ropivacaine or placebo as an adjunct to anaesthesia. Patients, surgeons and assessors were blinded. The primary outcome was pain measured on a numerical rating scale (NRS) after 24 h. Secondary outcomes were need for rescue analgesia, and pain after 1, 2, 3, 6 and 12 h. The mean, rest and maximum NRS scores were measured for 14 days.

RESULTS

A total of 138 patients were included, of whom 46 and 44 received general anaesthesia with or without ropivacaine respectively, and 23 and 25 received spinal anaesthesia with or without ropivacaine respectively (P = 0·858). The mean NRS score differed significantly at 24 h (mean(s.d.) 1·1(0·1) versus 2·3(0·2); P < 0·001), but not at 1 h (1·4(0·2) versus 2·2(0·3); P = 0·051). The NRS score was lower with use of ropivacaine at 2 h (1·0(0·2) versus 1·6(0·2); P = 0·045), 3 h (0·9(0·2) versus 1·5(0·2); P = 0·022), 6 h (1·1(0·2) versus 1·8(0·2); P = 0·042) and 12 h (1·2(0·2) versus 1·8(0·2); P = 0·034). The use of oral morphine equivalents was 10·2(1·4) and 16·6(2·5) mg with and without ropivacaine respectively (P = 0·028). The mean and maximum NRS scores within 14 days were lower when ropivacaine was used (95 per cent c.i. for difference 0·14 to 0·49 (P = 0·002) and 0·39 to 0·63 (P < 0·001) respectively). There was no injection-associated morbidity.

CONCLUSION

Perianal block as an adjunct to general or regional anaesthesia should be recommended for proctological surgery. It yields a reduction in pain, a reduced need for opioids, and a faster recovery with minimal risk of adverse events. Registration number: NCT03405922 ( http://www.clinicaltrials.gov).

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.

Perioperative Management of the Ambulatory Anorectal Surgery Patient

Ambulatory surgery is appropriate for most anorectal pathology. Ambulatory anorectal surgery can be performed at reduced cost compared with inpatient procedures with excellent safety, improved efficiency, and high levels of patient satisfaction. Several perioperative strategies are employed to control pain and avoid urinary retention, including the use of a multimodal pain regimen and restriction of intravenous fluids. Ambulatory anorectal surgery often utilizes standardized order sets and discharge instructions.