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Chen CC, Chang KT, Lee YW, Chen JS, Wei PL, Chang CL, Huang YJ. Effectiveness of pudendal nerve block in the management of acute post-haemorrhoidectomy pain in Asian individuals using inverse probability of treatment weighting (IPTW). Asian J Surg 2024:S1015-9584(24)01643-9. [PMID: 39191591 DOI: 10.1016/j.asjsur.2024.07.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/21/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Inadequate management of acute post-haemorrhoidectomy pain is a major concern. Optimal pain management is necessary to reduce acute postoperative pain and improve care quality. Therefore, we investigated the efficacy of postoperative pudendal nerve block (PNB) in reducing acute post-haemorrhoidectomy pain in Asian individuals. METHODS This retrospective cohort study analysed 108 adult patients with grade 3 haemorrhoids. Patients with anorectal cancer were excluded from this study. Among the 108 patients, 79 and 29 received spinal anaesthesia (SA) with PNB (SAPNB) and SA alone, respectively. Propensity score matching and inverse probability of treatment weighting were performed to adjust for the effects of confounders. RESULTS Patients receiving SAPNB had significantly lower postoperative pain scores 6, 12, and 18 h after haemorrhoidectomy but significantly higher postoperative pain scores 24 and 48 h after haemorrhoidectomy than did patients receiving SA alone. PNB, older age, female sex, reduced operation time, and absence of cardiovascular disease reduced the risk of moderate to severe postoperative pain. Only the addition of PNB was consistently associated with a reduced risk of moderate to severe pain 6, 12, and 18 h after haemorrhoidectomy. Patients receiving SAPNB had significantly lower risks of perianal swelling and urinary retention but a significantly higher risk of nausea than did those receiving SA alone. The two groups exhibited similarity in their rates of postoperative readmission because of poor pain management and their lengths of stay upon readmission. CONCLUSION The addition of PNB to SA may effectively reduce acute post-haemorrhoidectomy pain.
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Affiliation(s)
- Chang-Cyuan Chen
- Department of Medical Education, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Kuei-Ting Chang
- Department of Medical Education, Chang Gung Memorial Hospital, Chiayi County, Taiwan
| | - Yuan-Wen Lee
- Department of Anaesthesiology, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Juan-Syun Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Po-Li Wei
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei Medical University, Taipei City, Taiwan; Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei City, Taiwan; Cancer Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei City, Taiwan; Translational Laboratory, Department of Medical Research, Taipei Medical University Hospital, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei City, Taiwan
| | - Chia-Li Chang
- Data Analyst, Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei City, Taiwan
| | - Yan-Jiun Huang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei Medical University, Taipei City, Taiwan; Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei City, Taiwan.
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Sun XW, Xu JY, Zhu CZ, Li SJ, Jin LJ, Zhu ZD. Analysis of factors impacting postoperative pain and quality of life in patients with mixed hemorrhoids: A retrospective study. World J Gastrointest Surg 2024; 16:731-739. [PMID: 38577073 PMCID: PMC10989325 DOI: 10.4240/wjgs.v16.i3.731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/05/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery. They are venous clusters formed by congestion, expansion, and flexion of the venous plexus in the lower part of the rectum. Mixed hemorrhoids bleed easily and recurrently, and this can result in severe anemia. Hence, they may have a negative effect on the health of the patient and surgical treatment is required. Milligan-Morgan hemorrhoidectomy has been widely used since 1937 for the treatment of grade III and IV hemorrhoids. However, most patients experience different degrees of postoperative pain that may cause anxiety. AIM To assess the factors influencing pain scores and quality of life (QoL) in patients with mixed hemorrhoids post-surgery. METHODS The clinical data of patients with mixed hemorrhoids who underwent Milligan-Morgan hemorrhoidectomy were collected retrospectively. The basic characteristics of the enrolled patients with mixed hemorrhoids were recorded, and based on the Goligher clinical grading system, the hemorrhoids were classified as grades III or IV. The endpoint of this study was the disappearance of pain in all patients. Quantitative data were presented as mean ± SD, such as age, pain score, and QoL score. Student's t-test was used to compare the groups. RESULTS A total of 164 patients were enrolled. The distribution of the visual analog scale pain scores of all patients at 3, 7, 14 and 28 d after surgery showed that post-surgery pain was significantly reduced with the passage of time. Fourteen days after the operation, the pain had completely disappeared in some patients. Twenty-eight days after the surgery, none of the patients experienced any pain. Comparing the World Health Organization Quality of Life - BREF self-reporting questionnaire scores of patients between 14 and 28 d after surgery, we observed that the quality-of-life scores of the patients post-surgery had significantly improved. There were six items that were compared at 14- and 28-d post-surgery. The mean QoL score 28 d after surgery (4.79 ± 0.46) was higher than that at 14 d post-surgery (3.79 ± 0.57). The mean health condition score 28 d after surgery (4.80 ± 0.41) was also higher than that at 14 d post-surgery (4.01 ± 0.62). The mean physical health score 28 d after surgery (32.10 ± 2.96) was significantly higher than that at 14 d post-surgery (23.41 ± 2.85). The mean psychological health score 28 d after surgery (27.22 ± 1.62) was significantly higher than that at 14 d post-surgery (21.37 ± 1.70). The mean social relations score 28 d after surgery (12.21 ± 1.59) was significantly higher than that at 14 d post-surgery (6.32 ± 1.66). The mean surrounding environment score 28 d after surgery (37.13 ± 2.88) was significantly higher than that at 14 d post-surgery (28.42 ± 2.86). The differences in quality-of-life scores at day 14 and day 28 post-surgery were observed to be statistically significant (P < 0.001). CONCLUSION Milligan-Morgan hemorrhoidectomy can significantly improve the postoperative QoL of patients. Age, sex, and the number of surgical resections were important factors influencing Milligan-Morgan hemorrhoidectomy.
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Affiliation(s)
- Xiao-Wen Sun
- Department of Gastrointestinal Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Jing-Yi Xu
- Surgical Department, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Chang-Zhen Zhu
- Department of Gastrointestinal Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Si-Jia Li
- Department of Gastrointestinal Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Lu-Jia Jin
- Department of Gastrointestinal Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Zhi-Dong Zhu
- Department of Gastrointestinal Surgery, Tsinghua University Affiliated Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
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Voinov MA. [The effectiveness of flavonoids in the postoperative treatment of patients with hemorrhoids]. Khirurgiia (Mosk) 2024:52-56. [PMID: 39268736 DOI: 10.17116/hirurgia202409152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
OBJECTIVE Evaluation of the effectiveness of flavonoids in the postoperative management of patients with hemorrhoids. MATERIAL AND METHODS A single-center randomized controlled clinical trial was conducted. Patients with stage III and IV hemorrhoids aged over 18 years who patients who underwent hemorrhoidectomy were included. The patients were divided into 2 groups - main and control. Patients in the main group were recommended to use a purified micronized flavonoid fraction - 65 patients. In the control group (70 patients), the use of this group of drugs was not expected. The observation period was 60 days. After discharge from the hospital, 5 patient visits were scheduled: on the 3rd, 7th, 21st, 40th and 60th day after surgery. Patients independently assessed the intensity of symptoms - pain, tenesmus, itching and bleeding. The randomization procedure was carried out using the method of simple randomization using envelopes. RESULTS 135 patients were randomized. There were no patients who dropped out of the study. The number of participants whose data were included in the analysis was 65 patients in the main group and 70 patients in the control group. Assessment of symptoms in the first 3 days of the postoperative period did not show a significant difference in the condition of the patients. Over time, we found significant changes in the dynamics of complaints between groups. After 7, 21, 40 and 60 days, a statistically significant lower severity of pain, bleeding and tenesmus was revealed among patients in the main group compared to the control group. This trend was not detected in the assessment of itching. There were no undesirable effects. CONCLUSION The use of purified micronized flavonoid fraction in the postoperative management of patients with hemorrhoids can significantly reduce the degree and duration of pain, bleeding and tenesmus.
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Affiliation(s)
- M A Voinov
- I.M. Sechenov First Moscow State Medical University (Sechenovskiy University), Moscow, Russia
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Xia S, Luo L, Wu W, Lu K, Jiang T, Li Y. The role of pudendal nerve block in hemorrhoid surgery: a systematic review and meta-analysis of double-blind randomized controlled trials. Front Med (Lausanne) 2023; 10:1283512. [PMID: 38152300 PMCID: PMC10751314 DOI: 10.3389/fmed.2023.1283512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Background Pudendal nerve block (PNB) is a commonly used anesthesia method that has been widely used in postoperative analgesia for hemorrhoids in recent years. Therefore, we conducted a systematic review and meta-analysis of double-blind randomized controlled trials (RCTs) to analyze the effectiveness of PNB in postoperative analgesia for hemorrhoids. Methods Relevant data and studies published from inception until August 14, 2023, were retrieved from PubMed, Embase, and Web of Science to evaluate the beneficial effects of PNB for analgesia following hemorrhoidectomy. Results This meta-analysis included 6 double-blind RCTs comprising 501 patients. We evaluated the function of PNB in improving outcomes of postoperative analgesia of hemorrhoids. Visual analogue scale (VAS) scores on postoperative within 6 h (MD, -3.04; 95% CI, -4.13 to -1.95; P < 0.0001), 12 h (MD, -3.14; 95% CI, -3.87 to -2.40; P < 0.0001), and 24 h (MD, -2.25; 95% CI, -2.95 to -1.55; P < 0.0001) were enhanced by the application of PNB, but not in 48 h (MD, -2.54; 95% CI, -5.29 to 0.20; P = 0.07). Conclusion Pudendal nerve block (PNB) could effectively relieve postoperative pain of hemorrhoids. However, our results still need to be confirmed by multi-center clinical studies.
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Affiliation(s)
| | | | - Wenjiang Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
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Jao SW, Hsiao KH, Lin HC, Lee CC, Lin TC, Chen WS, Lin CC, Lee TY, Jiang JK, Wu CC, Hu OYP. Safety and Efficacy of Oral Nalbuphine on Postoperative Pain in Hemorrhoidectomy Patients: A Randomized, Double-blind, Placebo-controlled, Pivotal Trial. Clin J Pain 2023; 39:686-694. [PMID: 37732966 DOI: 10.1097/ajp.0000000000001160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Severe postoperative pain requiring opioid treatment has been reported in 20% to 40% of hemorrhoidectomy patients. Compared with morphine, nalbuphine offers better hemodynamic stability, a lower risk of respiratory depression, and a lower potential for addiction. Nalbuphine was developed from the intravenous form into an oral form (PHN131) to alleviate moderate-to-severe pain. MATERIALS AND METHODS A randomized, double-blind, placebo-controlled, multiple-dose, parallel-design trial was conducted to evaluate the safety and efficacy of PHN131 in patients undergoing hemorrhoidectomy. Eligible patients were randomly assigned to receive either PHN131 soft capsules containing nalbuphine hydrochloride 60 mg or placebo capsules. Intramuscular diclofenac was the rescue analgesic. Pain was measured by the area under the curve of mean Visual Analog Scale pain intensity scores. RESULTS Visual Analog Scale results in patients receiving PHN131 were significantly lower than placebo group scores through 48 hours postoperatively (149.2±75.52 vs. 179.6±65.97; P =0.0301). According to Brief Pain Inventory Short-Form scores, the impact of pain on quality of life was significantly smaller for the PHN131 group than for the placebo group. Time to the first use of diclofenac postoperatively was significantly longer in the PHN131 group than in the placebo group. The cumulative dosage of diclofenac in the PHN131 group was only around half of that in the placebo group ( P <0.0001). Drug-related adverse events were mild-to-moderate and resolved by the treatment end. No drug-related severe adverse events were observed. DISCUSSION Our findings demonstrate that PHN131 is effective and well-tolerated in the treatment of moderate-to-severe post hemorrhoidectomy pain and may provide another option for patients to control their pain.
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Affiliation(s)
- Shu-Wen Jao
- Division of Colon and Rectal Surgery, Tri-Service General Hospital
- National Defense Medical Center
| | - Koung-Hung Hsiao
- Department of Colorectal Surgery, Taipei Tzu Chi Hospital, Taipei Branch
| | | | - Chia-Cheng Lee
- Division of Colon and Rectal Surgery, Tri-Service General Hospital
| | - Tzu-Chen Lin
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Wei-Shone Chen
- Division of Colon and Rectal Surgery, En Chu Kong Hospital
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Tsai-Yu Lee
- Division of Colon and Rectal Surgery, Sijhih Cathay General Hospital, New Taipei City
| | - Jeng-Kai Jiang
- Division of Colon and Rectal Surgery, Taipei Veterans General Hospital
| | - Chang-Chieh Wu
- National Defense Medical Center
- Division of Colon and Rectal Surgery, Tri-Service General Hospital Keelung Branch, Keelung City, Taiwan
| | - Oliver Yoa-Pu Hu
- School of Pharmacy, National Defense Medical Center
- School of Pharmacy, Taipei Medical University, Taipei City
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Mallmann C, Langenbach MR, Florescu RV, Köhler A, Barkus J, Ritz JP, Gebauer F, Lefering R, Boenicke L. Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial. Int J Colorectal Dis 2023; 38:262. [PMID: 37919535 PMCID: PMC10622377 DOI: 10.1007/s00384-023-04557-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
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.
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Affiliation(s)
- Christoph Mallmann
- Department of General, Visceral and Oncological Surgery, Helios University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
| | | | | | | | - Jörg Barkus
- Helios Klinikum Niederberg, Velbert, Germany
| | | | - Florian Gebauer
- Department of General, Visceral and Oncological Surgery, Helios University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Witten, Germany
| | - Lars Boenicke
- Department of General, Visceral and Oncological Surgery, Helios University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany.
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Bikfalvi A, Faes C, Freys SM, Joshi GP, Van de Velde M, Albrecht E. PROSPECT guideline for haemorrhoid surgery: A systematic review and procedure-specific postoperative pain management recommendations. EUROPEAN JOURNAL OF ANAESTHESIOLOGY AND INTENSIVE CARE 2023; 2:e0023. [PMID: 39917290 PMCID: PMC11783633 DOI: 10.1097/ea9.0000000000000023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2025]
Abstract
BACKGROUND Haemorrhoidectomy is associated with moderate-to-severe postoperative pain. OBJECTIVE The aim of this systematic review was to assess the available literature and update previous PROSPECT (procedure specific postoperative pain management) recommendations for optimal pain management after haemorrhoidectomy. DESIGN AND ELIGIBILITY CRITERIA A systematic review utilising PROSPECT methodology was undertaken. DATA SOURCES Randomised controlled trials published in the English language from January 1, 2016 to February 2, 2022 assessing postoperative pain using analgesic, anaesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Database. RESULTS Of the 371 randomized controlled trials (RCTs) identified, 84 RCTs and 19 systematic reviews, meta-analyses met our inclusion criteria (103 publications). Interventions that improved postoperative pain relief included: paracetamol and nonsteroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors, systemic steroids, pudendal nerve block, topical metronidazole, topical diltiazem, topical sucralfate or topical glyceryl trinitrate, and intramuscular injection of botulinum toxin. DISCUSSION This review has updated the previous recommendations written by our group. Important changes are abandoning oral metronidazole and recommending topical metronidazole, topical diltiazem, topical sucralfate, topical glyceryl trinitrate. Botulinum toxin can also be administered. Contemporary publications confirm the analgesic effect of bilateral pudendal nerve block but invalidate recommendations on perianal infiltration. The choice of the surgery is mostly left to the discretion of the surgeons based on their experience, expertise, type of haemorrhoids, and risk of relapse. That said, excisional surgery is more painful than other procedures.
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Affiliation(s)
- Alexis Bikfalvi
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
| | - Charlotte Faes
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
| | - Stephan M Freys
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
| | - Girish P Joshi
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
| | - Marc Van de Velde
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
| | - Eric Albrecht
- From the Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland (AB, EA), the Department of Cardiovascular Sciences and Department of Anaesthesia, University Hospitals of the KU Leuven, Belgium (CF, MvdV), the Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Germany (SMF), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Bonomo LD, Falletto E, Cuccomarino S, Nicotera A, Jannaci A. Hemorrhoidal Artery Ligation for the Treatment of Grade II-III Hemorrhoids: Is it Worth the Use of Doppler Guide in Long-Term Follow-Up?: A Single-Center Cohort Study. ANNALS OF SURGERY OPEN 2023; 4:e296. [PMID: 37601476 PMCID: PMC10431348 DOI: 10.1097/as9.0000000000000296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/03/2023] [Indexed: 08/22/2023] Open
Abstract
Background Hemorrhoidal artery ligation (HAL) may reduce postoperative pain and complications and shorten patients' recovery when compared to standard hemorrhoidectomy. It is unclear if the Doppler guide (DG) is useful in reducing recurrence risk. Objective To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade. Methods Between January 1, 2014 and January 31, 2021, 122 patients affected by grade II-III hemorrhoidal prolapse underwent DG-HAL or HAL at Chivasso Hospital, Italy. Mucopexy was routinely performed. After discharge, patients were subjected to 1-week, 1-, 3-, 6-, and 12-month clinical assessment. Thereafter, they were interviewed by telephone annually. Results Seventy-six (62.3%) DG-HAL and 46 (37.7%) HAL procedures were performed. Median surgical time was 30 (15-45) minutes for DG-HAL versus 25 (15-40) minutes for HAL (P = 0.005). No intraoperative complications occurred. Postoperative bleeding needing surgery occurred in 2 (1.6%) patients in the DG-HAL group. During a median follow-up of 46 months (6-86), we registered 18 (23.7%) recurrences in the DG-HAL group and 13 (28.3%) in the HAL one (P = 0.574). No cases of incontinence or anal stenosis occurred. No significant difference was observed between the two groups in terms of patients' satisfaction. At multivariate analysis, age ≥ 65 years resulted a protective factor for recurrence (odds ratio 0.31; 95% confidence interval 0.09-0.98; P = 0.047). Conclusions In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.
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Affiliation(s)
| | - Ezio Falletto
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | | | - Antonella Nicotera
- From the General Surgery Unit, S.S. Pietro e Paolo Hospital, Borgosesia, Italy
| | - Alberto Jannaci
- Department of General Surgery, Chivasso Hospital, Chivasso, Italy
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Yang Y, Feng K, Lei Y, Qiu L, Liu C, Li G. Comparing the efficacy and safety of different analgesic strategies after open hemorrhoidectomy: a systematic review and network meta-analysis. Int J Colorectal Dis 2023; 38:4. [PMID: 36609578 DOI: 10.1007/s00384-022-04294-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To evaluate the clinical efficacy and safety of different analgesic interventions in the treatment of pain after open hemorrhoidectomy by systematic review and network meta-analysis. METHODS Randomized controlled trials that met the inclusion criteria in PubMed, Cochrane Library, Embase, Web of Science, Scopus, CNKI, WANFANG DATA, and VIP were searched from the date of database construction to June 28, 2022. RESULTS Among the 13 randomized controlled trials (RCTs), 731 patients were included in the network meta-analysis. Most interventions are more effective than placebo in relieving postoperative pain. 24 h postoperative Visual Analogue Scale (VAS): glyceryl trinitrate (GTN) (mean difference (MD) - 4.20, 95% CI - 5.35, - 3.05), diltiazem (MD - 1.97, 95% CI - 2.44, - 1.51), botulinum toxin (BT) (MD - 1.50, 95% CI - 2.25, - 0.75), sucralfate (MD - 1.01, 95% CI - 1.53, - 0.49), and electroacupuncture (EA) (MD - 0.45, 95% CI - 0.87, - 0.04). 48 h postoperative VAS: diltiazem (MD - 2.45, 95% CI - 2.74, - 2.15), BT (MD - 2.18, 95% CI - 2.52, - 1.84), and sucralfate (MD - 1.41, 95% CI - 1.85, - 0.97). 7 d postoperative VAS: diltiazem (MD - 2.49, 95% CI - 3.20, - 1.78) and sucralfate (MD - 1.42, 95% CI - 2.00, - 0.85). The first postoperative defecation VAS: EA (MD - 0.70, 95% CI - 0.95, - 0.46). There are few data on intervention safety, and additional high-quality RCTs are expected to study this topic in the future. CONCLUSION Diltiazem ointment may be the most effective medication for pain relief following open hemorrhoidectomy, and it can dramatically reduce pain within one week of surgery. The second and third recommended medications are BT and sucralfate ointment. GTN has a significant advantage in alleviating pain 24 h after open hemorrhoidectomy, but whether it causes headache is debatable; thus, it should be used with caution. EA's analgesic efficacy is still unknown. There was limited evidence on the safety of the intervention in this study, and it was simply presented statistically.
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Affiliation(s)
- Yue Yang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Ke Feng
- Department of General Surgery, Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China
| | - Yuting Lei
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Li Qiu
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Guofeng Li
- Department of Anorectal Diagnosis and Treatment Center, Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China.
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Wang G, Wu Y, Cao Y, Zhou R, Tao K, Wang L. Psychological states could affect postsurgical pain after hemorrhoidectomy: A prospective cohort study. Front Surg 2023; 9:1024237. [PMID: 36684369 PMCID: PMC9852767 DOI: 10.3389/fsurg.2022.1024237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/21/2022] [Indexed: 01/09/2023] Open
Abstract
Background Open hemorrhoidectomy is one of the standard procedures for grade IV hemorrhoids. Postsurgical pain is a common problem for patients. We aim to prospectively evaluate potential factors affecting postoperative pain among hemorrhoidectomy patients. Methods An observational study was conducted on 360 patients who had undergone Milligan-Morgan open hemorrhoidectomy. Details of the surgery and baseline information were recorded. Preoperative anxiety and depression were analyzed via the self-rating anxiety scale 20 (SAS-20) and self-rating depression scales 20 (SDS-20), respectively. Postoperative pain score was performed daily after surgery until the patient was discharged. The numerical pain score was evaluated by the visual analogue scale (VAS). The association between preoperative psychological states (anxiety or depression) and postoperative pain was analyzed using a generalized additive mixed model. Results A total of 340 patients eventually provided complete data and were included in our study. The average age was 43.3 ± 14.4 years, and 62.1% of patients were women. In total, 14.9% of patients had presurgical anxiety and 47.1% had presurgical depression. Postsurgical pain reached a peak point 1-2 days after surgery and went down to a very low level around 4-5 days after surgery. More excision of hemorrhoids could lead to more pain experience after surgery. Presurgical depression was associated with postsurgical pain. Patients who had presurgical depression had higher pain scores after surgery (2.3 ± 1.9 vs. 3.3 ± 1.9, p = 0.025). Conclusion Preoperative depression and the amount of excisional hemorrhoids are positively related to postsurgical pain.
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Affiliation(s)
- Geng Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanjue Wu
- Department of Clinical Nutrition, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Zhou
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linfang Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Correspondence: Linfang Wang
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Muacevic A, Adler JR, Alosaimi MA, Alhamyani AS, Aljuaid AM, Alnefaie AM, Alhejji KF, Ali MZ. The Effect of High Altitude on Short-Term Outcomes of Post-hemorrhoidectomy. Cureus 2023; 15:e33873. [PMID: 36819323 PMCID: PMC9933788 DOI: 10.7759/cureus.33873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Background Hemorrhoids are caused by the distal displacement of the hemorrhoidal cushions and venous distention. Hemorrhoidal illness is still a prevalent issue. Hemorrhoidal symptoms affect 5% of the general population and 50% of people over the age of 50. Surgical therapy ensures satisfactory results that are much better than those obtained with conservative treatments, particularly for grade III and IV hemorrhoids. Objectives This study aims to compare postoperative complications of hemorrhoidectomy among patients who live in a high-altitude region (Taif) and a sea-level (low-altitude level) region (Jeddah). Methods This retrospective study was conducted among patients who underwent hemorrhoidectomy between January 2019 and January 2022 in Taif and Jeddah, Saudi Arabia. Simple random sampling was used to select the study population, and data were collected from patient files. Data analysis was conducted using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY). Results A total of 135 patients were included in this study. Most of our patients were males (73.3%). Patients from Jeddah represented more than half of the study population, and 45.2% were from Taif. The majority of low-altitude area patients require less than a week to return to normal activities (54.1%), whereas the majority of high-altitude area patients (59%) require more than a week (P = 0.047). 94.1% of participants felt pain on Day 1, and 54.1% had pain on Day 7. According to our findings, approximately one-fourth of patients (25.2%) developed recurrent hemorrhoids, and 27.4% experienced recurrent hemorrhoid symptoms. When we compared low-altitude regions and high-altitude regions in postoperative complications of hemorrhoidectomy, we found that urinary retention was most common in the high-altitude regions (37.7%). Conclusion Our results found that urinary retention was the most common complication in the high-altitude region. Early return to regular activity with less postoperative pain on Day 7 was a significant finding among low-altitude area patients.
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Sutter A, Poylin V. Reducing Complications After Surgery for Benign Anorectal Conditions. Adv Surg 2022; 56:69-78. [PMID: 36096578 DOI: 10.1016/j.yasu.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
While generally perceived as mundane and low-risk procedures, anorectal surgeries by virtue of their anatomic real-estate-dense with nerves, blood supply, and structures critical to the quality of life-are fraught with the potential for complications. While these complications are generally not life-threatening, their impact to the quality of life can be severe. Furthermore, the sheer volume of anorectal procedures performed each year means that even low complication rates or less severe complications can have significant economic impact.
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Affiliation(s)
- Alton Sutter
- Wake Forest Baptist Hospital, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Vitaliy Poylin
- Division of Gastrointestinal and Oncologic Surgery, Feinberg School of Medicine, Northwestern Medical Group, 676 North St. Clair Street, Suite 650, Chicago, IL 60611, USA.
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Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial. Dis Colon Rectum 2022; 65:1034-1041. [PMID: 35714359 DOI: 10.1097/dcr.0000000000002250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pain management after hemorrhoidectomy continues to be challenging. OBJECTIVE The aim of this study was to evaluate the effectiveness of infiltration of bupivacaine hydrochloride and triamcinolone acetonide in surgical wounds of Milligan-Morgan hemorrhoidectomy for postoperative pain relief. DESIGN A double-blind randomized controlled clinical trial was conducted between May 2015 and June 2019. SETTINGS This study was carried out in a secondary referral hospital center in Spain. PATIENTS Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included. INTERVENTIONS Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone and patients allocated in the control group did not receive any intervention. MAIN OUTCOMES MEASURES The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay. Secondary end points were pain at follow-up, pain during defecation, analgesic requirements, wound healing rate, and complications. RESULTS A total of 128 patients were randomly assigned (64 in each group). The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different ( p < 0.05). No differences were observed regarding pain during defecation. Morphine requirements were significant lower in the intervention group (6.3% vs 21.9% patients; p = 0.01; 5 vs 23 cumulative doses; p = 0.01). Wound healing and complication rates were similar in both groups. LIMITATIONS Use of placebo was not considered in the control group ("intervention group" vs "control group" clinical trial). Data regarding pain or other complications at 48 hours postoperatively were pooled and expressed as median of values. CONCLUSIONS Infiltration of surgical wounds with bupivacaine and triamcinolone decreases postoperative pain and reduces morphine requirements in Milligan-Morgan hemorrhoidectomies. See Video Abstract at http://links.lww.com/DCR/B867 .Clinical trial registration: European Registry of Clinical Trials. EUDRACT 2014- 003043-35. INFILTRACIN DE BUPIVACANA Y TRIAMCINOLONA EN HERIDAS QUIRRGICAS DE HEMORROIDECTOMA DE MILLIGANMORGAN PARA EL CONTROL DEL DOLOR POSOPERATORIO ENSAYO CLNICO DOBLE CIEGO, ALEATORIZADO Y CONTROLADO ANTECEDENTES:El manejo del dolor posterior a una hemorroidectomía sigue siendo un desafío.OBJETIVO:El objetivo de este estudio fue evaluar la efectividad de la infiltración de bupivacaína y triamcinolona en heridas quirúrgicas de hemorroidectomía de Milligan-Morgan para el alivio del dolor posoperatorio.DISEÑO:Se realizó un ensayo clínico controlado, aleatorizado, doble ciego entre mayo del 2015 y junio del 2019.ENTORNO CLINICO:Este estudio se llevó a cabo en un centro hospitalario de referencia secundaria en España.PACIENTES:Se incluyeron pacientes que se sometieron a una hemorroidectomía de Milligan-Morgan electiva por hemorroides de grado III-IV.INTERVENCIONES:Los pacientes asignados al grupo de intervención recibieron una única infiltración de bupivacaína y triamcinolona y los pacientes asignados al grupo de control no recibieron ninguna intervención.PRINCIPALES RESULTADOS RESULTADOS:El factor de valoración principal fue la mediana del dolor máximo según la escala análoga visual durante las 48 horas de estancia hospitalaria. Las variables secundarias fueron dolor durante el seguimiento, dolor durante la defecación, requerimientos de analgésicos, tasa de cicatrización de heridas y complicaciones.RESULTADOS:Se asignó aleatoriamente a un total de 128 pacientes (64 en cada grupo). La mediana de puntuación máxima de dolor a las 48 horas fue de 3 puntos en el grupo de intervención y de 6 puntos en el grupo de control con diferencias significativas (p < 0,05). No se observaron diferencias en cuanto al dolor durante la defecación. Las necesidades de morfina fueron significativamente menores en el grupo de intervención (6,3% versus 21,9% de los pacientes; p = 0,01; 5 versus 23 dosis acumuladas; p = 0,01). Las tasas de curación de heridas y complicaciones fueron similares en ambos grupos.LIMITACIONES:No se consideró el uso de placebo en el grupo de control (ensayo clínico: "grupo de intervención" versus "grupo control"). Los datos con respecto al dolor u otras complicaciones después de 48 horas postoperatorias se agruparon y expresaron como mediana de los valores.CONCLUSIONES:La infiltración de heridas quirúrgicas con bupivacaína y triamcinolona disminuye el dolor posoperatorio y reduce los requerimientos de morfina en la hemorroidectomía de Milligan-Morgan. Consulte Video Resumen en http://links.lww.com/DCR/B867 . (Traducción- Dr. Francisco M. Abarca-Rendon).Registro de ensayos clínicos: Registro europeo de ensayos clínicos. EUDRACT 2014- 003043-35.
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Yano T, Kabata D, Kimura S. Pain at the First Post-hemorrhoidectomy Defecation Is Associated with Stool Form. J Anus Rectum Colon 2022; 6:168-173. [PMID: 35979270 PMCID: PMC9328793 DOI: 10.23922/jarc.2021-052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: Methods: Results: Conclusions: Trial registration:
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Affiliation(s)
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine
| | - Seiichi Kimura
- Department of Medical Statistics, Osaka City University Graduate School of Medicine
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Li L, Wu S, Wang J, Wang C, Zuo W, Yu L, Song J. Development of the Emoji faces pain scale and its validation on mobile device in adult surgery patients: A longitudinal observational study (Preprint). J Med Internet Res 2022; 25:e41189. [PMID: 37067854 PMCID: PMC10152337 DOI: 10.2196/41189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/05/2023] [Accepted: 03/15/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Measuring pain on digital devices using classic unidimensional pain scales such as the visual analog scale (VAS), numerical rating scale (NRS), and faces pain scale (FPS) has been proven to be reliable and valid. Emoji are pictographs designed in colorful form following the Unicode standard. It could be more beneficial to use emoji as faces of FPS on digital devices because emoji can easily fit on most devices and emoji are open-source so no approval would be needed before use. With a concise and user-friendly design, the emoji faces pain scale (Emoji-FPS) might be more generalizable to a wider population and more preferred by digital device users. OBJECTIVE This study was designed to develop an Emoji-FPS as well as to evaluate its reliability, validity, and preference on mobile devices in adult patients who underwent surgery. METHODS A modified Delphi technique with 2 rounds of web-based surveys was applied to obtain panelists' consensus on the sequence of emoji that can best represent 6 levels of pain. The initial candidate sequences of emoji for the Delphi process were constructed referring to 2 well-validated FPSs (Wong-Baker FACES pain rating scale [Wong-Baker FACES] and faces pain scale-revised [FPS-R]). Then, a prospective cohort of patients scheduled to receive perianal surgery was recruited and asked to complete a web-based questionnaire on a mobile device at 5 time points (before surgery [T1], wake up after surgery [T2], 4 hours after surgery [T3], the second day after surgery [T4], and 15 minutes after T4 [T5]). The 4 well-validated pain scales (NRS, VAS, Wong-Baker FACES, and FPS-R) were used as reference scales. RESULTS After 2 rounds of surveys on 40 Delphi panelists, an Emoji-FPS was finally determined to represent 6 pain levels (0, 2, 4, 6, 8, and 10) from "no hurt" to "hurts worst." For validation, 300 patients were recruited and 299 were analyzed, the mean age of whom was 38.5 (SD 10.5) years, and 106 (35.5%) were women. For concurrent validity, the Emoji-FPS was highly correlated with 4 reference scales with Spearman correlation coefficient ρ ranging from 0.91 to 0.95. Excellent agreements were observed between 4 versions of Emoji-FPS (iOS, Android, Microsoft, and OpenMoji), with weighted κ coefficients ranging from 0.96 to 0.97. For discriminant validity, patients' mean preoperative Emoji-FPS score (T1) was significantly higher than their postoperative Emoji-FPS score (T4) with a difference of 1.4 (95% CI 1.3-1.6; P<.001). For test-retest reliability, Emoji-FPS scores measured at T4 and T5 were highly correlated with a ρ of 0.91. The Emoji-FPS was mostly preferred, followed by the Wong-Baker FACES, FPS-R, NRS, and VAS. CONCLUSIONS The Emoji-FPS is reliable and valid compared with traditional pain scales in adult surgery patients.
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Affiliation(s)
- Lili Li
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Sicheng Wu
- Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China (Hong Kong)
| | - Jian Wang
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chunchun Wang
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Weixin Zuo
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liping Yu
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiangang Song
- Anesthesiology Department, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Acupuncture and Anesthesia Research Institute, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Chen H, Zhang W, Sun Y, Jiao R, Liu Z. The Role of Acupuncture in Relieving Post-Hemorrhoidectomy Pain: A Systematic Review of Randomized Controlled Trials. Front Surg 2022; 9:815618. [PMID: 35419404 PMCID: PMC8995644 DOI: 10.3389/fsurg.2022.815618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Post-hemorrhoidectomy pain (PHP) remains one of the complications of hemorrhoidectomy and can delay patient's recovery. Current clinical guideline on PHP remains skeptical on the effectiveness of acupuncture, which has been applied for PHP in practice with inconsistent evidence. Objectives This systematic review aimed to evaluate the effectiveness of acupuncture on PHP by reviewing existing evidence. Methods Nine databases such as PubMed and Embase were searched for randomized controlled trials (RCTs) from inception to 30th September 2021. The outcome measures on pain level after hemorrhoidectomy, dose of rescue analgesic drug used, quality of life, adverse events, etc., were extracted and analyzed in a narrative approach. Results Four RCTs involving 275 patients were included in the analysis. One study showed that the visual analog scale (VAS) score was significantly lower in the electro-acupuncture (EA) group compared to that in the sham acupuncture (SA) group at 6, 24 h after surgery and during the first defecation (p < 0.05). Similar trends were found in the verbal rating scale (VRS) and Wong-Baker Faces scale (WBS) score but at different time points. Another study also found EA was effective on relieving pain during defecation up to 7 days after surgery when compared with local anesthetics (p < 0.05). However, two studies evaluating manual acupuncture (MA) compared with active medications for PHP showed inconsistent results on effectiveness. Variability was found in the quality of included studies. Conclusions Although benefit of acupuncture on PHP, especially EA on defecation after surgery, was observed at some time points, evidence on effectiveness of acupuncture on PHP was not conclusive. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD42018099961.
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Affiliation(s)
- Huan Chen
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Weina Zhang
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yuanjie Sun
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruimin Jiao
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Science, Beijing, China
| | - Zhishun Liu
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Zhishun Liu
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Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58030418. [PMID: 35334594 PMCID: PMC8955987 DOI: 10.3390/medicina58030418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Excisional hemorrhoidectomy is considered as a mainstay operation for high-grade hemorrhoids and complicated hemorrhoids. However, postoperative pain remains a challenging problem after hemorrhoidectomy. This systematic review aims to identify pharmacological and non-pharmacological interventions for reducing post-hemorrhoidectomy pain. Materials and Methods: The databases of Ovid MEDLINE, PubMed and EMBASE were systematically searched for randomized controlled trails (published in English language with full-text from 1981 to 30 September 2021) to include comparative studies examining post-hemorrhoidectomy pain as their primary outcomes between an intervention and another intervention (or a sham or placebo). Results: Some 157 studies were included in this review with additional information from 15 meta-analyses. Fundamentally, strategies to reduce post-hemorrhoidectomy pain were categorized into four groups: anesthetic methods, surgical techniques, intraoperative adjuncts, and postoperative interventions. In brief, local anesthesia-alone or combined with intravenous sedation was the most effective anesthetic method for excisional hemorrhoidectomy. Regarding surgical techniques, closed (Ferguson) hemorrhoidectomy performed with a vascular sealing device or an ultrasonic scalpel was recommended. Lateral internal anal sphincterotomy may be performed as a surgical adjunct to reduce post-hemorrhoidectomy pain, although it increased risks of anal incontinence. Chemical sphincterotomy (botulinum toxin, topical calcium channel blockers, and topical glyceryl trinitrate) was also efficacious in reducing postoperative pain. So were other topical agents such as anesthetic cream, 10% metronidazole ointment, and 10% sucralfate ointment. Postoperative administration of oral metronidazole, flavonoids, and laxatives was associated with a significant reduction in post-hemorrhoidectomy pain. Conclusions: This systematic review comprehensively covers evidence-based strategies to reduce pain after excisional hemorrhoidectomy. Areas for future research on this topic are also addressed at the end of this article.
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Yoon DH, Mirza KL, Wickham C, Noren ER, Chen J, Lee SW, Cologne KG, Ault GT. Reduction of Opioid Overprescribing and Use Following Standardized Educational Intervention: A Survey of Patient Experiences Following Anorectal Procedures. Dis Colon Rectum 2021; 64:1129-1138. [PMID: 34397561 PMCID: PMC8369042 DOI: 10.1097/dcr.0000000000001970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A pilot study conducted at our institution showed that a significant amount of prescribed postoperative opioids is left unused with the potential for diversion and misuse. OBJECTIVE This study aimed to evaluate the impact of provider- and patient-targeted educational interventions on postoperative opioid prescription and use following anorectal procedures. DESIGN Patients were enrolled on July 2019 through March 2020 after implementing educational interventions (study) and were compared with the pilot study group (control) enrolled on August 2018 through May 2019. A telephone survey was conducted 1 week postoperatively. SETTINGS This study was conducted at a 600-bed, safety-net hospital in southern California. PATIENTS Adult patients undergoing ambulatory anorectal procedures were included. Patients who had undergone an examination under anesthesia, had been incarcerated, and had used opioids preoperatively were excluded. INTERVENTIONS Educational interventions were developed based on the pilot study results. Providers received education on recommended opioid prescription quantities and a multimodal pain regimen. Standardized patient education infographics were distributed to patients pre- and postoperatively. MAIN OUTCOME MEASURES The primary outcomes measured were total opioid prescribed, total opioid consumed, pain control satisfaction levels, and the need for additional opioid prescription. RESULTS A total of 104 of 122 (85%) patients enrolled responded to the survey and were compared with the 112 patients included in the control group. Despite similar demographics, the study cohort was prescribed fewer milligram morphine equivalents (78.8 ± 11.3 vs 294.0 ± 33.1, p < 0.001), consumed fewer milligram morphine equivalents (23.0 ± 28.0 vs 57.1 ± 45.8, p < 0.001), and had a higher rate of nonopioid medication use (72% vs 10%, p < 0.001). The 2 groups had similar pain control satisfaction levels (4.1 ± 1.3 vs 3.9 ± 1.1 out of 5, p = 0.12) and an additional opioid prescription requirement (5% vs 4%, p = 1.0). LIMITATIONS This study was limited by its single-center experience with specific patient population characteristics. CONCLUSION Educational interventions emphasizing evidence-based recommended opioid prescription quantities and regimented multimodal pain regimens are effective in decreasing excessive opioid prescribing and use without compromising satisfactory pain control in patients undergoing ambulatory anorectal procedures. See Video Abstract at http://links.lww.com/DCR/B529. REDUCCIN DE LA SOBREPRESCRIPCIN Y EL USO DE OPIOIDES DESPUS DE UNA INTERVENCIN EDUCATIVA ESTANDARIZADA UNA ENCUESTA DE LAS EXPERIENCIAS EN PACIENTES POSTOPERADOS DE PROCEDIMIENTOS ANORRECTALES ANTECEDENTES:Un estudio piloto realizado en nuestra institución mostró que una cantidad significativa de opioides posoperatorios recetados no se usa, con potencial de desvío y uso indebido.OBJETIVO:Evaluar el impacto de las intervenciones educativas dirigidas al paciente y al proveedor sobre la prescripción y el uso de opioides posoperatorios después de procedimientos anorrectales.DISEÑO:Los pacientes se incluyeron entre julio de 2019 y marzo de 2020 después de implementar intervenciones educativas (estudio) y se compararon con el grupo de estudio piloto (control) inscrito entre agosto de 2018 y mayo de 2019. Se realizó una encuesta telefónica una semana después de la cirugía.ENTORNO CLÍNICO:Hospital de 600 camas en el sur de California.PACIENTES:Pacientes adultos sometidos a procedimientos anorrectales ambulatorios. Los criterios de exclusión fueron pacientes que recibieron un examen bajo anestesia, pacientes encarcelados y uso preoperatorio de opioides.INTERVENCIONES:Se desarrollaron intervenciones educativas basadas en los resultados del estudio piloto. Los proveedores recibieron educación sobre las cantidades recomendadas de opioides recetados y un régimen multimodal para el dolor. Se distribuyeron infografías estandarizadas de educación para el paciente antes y después de la operación.PRINCIPALES MEDIDAS DE RESULTADO:Opioide total prescrito, opioide total consumido, niveles de satisfacción del control del dolor y necesidad de prescripción adicional de opioides.RESULTADOS:Un total de 104 de 122 (85%) pacientes inscritos respondieron a la encuesta y se compararon con los 112 pacientes incluidos en el grupo de control. A pesar de una demografía similar, a la cohorte del estudio se le prescribió menos miligramos de equivalente de morfina (MME) (78,8 ± 11,3 frente a 294,0 ± 33,1, p <0,001), consumió menos MME (23,0 ± 28,0 frente a 57,1 ± 45,8, p <0,001) y presentaron una mayor tasa de uso de medicamentos no opioides (72% vs 10%, p <0,001). Los dos grupos tenían niveles similares de satisfacción del control del dolor (4,1 ± 1,3 frente a 3,9 ± 1,1 de 5, p = 0,12) y la necesidad de prescripción de opioides adicionales (5% frente a 4%, p = 1,0).LIMITACIONES:Experiencia en un solo centro con características específicas de la población de pacientes.CONCLUSIÓN:Las intervenciones educativas que enfatizan las cantidades recomendadas de prescripción de opioides basadas en la evidencia y los regímenes de dolor multimodales reglamentados son efectivas para disminuir la prescripción y el uso excesivos de opioides sin comprometer el control satisfactorio del dolor en pacientes sometidos a procedimientos anorrectales ambulatorios. Video Resumen en http://links.lww.com/DCR/B529.
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Affiliation(s)
- Dong Hum Yoon
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kasim L. Mirza
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Carey Wickham
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Erik R. Noren
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jason Chen
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Sang W. Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kyle G. Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Glenn T. Ault
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Pei X, Song S, Li H, Lu D. Efficacy and safety of acupoint catgut embedding in treating postoperative pain of mixed hemorrhoids: A randomized controlled trial protocol. Medicine (Baltimore) 2021; 100:e25948. [PMID: 34106667 PMCID: PMC8133192 DOI: 10.1097/md.0000000000025948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Pain is a common complication after mixed hemorrhoids, which seriously affects the recovery of patients and prolongs the length of hospital stay. Acupoint catgut embedding has advantages in improving a variety of acute and chronic pain diseases, but there is still a lack of rigorous randomized controlled studies to verify its efficacy and safety in the treatment of postoperative pain of mixed hemorrhoids. Therefore, the purpose of this randomized controlled trial is to evaluate the clinical efficacy of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids. METHODS This is a prospective randomized controlled trial to study the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids. Approved by the clinical research ethics committee of our hospital, the patients were randomly divided into observation group and control group according to 1:1. The observation group received acupoint catgut embedding before the operation, while the control group received no special treatment. The efficacy and safety indexes were concerned after the operation, and the observation indexes included: resting state and visual analogue scale (VAS) score during defecation, postoperative hospitalization time, total amount of analgesic use, adverse reactions, etc. Finally, we carried on the data statistical analysis through the SPSS version 19.0. DISCUSSION This study will evaluate the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids, and the results of this study will provide a new idea for the selection of postoperative analgesia for mixed hemorrhoids resection. TRIAL REGISTRATION OSF Registration number: DOI 10.17605/OSF.IO/T2ZGY.
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Affiliation(s)
- Xiaorui Pei
- Department of General Surgery, Tianjin TEDA Hospital
| | - Shijun Song
- Department of Hepatobiliary and Pancreatic Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Haotian Li
- Department of General Surgery, Tianjin TEDA Hospital
| | - Debao Lu
- Department of General Surgery, Tianjin TEDA Hospital
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21
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Abstract
BACKGROUND Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, especially in a surgical day care setting. OBJECTIVE The aim of this study was to investigate the use of pudendal nerve block in patients undergoing hemorrhoidectomy. DATA SOURCES PubMed, Google Scholar, Cochrane Library, and Web of Science databases were searched up to December 2020. STUDY SELECTION Randomized trials evaluating the pudendal nerve block effect in patients undergoing hemorrhoidectomy were selected. INTERVENTIONS Hemorrhoidectomy under general or spinal anesthesia with or without pudendal nerve block was performed. MAIN OUTCOME MEASURES Opioid consumption, pain on the visual analogue scale, length of hospital stay, and readmission rate were the main outcomes of interest and were plotted by using a random-effects model. RESULTS The literature search revealed 749 articles, of which 14 were deemed eligible. A total of 1214 patients were included, of whom 565 received the pudendal nerve block. After hemorrhoidectomy, patients in the pudendal nerve block group received opioids less frequently (relative risk, 0.364; 95% CI, 0.292-0.454, p < 0.001) and in a lower cumulative dose (standardized mean difference, -0.935; 95% CI, -1.280 to -0.591, p < 0.001). Moreover, these patients experienced less pain at 24 hours (standardized mean difference, -1.862; 95% CI, -2.495 to -1.228, p < 0.001), had a shorter length of hospital stay (standardized mean difference, -0.742; 95% CI, -1.145 to -0.338, p < 0.001), and had a lower readmission rate (relative risk, 0.239; 95% CI, 0.062-0.916, p = 0.037). Sensitivity analysis excluded the occurrence of publication bias on the primary end point, and the overall evidence quality was judged "high." LIMITATIONS Occurrence of publication bias among some secondary end points and heterogeneity are the main limitations of this study. CONCLUSIONS This systematic review and meta-analysis show significant advantages of pudendal nerve block use. A reduction in opioid consumption, postoperative pain, complications, and length of stay can be demonstrated. Despite the limitations, pudendal nerve block in patients undergoing hemorrhoidectomy should be considered.
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22
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Wilkie BD, Chandra R, Chua J, Lam DCS, Paratz ED, An V, Keck JO. Efficacy of postoperative oral metronidazole for haemorrhoidectomy pain: a randomized double-blind, placebo-controlled trial. Colorectal Dis 2021; 23:274-282. [PMID: 32750730 DOI: 10.1111/codi.15291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- B D Wilkie
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - R Chandra
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Monash University, Clayton, Victoria, Australia
| | - J Chua
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia
| | - D C S Lam
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,Department of Surgery, Northern Health, Melbourne, Vic, Australia
| | - E D Paratz
- St Vincent's Hospital Melbourne, Fitzroy, Melbourne, Victoria, Australia
| | - V An
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,Monash University, Clayton, Victoria, Australia
| | - J O Keck
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,St Vincent's Hospital Melbourne, Fitzroy, Melbourne, Victoria, Australia
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Sirikurnpiboon S, Jivapaisarnpong P. Botulinum Toxin Injection for Analgesic Effect after Hemorrhoidectomy: A Randomized Control Trial. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:186-192. [PMID: 33134600 PMCID: PMC7595677 DOI: 10.23922/jarc.2020-027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022]
Abstract
Objectives: Hemorrhoid is a common disease in surgical practice, but only a few numbers of patients need surgical treatment. The most common concern of patients is postoperative pain. This study aimed to evaluate the efficacy and safety of an intersphincteric injection of botulinum toxin for post-hemorrhoidectomy pain relief. Methods: Overall, 90 patients were enrolled, and 44 were randomized into a botulinum toxin injection group. Preoperative gradings were grade III 37 patients and grade II 2 patients. Patients received an intersphincteric injection of 0.5 ml of a solution containing 30 units of botulinum toxin (BTX). The postoperative data were collected pain score in a visual analog score (VAS), an analgesic used, hospital stay, and complication. Results: The VAS was lower in the BTX group at 12 hours and 24 hours postoperative phase. VAS at 12 hours 4.435 ± 2.149 vs 6.232 ± 2.307 (p < 0.001), VAS at 24 hours 2.205 ± 2.079 vs 3.744 ± 2.361(p = 0.003). The BTX group has a shorter time in defection without pain than the control group (3 vs. two days, p = 0.007). There was no difference in immediate and delay complications between the two groups. Conclusions: Postoperative hemorrhoidectomy needs multimodalities for pain reduction. Botulinum toxin has some benefit in postoperative pain reduction.
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Affiliation(s)
- Siripong Sirikurnpiboon
- Division of Colorectal Surgery, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Paiboon Jivapaisarnpong
- Division of Colorectal Surgery, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
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Abstract
BACKGROUND Hemorrhoids cause more than 4 million ambulatory care visits in the United States annually, and hemorrhoidectomy is associated with significant postoperative pain. There are currently no evidence-based opioid-prescribing guidelines for hemorrhoidectomy patients. OBJECTIVE The purpose of this study was to investigate patterns of opioid prescribing and to identify factors associated with opioid refill after hemorrhoidectomy. DESIGN This was a retrospective database review. SETTINGS The study was conducted using the Department of Defense Military Health System Data Repository (2006-2014). PATIENTS Opioid-naïve patients aged 18 to 64 years enrolled in TRICARE insurance who underwent surgical hemorrhoidectomy were included in this study. MAIN OUTCOME MEASURES We measured patterns of opioid prescriptions and predictors of a second opioid prescription within 2 weeks of the end date for the first prescription after hemorrhoidectomy. RESULTS A total of 6294 patients were included; 5536 (88.0%) filled an initial opioid prescription with a median 5-day supply, and 1820 (32.9%) required an opioid refill. The modeled risk of refill based on initial prescription supply ranged from a high of 39.2% risk with an initial prescription of 1-day supply to an early nadir (26.1% risk of refill) with an initial 10-day supply. A variety of sociodemographic and clinical characteristics influenced the likelihood of opioid refill, including black race (OR = 0.75 (95% CI, 0.62-0.89)), history of substance abuse (OR = 3.26 (95% CI, 1.37-7.34)), and length of index opioid prescription (4-6 d, OR = 0.83 (95% CI, 0.72-0.96) or ≥7 d, OR = 0.67 (95% CI, 0.57-0.78) vs 1-3 d). LIMITATIONS Variables assessed were limited because of the use of claims-based data. CONCLUSIONS There is wide variability in the length of prescription opioid use after hemorrhoidectomy. Approximately one third of patients require a second prescription in the immediate postoperative period. The optimal duration appears to be between a 5- and 10-day supply. Clinicians may be able to more efficiently discharge patients with adequate analgesia while minimizing the potential for excess supply. See Video Abstract at http://links.lww.com/DCR/B112. PRESCRIPCIÓN DE MÉDICAMENTOS OPIOIDES DESPUÉS DE HEMORROIDECTOMÍA: Las afecciones hemorroidarias ocasionan anualmente más de cuatro millones de consultas ambulatorias en los Estados Unidos. La hemorroidectomía esta asociada con dolor postoperatorio muy significativo. Actualmente no existen pautas claras para la prescripción de medicamentos opioides después de hemorroidectomía, basada en la evidencia.Investigar los patrones de prescripción de medicamentos opioides e identificar los factores asociados con la acumulación de dichos opioides después de una hemorroidectomía.Revisión retrospectiva de una base de datos.Almacén de datos del Sistema de Salud militar del Departamento de Defensa de los Estados Unidos de América (2006-2014).Todos aquellos sometidos a hemorroidectomía quirúrgica, sin tratamiento opiode previo, comprendiodos entre 18-64 años y beneficiarios de seguro TRICARE.Patrones de prescripción de recetas de opioides, predictores de una segunda receta de opioides dentro las dos semanas posteriores a la fecha de finalización de la primera receta después de la hemorroidectomía.6.294 pacientes fueron incluidos en el estudio. 5.536 (88,0%) completaron una receta inicial de opioides con un suministro promedio de cinco días, y 1.820 (32,9%) pacientes requirieron reabastecerse de opioides. El riesgo modelado de reabastecimiento de opiodes basado en el suministro de la prescripción inicial, varió desde un alto riesgo (39.2%) con una prescripción inicial de suministro por día, hasta un acmé temprano (26.1% de riesgo de reabastecimiento) con un suministro inicial de 10 días. Una gran variedad de características socio-demográficas y clínicas influyeron en la probabilidad del reabastecimeinto de los opioides, incluida la raza negra (OR 0.75, intervalo de confianza (IC) del 95% (0.62, 0.89)), los antecedentes de abuso de substancias (OR 3.26, IC del 95% (1.37, 7.34)) y la duración del índice de la prescripción de opioides (4-6 días (OR 0.83, IC 95% (0.72, 0.96)), o 7 días o más (OR 0.67, IC 95% (0.57, 0,78)) comparados a 1-3 días.Las variables analizadas fueron limitadas debido al uso de datos basados en reclamos.Existe una gran variabilidad en la duración del uso de opioides recetados después de hemorroidectomía. Aproximadamente un tercio de los pacientes requieren una segunda prescripción en el postoperatorio inmediato. La duración óptima parece estar entre un suministro de cinco y 10 días. Los médicos pueden dar de alta de manera más eficiente a los pacientes con analgesia adecuada y minimizar el potencial de exceso de suministro. Consulte Video Resumen en http://links.lww.com/DCR/B112. (Traducción-Dr. Xavier Delgadillo).
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25
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Fadel MG, Peltola L, Pellino G, Frunza G, Kontovounisios C. The Role of Pudendal Nerve Block in Colorectal Surgery: A Systematic Review. J INVEST SURG 2020; 34:1238-1245. [PMID: 32633163 DOI: 10.1080/08941939.2020.1786611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Colorectal surgery is associated with significant pain often requiring opioid and non-opioid analgesics. Pudendal nerve blocks (PNBs) can be administered with the aim to reduce pain and improve patient satisfaction. However, there are no current accepted guidelines for the use of PNB in colorectal surgery. METHOD We evaluated the available literature on the role of PNB in colorectal surgery to determine which technique and anesthetic agent may provide optimal pain relief and safety. Studies from January 1970 to December 2019 assessing PNB in colorectal surgery were retrieved from MEDLINE and EMBASE databases. Indication for PNB, technique, anesthetic agent, postoperative pain outcomes, patient satisfaction and complications were extracted. RESULTS We initially identified 339 studies of which 17 (nine randomized controlled trials, three cohort studies, one case-control study and four reviews) specifically met the inclusion criteria. The most common indication found for PNB is hemorrhoidectomy using either bupivacaine or lidocaine. The anatomical landmark and neurostimulation are the most favorable techniques being applied. The majority of studies reported better pain scores, less analgesia requirement and higher patient satisfaction when performing a bilateral PNB, with no major complications. CONCLUSIONS The current evidence, though limited, supports the use of bilateral PNBs in colorectal surgical procedures in particular hemorrhoidectomies. PNBs can be safe and effective in improving patient outcomes particularly when using bupivacaine or lidocaine with either the anatomical landmark or neurostimulation technique.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - Laura Peltola
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.,Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gabriela Frunza
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Ng KS, Holzgang M, Young C. Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020. Ann Coloproctol 2020; 36:133-147. [PMID: 32674545 PMCID: PMC7392573 DOI: 10.3393/ac.2020.05.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.
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Affiliation(s)
- Kheng-Seong Ng
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Melanie Holzgang
- Department of Colorectal Surgery, St. James's University Hospital, Leeds, UK
| | - Christopher Young
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Ala S, Alvandipour M, Saeedi M, Mansourifar M, Monajati M, Shiva A. Effect of Topical Baclofen 5% on Post-Hemorrhoidectomy Pain: Randomized Double Blind Placebo-Controlled Clinical Trial. J Gastrointest Surg 2020; 24:405-410. [PMID: 30783957 DOI: 10.1007/s11605-019-04147-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/01/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Baclofen is an agonist for a subtype of gamma-amino butyric acid (GABA-B) receptors and traditionally been used for the systemic treatment of spasticity. Topical application of baclofen has been shown to reduce pain in patients with localized neuropathic pain. OBJECTIVES In this study, we investigate the efficacy of baclofen cream (5%) in reducing postoperative pain and analgesic requirement after open hemorrhoidectomy. DESIGN The patients were randomly assigned to either baclofen (5%) cream or placebo immediately after surgery and then every 12 h for 14 days. PATIENTS A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were randomly assigned to this trial. SETTING This study was conducted at a single educational hospital. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were intensity of pain, measured with a visual analog scale, and the analgesic requirement, measured by the amount of the acetaminophen consumption. RESULTS No significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the baclofen group was significantly lower on week 1 (P = 0.01) and week 2 (P = 0.02) than the placebo group. Similarly, patients in the baclofen group consumed significantly less analgesic medication on week 1 (P = 0.025) and week 2 (P = 0.024) than the control group. CONCLUSION Topical application of baclofen effectively relieves pain after hemorrhoidectomy with minimal side effects.
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Affiliation(s)
- Shahram Ala
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mina Alvandipour
- Department of Surgery, Imam Khomeini General Hospital Affiliated to Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | - Majid Saeedi
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mohaddeseh Mansourifar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mahila Monajati
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Afshin Shiva
- Department of Clinical Pharmacy, Nephrology and Kidney Transplant Research Center, Faculty of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
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Zhao Y, Zhang L, Wang Y, Liao C, Chen Y, Zhen Q, Li Y. Acupuncture therapy for postoperative pain of anorectal diseases: A systematic review protocol. Medicine (Baltimore) 2020; 99:e19112. [PMID: 32049824 PMCID: PMC7035068 DOI: 10.1097/md.0000000000019112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The incidence of anorectal diseases has been increasing year by year, and the acupuncture treatment for postoperative pain of anorectal diseases has the excellent therapeutic effect. Currently, there are no relevant articles for systematic review. METHODS We will search the randomized controlled trials related to acupuncture therapy and postoperative anorectal diseases from inception to January 2020. The following database is our focus area: PubMed, EMBASE, Springer, EBSCO, Web of Science, Cochrane, Controlled Trials Register (CENTRAL), the Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wan-Fang Database and Chinese Scientific Journal Database (VIP database). The primary outcome is the pain of visual analogue scale (VAS). The secondary outcomes are the Symptom Checklist, Wong-Baker Faces Pain Rating (WB) Scale, verbalrating scale (VRS), and 36-Item Short Form Health Survey (SF-36) scale. We will use Review Manager Software (RevMan) V.5.2 for data analysis and quantitative data synthesis. The Cochrane collaborative tool will be used to assess the risk of bias in the included studies. RESULTS Given the available evidence, this study will provide high level results for acupuncture therapy in treating postoperative pain of anorectal diseases. CONCLUSION The conclusions of this study will provide evidence for whether acupuncture is effective in treating postoperative pain of anorectal diseases. PROSPERO REGISTRATION NUMBER CRD42020150015.
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29
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Brusciano L, Gambardella C, Terracciano G, Gualtieri G, Schiano di Visconte M, Tolone S, Del Genio G, Docimo L. Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids. Updates Surg 2019; 72:851-857. [PMID: 31760588 DOI: 10.1007/s13304-019-00694-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/16/2019] [Indexed: 02/08/2023]
Abstract
Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II-III degrees hemorrhoids. Consecutive patients with II-III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.
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Affiliation(s)
- Luigi Brusciano
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Claudio Gambardella
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy.,Department of Cardiothoracic Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gianmattia Terracciano
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Giorgia Gualtieri
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | | | - Salvatore Tolone
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Gianmattia Del Genio
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Ludovico Docimo
- University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy.
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30
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Ceulemans A, De Looze D, Van de putte D, Stiers E, Coppens M. High post-operative pain scores despite multimodal analgesia in ambulatory anorectal surgery: a prospective cohort study. Acta Chir Belg 2019; 119:224-230. [PMID: 30189793 DOI: 10.1080/00015458.2018.1500802] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Ambulatory surgery for anorectal procedures has become widely accepted. Recent reviews recommend a multimodal approach to pain management. However, these recommendations are largely based on single intervention studies. Our goal was to evaluate post-operative pain in patients receiving a multimodal analgesic regimen. Methods: All patients undergoing an ambulatory anorectal procedure between December 2015 and September 2016 received a pain diary. Mean pain throughout the day and pain during defecation where recorded on day 0-14 and day 21 postoperatively using a numeric rating scale-11. Use of oral analgesics was also recorded. Results: Forty-two patients completed the pain diary. The use of local anesthetic infiltration did not result in a significant difference in pain scores in this study. Patients who received written information on postoperative pain management and hygienic measures had higher intake of oral analgesics. Despite receiving multimodal analgesic treatment, patients undergoing surgery for hemorrhoids or anal fissures reported pain scores ≥4 and used analgesics longer. Conclusion: A multimodal analgesic approach consisting of local anesthetic infiltration, multiple oral analgesics and written information seems to be insufficient for certain patient groups after ambulatory anorectal surgery. Especially patients undergoing surgery for hemorrhoids or an anal fissure should receive adequate analgesia. Pain during defecation is problematic and finding a solution for this problem remains challenging. Further research into the combined use of different analgesic modalities is recommended.
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Affiliation(s)
- Aline Ceulemans
- Department of Ambulatory Surgery, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Danny De Looze
- Department of Ambulatory Surgery, Ghent University, Ghent, Belgium
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Dirk Van de putte
- Department of Ambulatory Surgery, Ghent University, Ghent, Belgium
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Eline Stiers
- Department of Ambulatory Surgery, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marc Coppens
- Department of Ambulatory Surgery, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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Wu J, Chen B, Yin X, Yin P, Lao L, Xu S. Effect of acupuncture on post-hemorrhoidectomy pain: a randomized controlled trial. J Pain Res 2018; 11:1489-1496. [PMID: 30122979 PMCID: PMC6084088 DOI: 10.2147/jpr.s166953] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To observe the clinical efficacy and safety of electroacupuncture (EA) in relieving pain after hemorrhoidectomy treatment for mixed hemorrhoids. Design This was a randomized controlled trial. Methods We conducted a single-center, single-blind, and randomized controlled clinical trial. Seventy-two patients with mixed hemorrhoids who had undergone hemorrhoidectomy were randomly assigned to the following 2 groups: the EA treatment group (EA) received surround needling with EA (n=36), and the control group received sham acupuncture (SA) treatment (n=36). The treatment was conducted within 15 min after the completion of the surgery and lasted for 30 min. The pain intensity was recorded by using the visual analog scale as the primary outcome. Secondary outcomes were verbal rating scale and Wong-Baker Faces Pain Rating. These measurements were evaluated at 11 time points: once every hour in the first 8 h after the treatment, 24 and 48 h after the treatment, and at the first defecation. Besides, quality of life was measured by Symptom Checklist-90 Scale at 24 and 48 h follow-ups. Results The EA group had significantly lower visual analog scale scores at the 3 time points of 6, 24 h, and during the defecation (p<0.05). Verbal rating scale showed a significantly lower score in the treatment group compared to the SA group at 4 h after the treatment as well as during defecation (p<0.05). The Wong-Baker Faces Pain Rating scores of EA group were significantly lower at 5, 7, and 8 h after treatment and during defecation (p<0.05) compared with those of SA group. Conclusion Acupuncture is effective in alleviating postoperative pain in patients who have undergone hemorrhoidectomy.
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Affiliation(s)
- Junyi Wu
- The Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China,
| | - Bei Chen
- The Acupuncture Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xuan Yin
- The Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China,
| | - Ping Yin
- The Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China,
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, People's Republic of China, .,University of Maryland School of Medicine, Baltimore, MD, USA,
| | - Shifen Xu
- The Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China,
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Wang WG, Lu WZ, Yang CM, Yu KQ, He HB. Effect of lateral internal sphincterotomy in patients undergoing excisional hemorrhoidectomy. Medicine (Baltimore) 2018; 97:e11820. [PMID: 30095654 PMCID: PMC6133531 DOI: 10.1097/md.0000000000011820] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Excisional hemorrhoidectomy (EH) is the major surgical option for high-grade symptomatic hemorrhoids, but it has some shortcomings, especially postoperative pain. This study was performed to assess the effect of lateral internal sphincterotomy (LIS) in patients undergoing excisional hemorrhoidectomy. METHODS A systematic literature search (Medline, Embase, Cochrane Library, Science Citation Index, Science Direct, Springer Link, Ovid Journals, and EBSCO) was performed to identify all eligible articles. Randomized controlled trials (RCTs) published until July 7, 2017 comparing EH combined with LIS (experimental group) with EH only (control group) were eligible for inclusion. The primary outcome of interest was postoperative pain. RESULTS Ten RCTs involving 1560 patients were identified for inclusion. The pooled analysis revealed that patients undergoing EH and LIS were associated with lower pain score [standardized mean difference (SMD), -0.75; 95% confidence interval (CI), -1.14 to -0.36; z = 3.76; P = .0002] and resting anal pressure [odds ratio (OR), -17.19; 95% CI, -25.66 to -8.72; z = 3.98; P < .0001], and lower incidence of anal stricture (OR, 0.12; 95% CI, 0.03-0.53; z = 2.85; P = .004). However, the differences of urinary retention, bleeding and length of hospital stay were similar between the 2 methods. CONCLUSION Our meta-analysis suggests that LIS effectively relieves postoperative pain and reduces patient's postoperative analgesic requirements. LIS also reduces the incidence of anal stenosis but increases the incidence of fecal incontinence.
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Affiliation(s)
- Wei-Guo Wang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Wen-Zhu Lu
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Chun-Mei Yang
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Ke-Qiang Yu
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Hong-Bo He
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
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Lee B, Schug SA, Joshi GP, Kehlet H, Bonnet F, Lavand’Homme P, Lirk P, Pogatzki-Zahn E, Raeder J, Rawal N, van der Velde M. Procedure-Specific Pain Management (PROSPECT) - An update. Best Pract Res Clin Anaesthesiol 2018; 32:101-111. [PMID: 30322452 DOI: 10.1016/j.bpa.2018.06.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/18/2018] [Indexed: 11/26/2022]
Abstract
Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps.
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Affiliation(s)
- Brian Lee
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - Stephan A Schug
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia; Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, Australia.
| | - Girish P Joshi
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Swarup A, Mathis KA, Hill MV, Ivatury SJ. Patterns of opioid use and prescribing for outpatient anorectal operations. J Surg Res 2018; 229:283-287. [PMID: 29937003 DOI: 10.1016/j.jss.2018.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/18/2018] [Accepted: 04/03/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgery for anorectal diseases is thought to cause significant pain postoperatively. There is little known regarding standardized opioid-prescribing trends and patient use following surgery for anorectal diseases. We aimed to evaluate and analyze opioid-prescribing trends and patient use for outpatient anorectal operations. MATERIALS AND METHODS All patients who underwent outpatient anorectal surgery performed over a 1-y period at a single institution were eligible. Procedures included hemorrhoidectomy, anal fistula repair/seton, anal fissure treatment with sphincterotomy, and transanal excision of rectal tumors. Demographic, operative, and postoperative data were obtained. Patients were given a survey to determine postoperative pain control with opioid and non-narcotic analgesia use; respondents were included in analysis. RESULTS Forty-two outpatient anorectal surgery patients were included: 13 had hemorrhoidectomy, 22 had anal fistula repair/seton, one had sphincterotomy, and six had transanal excisions. All patients had multimodality treatment with either an anal block and/or postoperative nonopioid analgesics. Ninety percent were prescribed opioids postoperatively with a median of 20 pills (range: 0-120 pills). Forty-three percent (18/42) did not fill their prescription. For those who used opioids, the median number of pills taken was four. Eighty percent of pills prescribed were not used. One patient required a refill. Greater than 60% of respondents reported good to excellent pain control on a five-point scale. CONCLUSIONS Most patients had adequate pain control after anorectal surgery with little to no use of opioids and that more than 80% of opioid pills prescribed were not consumed. We intend to standardize our prescribing opioid quantities for outpatient anorectal operations to reflect this reduced use.
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Affiliation(s)
- Abhishek Swarup
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Lebanon, New Hampshire
| | | | - Maureen V Hill
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Lebanon, New Hampshire
| | - Srinivas Joga Ivatury
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Lebanon, New Hampshire.
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Efficacy of Mesoglycan in Pain Control after Excisional Hemorrhoidectomy: A Pilot Comparative Prospective Multicenter Study. Gastroenterol Res Pract 2018; 2018:6423895. [PMID: 29743886 PMCID: PMC5884030 DOI: 10.1155/2018/6423895] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 12/31/2017] [Indexed: 02/07/2023] Open
Abstract
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.
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Yıldırım D, Dönmez T, Aktürk OM, Kocakuşak A, Çakır M, Yurtteri ME. Is there any benefit of harmonic scalpel for hemorrhoidectomy versus conventional diathermy? ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2018. [DOI: 10.25000/acem.384326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Parrish AB, O’Neill SM, Crain SR, Russell TA, Sonthalia DK, Nguyen VT, Aboulian A. An Enhanced Recovery After Surgery (ERAS) Protocol for Ambulatory Anorectal Surgery Reduced Postoperative Pain and Unplanned Returns to Care After Discharge. World J Surg 2018; 42:1929-1938. [DOI: 10.1007/s00268-017-4414-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Trenti L, Biondo S, Galvez A, Bravo A, Cabrera J, Kreisler E. Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy versus conventional hemorrhoidectomy for grade III and IV hemorrhoids: postoperative morbidity and long-term outcomes. Tech Coloproctol 2017; 21:337-344. [DOI: 10.1007/s10151-017-1620-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/29/2017] [Indexed: 12/14/2022]
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Garcia JBS, Bonilla P, Kraychete DC, Flores FC, Valtolina EDPD, Guerrero C. [Optimizing post-operative pain management in Latin America]. Rev Bras Anestesiol 2017; 67:395-403. [PMID: 28410820 DOI: 10.1016/j.bjan.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/26/2016] [Indexed: 11/25/2022] Open
Abstract
Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.
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Affiliation(s)
- João Batista Santos Garcia
- Universidade Federal do Maranhão (UFMA), Departamento de Anestesiologia, Dor e Cuidados Paliativos, São Luís, MA, Brasil.
| | - Patricia Bonilla
- Instituto Oncológico Luis Razetti, Departamento de Medicina Paliativa, Caracas, Venezuela
| | - Durval Campos Kraychete
- Universidade Federal da Bahia (UFBA), Departamento de Anestesiologia e Cirurgia, Bahia, BA, Brasil
| | - Fernando Cantú Flores
- Hospital Zambrano-Hellion TEC Salud, Departamento de Anestesia/Tratamento da Dor do Instituto de Dor, San Pedro Garza García, México
| | | | - Carlos Guerrero
- Hospital Universitario Fundacion Santa Fe, Departamento de Anestesia - Clínica de Dor, Bogotá, Colômbia
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Systemic Metronidazole May Not Reduce Posthemorrhoidectomy Pain: A Meta-Analysis of Randomized Controlled Trials. Dis Colon Rectum 2017; 60:446-455. [PMID: 28267013 DOI: 10.1097/dcr.0000000000000792] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hemorrhoidectomy is associated with significant postoperative pain. Oral metronidazole has been recommended as an adjunct to improve posthemorrhoidectomy analgesia. OBJECTIVE This study aimed to evaluate the impact of oral metronidazole on patient-reported pain following hemorrhoidectomy. DATA SOURCES We conducted a systematic search in the MEDLINE, EMBASE, ISI Web of Science, and Cochrane Central Register of Controlled Trials databases. STUDY SELECTION Randomized controlled trials examining adults who underwent surgical hemorrhoidectomy were included. Participants in an active intervention group received oral metronidazole postoperatively, and those in a control group received placebo or usual care. Postoperative pain was assessed for at least 3 days postoperatively. INTERVENTION A random-effects model was used. MAIN OUTCOMES MEASURES The primary outcome was pain during the first 2 postoperative weeks, measured on a visual analogue scale. The secondary outcome was time to return to normal activities. RESULTS Patients who received oral metronidazole had significantly lower reported pain scores on postoperative day 1 (standardized mean difference, -0.87 ± 0.44; 95% CI, -1.73 to -0.015; p = 0.046; n = 4) and day 4 (standardized mean difference, -1.43 ± 0.71; 95% CI, -2.83 to -0.037; p = 0.044; n = 3). Metronidazole use was associated with a significantly shorter time to return to normal activities (standardized mean difference, -0.76 ± 0.34; 95% CI, -1.43 to -0.088, p = 0.027). The improvements disappeared in a sensitivity analysis excluding the largest trial with a high risk of bias, and no significance was observed during the remaining postoperative days. LIMITATIONS The meta-analysis was limited by lack of double blinding, absence of a placebo, and unclear or high risk of bias in a proportion of the included trials. CONCLUSIONS Although a favorable adverse effect profile supports consideration of oral metronidazole to reduce posthemorrhoidectomy pain, pooled analysis reveals inconsistent results with no pain reduction on most postoperative days. The current recommendation for routine prescription of oral metronidazole should be reevaluated in the absence of additional well-designed trials.
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Medina-Gallardo A, Curbelo-Peña Y, De Castro X, Roura-Poch P, Roca-Closa J, De Caralt-Mestres E. Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients. Int J Surg Case Rep 2016; 30:73-75. [PMID: 27960130 PMCID: PMC5153430 DOI: 10.1016/j.ijscr.2016.11.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/13/2016] [Accepted: 11/13/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Surgery is the only curative method of hemorrhoidal disease. Currently the Milligan-Morgan hemorrhoidectomy is still considered the "gold standard", since it is the best performing technique. However, postoperative pain remains a major problem. We analize the postoperative analgesic requirements for this procedure in 117 patients. PRESENTATION OF CASES Between 2012 and 2013, 117 consecutive patients undergoing Milligan-Morgan hemorroidectomy, with an analysis of sex, age, total vascular anal cushions removed, hospital stay, complications, and relation with postoperative analgesic requirements. Patients with documented allergy to NSAIDs or pyrazolones were excluded. Additionally 23 patients undergoing Milligan-Morgan hemorrhoidectomy associated to internal lateral sphincterotomy were also analyzed. RESULTS The mean age of patients was 51.7 years. The 50.8% were women and 49.2% men. In 33.3% of cases, one vascular anal cushion was removed, 2 in 39.3%, and 3 in 27.4%. The average stay for the 3 groups was 2.0days. An analgesic dose average of 4.1 by day was given, with opioid requirements in 22.2% of cases. It was statistically significant that as more anal cushions were eliminated was higher the opioids need. No significant difference of opioids use was found regarding patients undergoing sphincterotomy as additional procedure. DISCUSSION Postoperative pain after a Milligan-Morgan hemorrhoidectomy currently remains a problem for colorectal surgery teams. This involves the use of opioids comparable to other major surgeries, finally causing not negligible days of admission charge. A protocolized analgesic treatment, as we actually do in our center, should be implemented after a Milligan-Morgan hemorrhoidectomy for improving the postoperative period pain management.
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Affiliation(s)
| | - Yuhamy Curbelo-Peña
- Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain.
| | - Xavier De Castro
- Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain.
| | - Pere Roura-Poch
- Department of Epidemiology, Vic University Hospital, Barcelona, Vic, Spain.
| | - Josep Roca-Closa
- Department of General Surgery, Vic University Hospital, Barcelona, Vic, Spain.
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Bjelanovic Z, Draskovic M, Veljovic M, Lekovic I, Karanikolas M, Stamenkovic D. Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. Cir Esp 2016; 94:588-594. [PMID: 27771095 DOI: 10.1016/j.ciresp.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/30/2016] [Accepted: 07/09/2016] [Indexed: 12/15/2022]
Abstract
INTRODUCTION This prospective, observational study evaluated transanal dearterialization (THD) efficacy and safety in grade 2-4 hemorrhoids (HD). METHODS THD was performed under sedation-locoregional anesthesia in 402 outpatients. Patients had follow-up evaluation 3 days, 2 weeks, 1, 6 and 12 months postoperatively. Postoperative complications and recurrence of symptoms at 12 months were analyzed. The relationship between the learning curve and the number of postoperative complications was studied. RESULTS Mean patient age was 46.4 (range 20-85) years. A total of 268 patients (66.6%) were male. Sixteen patients (4.0%) had grade 2 HD, 210 (52.2%) had grade 3 and 176 (43.8%) had grade 4 HD. Surgery lasted 23 (17-34) min. A total of 67 patients had complications: bleeding in 10 patients (2.5%), hemorrhoidal thromboses in 10 (2.5%), perianal fistulas in 5 (1.2%), fissures in 14 (3.5%), urinary retention in 3 (0.8%), residual prolapse in 19 (4.7%), severe anal pain in 3 (0.8%), and perianal abscess in 3 patients (0.8%). Recurrent HD occurred in 6.3% (1/16) of grade 2 HD patients, 5.8% (12/210) of grade 3 patients and 9.7% (17/176) of grade 4 patients. Twelve months after THD, bleeding was controlled in 363 patients (90.5%), prolapse was controlled in 391 (97.3%) and pain markedly improved in 390 patients (97%). CONCLUSION THD appears safe and effective for grade 2-4 HD, and the number of complications decreased with increasing surgeon experience. THD advantages include mild pain, fast recovery, early return to daily activities and low incidence of complications.
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Affiliation(s)
- Zoran Bjelanovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia.
| | - Miroljub Draskovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia
| | - Milic Veljovic
- Clinic for Anesthesiology and Intensive Care, Military Medical Academy, Belgrado, Serbia
| | - Ivan Lekovic
- Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrado, Serbia
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, San Luis, Misuri, Estados Unidos
| | - Dusica Stamenkovic
- Clinic for Anesthesiology and Intensive Care, Military Medical Academy, Belgrado, Serbia
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Evidence-Based Management of Pain After Excisional Haemorrhoidectomy Surgery: A PROSPECT Review Update. World J Surg 2016; 41:603-614. [DOI: 10.1007/s00268-016-3737-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Serra M, Vives R, Cañellas M, Planell J, Oliva JC, Colilles C, Pontes C. Outpatient multimodal intravenous analgesia in patients undergoing day-case surgery: description of a three year experience. BMC Anesthesiol 2016; 16:78. [PMID: 27619387 PMCID: PMC5020512 DOI: 10.1186/s12871-016-0246-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 09/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background The use of elastomeric devices for ambulatory intravenous pain treatment in Major Ambulatory Surgery (MAS) has been described to improve postoperative pain management. The objective of the study was to describe the first 3 years experience of the use of elastomeric devices for ambulatory intravenous pain treatment in MAS implemented at our site since 2010. Methods Data were retrieved from the medical records for all patients who, between January 2010 and March 2014, underwent surgical procedures at the ambulatory surgical centre at our hospital and were prescribed a home-based continuous intravenous analgesia. Results Data were retrieved from the medical records of 1128 patients. The most frequent surgical interventions included orthopedic and proctology surgeries. 80 % of patients were discharged home without pain; during the first 48 h after discharge roughly 40 % of subjects were completely free of pain, 50 % reported mild pain (VAS 1 to 3) and 9 % reported higher pain scores (4 and above). Peripheral nerve block was associated to better pain control in the immediate postoperative period. Vomiting in the first 24 h was 4.6 % before introducing haloperidol into the drug schemes, and 2.6 % thereafter. Complications related with the intravenous route required treatment withdrawal in 1.1 % cases. Only 3.5 % of patients returned to the hospital in the first 72 h, mainly for non-pain related reasons. Overall, 99.5 % of patients were satisfied with the treatment received at home. Conclusion Our initial experience suggest that outpatient multimodal intravenous analgesia in patients undergoing day-case surgery is a feasible alternative in our setting, that allows an effective management of postoperative pain with a small rate of adverse events and complications requiring readmission.
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Affiliation(s)
- Magdalena Serra
- Anesthesiology Department, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Roser Vives
- Clinical Pharmacology Unit, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain.,Departamento de Farmacologia, de Terapèutica i de Toxicologia, Universitat Autònoma de Barcelona, Edifici Taulí planta -1 Hospital de Sabadell C/ Parc taulí n° 1, Sabadell, Barcelona, 08208, Spain
| | - Montserrat Cañellas
- Anesthesiology Department, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Josep Planell
- Anesthesiology Department, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Joan Carles Oliva
- Statistics Unit, Institut d'Investigació e Innovació Parc Taulí, Sabadell, Barcelona, Spain
| | - Carmen Colilles
- Anesthesiology Department, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Caridad Pontes
- Clinical Pharmacology Unit, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain. .,Departamento de Farmacologia, de Terapèutica i de Toxicologia, Universitat Autònoma de Barcelona, Edifici Taulí planta -1 Hospital de Sabadell C/ Parc taulí n° 1, Sabadell, Barcelona, 08208, Spain.
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Huang HX, Yao YB, Tang Y. Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids. Exp Ther Med 2016; 12:1022-1028. [PMID: 27446315 PMCID: PMC4950541 DOI: 10.3892/etm.2016.3339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/12/2016] [Indexed: 12/22/2022] Open
Abstract
The aim of the present study was to examine the clinical value of ‘tying, binding and fixing operation’ in treating severe mixed hemorrhoids. A total of 160 patients with severe mixed hemorrhoids were selected and randomly divided into the experimental (n=80) and control (n=80) groups. The groups were treated using ‘tying, binding and fixing operation’ and Doppler ultrasound-guided hemorrhoidal artery ligation (DG-HAL), respectively. The results showed that the average operative time of the experimental group (35.57±6.17) was significantly higher than that of the control group (12.73±4.92). There was no significant difference of blood loss during the operation between the two groups (P>0.05). There was also no significant difference in improving the hemorrhage symptom between the two groups (P>0.05). In addition, concerning improvement of prolapse symptoms and reduction of the volume of hemorrhoids, the experimental group were significantly improved as compared to the control group. No anal function damage in the two groups was identified, and the length of stay in hospital for the two groups was not significantly different (P>0.05). However, the hospitalization cost in the experimental group (5,334.77±875.54) was significantly lower than that of the control group (8,551.81±1,806.54) and satisfaction degree was significantly higher than that of the control group. The incidences of perianal pain, anal edema and dysuria between two groups were not significantly different (P>0.05). There were 10 cases of secondary hemorrhage and 18 cases of infection in the experimental group, and 12 cases of secondary hemorrhage and 14 cases of infection in the control group, although the differences between the two groups were not statistically significant (P>0.05). The incidence rate of local hematoma in the experimental group (1.2%) was significantly lower than that in the control group (15.0%). The recurrence rate of the control group (22.5%) was also significantly higher than that of the experimental group (2.5%). In conclusion, tying, binding and fixing operation is a promising method that may be employed for the treatment of sever mixed hemorrhoids, and it is better than DG-HAL in improving the prolapse and reducing the volume of hemorrhoids.
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Affiliation(s)
- Hong-Xiang Huang
- Department of Anorectal Surgery, Xin Hua Hospital Affilliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Yi-Bo Yao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, P.R. China
| | - Ying Tang
- Department of Anorectal Surgery, Xin Hua Hospital Affilliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
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Shaw D, Ternent CA. Perioperative Management of the Ambulatory Anorectal Surgery Patient. Clin Colon Rectal Surg 2016; 29:7-13. [PMID: 26929746 PMCID: PMC4755778 DOI: 10.1055/s-0035-1570023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Darcy Shaw
- Colon and Rectal Surgery Inc., Omaha, Nebraska
| | - Charles A. Ternent
- Department of Surgery, Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Department of Surgery, Department of Surgery, University of Nebraska College of Medicine, Omaha, Nebraska
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Stapled hemorrhoidopexy: functional results, recurrence rate, and prognostic factors in a single center analysis. Int J Colorectal Dis 2016; 31:35-9. [PMID: 26245950 DOI: 10.1007/s00384-015-2354-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Since its introduction, stapled hemorrhoidopexy (SHP), the so-called Longo procedure, became a widely accepted treatment option for prolapsing hemorrhoids. Nevertheless, from the early years, concerns grew about the early functional results and potential recurrences. In order to evaluate of SHP with special respect to early defecation disorders und recurrences, our single institute high-volume results were evaluated. METHOD One thousand one hundred forty-four consecutive patients with SHP for prolapsing hemorrhoids were evaluated in a period from January 2007 to December 2013. In a prospective analysis, patients were followed with special respect to postoperative complications, functional disorders, mainly perianal irritation, stenosis, and recurrence. RESULTS During the timeframe, a total of 663 men and 481 women were treated for prolapsing hemorrhoids. The mean age was 52.6 years (±14.4 years). Indication for surgery was prolapsing hemorrhoids in all cases. In addition to prolapse, 90 patients (7.9 %) suffered from bleeding, 96 patients (8.4 %) had itching, and 95 (8.3 %) had anal wetness; the mean operative time was 11 min (±4 min). Patients were treated as inpatients; the mean hospital stay was 3 days (±1 day). Early complications were observed in 14 patients (1.2 %). The follow-up revealed inflammatory reaction at the stapleline in 8 patients (0.7 %) and rectal stenosis in 22 cases (1.9 %), and recurrence was observed in 46 cases (4.0 %). CONCLUSION The data presented here provide evidence that SHP is a save procedure with a very low rate for functional disorders and low recurrence rate. Therefore, in our hands, SHP remains standard for prolapsing hemorrhoids.
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Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis. Int J Colorectal Dis 2015; 30:437-45. [PMID: 25427629 DOI: 10.1007/s00384-014-2073-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The aims of this study are to review the advantages and drawbacks of the ambulatory management of patients scheduled for haemorrhoidal surgery and to highlight the reasons for unplanned hospital admission and suggest preventive strategies. METHODS We conducted a systematic review of the literature from January 1999 to January 2013 using MEDLINE and EMBASE databases. Manuscripts were specifically analysed for failure and side effects of haemorrhoidal surgery in ambulatory settings. RESULTS Fifty relevant studies (6082 patients) were retrieved from the literature review. The rate of ambulatory management failure ranged between 0 and 61%. The main reasons for failure were urinary retention, postoperative haemorrhage and unsatisfactory pain control. Spinal anaesthesia was associated with the highest rates of urinary retention. Doppler-guided haemorrhoidal artery ligation has less frequent side effects susceptible to impair ambulatory management than haemorrhoidectomy and stapled haemorrhoidopexy. However, the fact that haemorrhoidopexy is less painful than haemorrhoidectomy may allow ambulatory management. CONCLUSION Day-case haemorrhoidal surgery can be performed whatever the surgical procedure. Postoperative pain deserves special prevention measures after haemorrhoidectomy, especially by using perineal block or infiltrations. Urinary retention is a common issue that can be responsible for failure; it requires a preventive strategy including short duration spinal anaesthesia. Doppler-guided haemorrhoidal artery ligation is easy to perform in outpatients but deserves more complete evaluation in this setting.
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Balta AZ, Ozdemir Y, Sucullu I, Filiz A, Yucel E, Akin ML. The Effect of Early Warm Plastic Bag Application on Postoperative Pain after Hemorrhoidectomy: A Prospective Randomized Controlled Trial. Am Surg 2015. [DOI: 10.1177/000313481508100232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ahmet Ziya Balta
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Yavuz Ozdemir
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Ilker Sucullu
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Aliilker Filiz
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Ergun Yucel
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Mehmet Levhi Akin
- Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
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Denoya PI, Fakhoury M, Chang K, Fakhoury J, Bergamaschi R. Dearterialization with mucopexy versus haemorrhoidectomy for grade III or IV haemorrhoids: short-term results of a double-blind randomized controlled trial. Colorectal Dis 2014; 15:1281-8. [PMID: 23711288 DOI: 10.1111/codi.12303] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/23/2013] [Indexed: 12/24/2022]
Abstract
AIM There is scepticism regarding anatomical rationale and Doppler guidance for ligation of haemorrhoidal arteries. The null hypothesis of this randomized controlled trial (RCT) was that there is no difference in pain following dearterialization or haemorrhoidectomy for grade III/IV internal haemorrhoids in a minimum of three quadrants. METHOD This was a single-centre, double-blind RCT. Patients were allocated to dearterialization or haemorrhoidectomy. Included haemorrhoids were grade III, prolapsing but reducible; and grade IV, chronic non-incarcerated. The primary end-point was pain. Patients with external component, acute incarcerated grade IV or recurrent haemorrhoids were not included. The interventions were dearterialization (with Doppler guidance and mucopexy) or haemorrhoidectomy. The main outcome measure was the Brief Pain Inventory (BPI). RESULTS Twenty dearterialization patients were comparable to 20 haemorrhoidectomy patients for age (P = 0.107), body mass index (P = 0.559), race (P = 0.437), American Society of Anesthesiology score (P = 0.569), comorbidities (P = 0.592), grade (P = 0.096), quadrants (P = 0.222), Fecal Incontinence Quality-of-Life Score (FIQOL; P = 0.388), coping (P = 0.532), depression (P = 0.505), embarrassment (P = 0.842), and Short Form Health Survey (SF-12) physical components (P = 0.337), SF-12 mental components (P = 0.396) and constipation (P = 0.628) scores. Dearterialization patients had shorter operative time (36 vs 54 min, P = 0.043) with less pain (P = 0.011) and urinary retention (P = 0.012). Dearterialization patients had first bowel movement earlier (1.3 vs 4.6 days, P = 0.001), less pain (P = 0.011) and lower pain intensity (P = 0.001). Narcotic requirements were reduced in dearterialization patients (25% vs 100%, P = 0.001), with less medication (4.9 vs 112 pills, P = 0.001) and shorter regimen (0 vs 7 days, P = 0.001). BPI did not differ on days 1, 3, 5, 7 and 14 except for less pain in dearterialization patients. At 3 months, symptomatic relief was the same with no differences in BPI, FIQOL or SF-12. CONCLUSION Compared with haemorrhoidectomy, dearterialization led to less pain in grade III/IV haemorrhoids.
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Affiliation(s)
- P I Denoya
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
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