Literature Reviews

Procedure-specific systematic review summary


Haemorrhoid Surgery 2006

Ong et al 2005

The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis

Ong CK, Lirk P, Seymour RA, Jenkins BJ

Anesth Analg 2005;100(3):757–73

Whether preemptive analgesic interventions are more effective than conventional regimens in managing acute postoperative pain remains controversial. We systematically searched for randomized controlled trials that specifically compared preoperative analgesic interventions with similar postoperative analgesic interventions via the same route. The retrieved reports were stratified according to five types of analgesic interventions: epidural analgesia, local anesthetic wound infiltration, systemic N-methyl-d-aspartic acid (NMDA) receptor antagonists, systemic nonsteroidal antiinflammatory drugs (NSAIDs), and systemic opioids. The primary outcome measures analyzed were the pain intensity scores, supplemental analgesic consumption, and time to first analgesic consumption. Sixty-six studies with data from 3261 patients were analyzed. Data were combined by using a fixed-effect model, and the effect size index (ES) used was the standardized mean difference. When the data from all three outcome measures were combined, the ES was most pronounced for preemptive administration of epidural analgesia (ES, 0.38; 95% confidence interval [CI], 0.28-0.47), local anesthetic wound infiltration (ES, 0.29; 95% CI, 0.17-0.40), and NSAID administration (ES, 0.39; 95% CI, 0.27-0.48). Whereas preemptive epidural analgesia resulted in consistent improvements in all three outcome variables, preemptive local anesthetic wound infiltration and NSAID administration improved analgesic consumption and time to first rescue analgesic request, but not postoperative pain scores. The least proof of efficacy was found in the case of systemic NMDA antagonist (ES, 0.09; 95% CI, -0.03 to 0.22) and opioid (ES, -0.10; 95% CI, -0.26 to 0.07) administration, and the results remain equivocal

Yosry 2004

Caudal injection of ketorolac is as effective as systemic administration with lower incidence of side effects.

Yosry M, Abou RFA, Nasr MA.

Egyptian Journal of Anaesthesia 2004;20(3):261-265.

Background: This study was designed to compare the efficacy and safety of intravenous vs. caudal administration of ketorolac 30 mg for control of postoperative pain. Methods: The study included 60 adult patients scheduled for haemorrhoidectomy. Patients were randomly divided into two equal groups to receive ketorolac 30 mg either caudally (group C) or intravenously (group V) before the start of surgery, Anaesthetic protocol was standardized in the two groups using fentanyl, and propofol for induction and maintenance of anaesthesia. Postoperative visual analogue scores (VAS) of pain were recorded at predefined time intervals, both in the supine and sitting position. Meperidine (1 mg/kg) was given on patient's request. No other analgesics were given. The need for postoperative meperidine and the number of doses required were recorded, as well as the time to request of postoperative analgesia. Side effects were recorded, namely gastric upsets, chest tightness, bleeding disorders, renal dysfunction, skin rash and anaphylaxis. Results: No significant differences were found between the two groups with respect to pain scores, or in the consumption of supplementary analgesics. Gastric upsets and bleeding disorders were significantly less common in group C (1 (3.3%) and 2 (6.7%), respectively) than group V (6 (20%) and 10 (33.3%), respectively). the incidence of chest tightness and skin rash was comparable in the two groups. No patient complained of renal dysfunction or anaphylaxis. Conclusion: Caudal administration of ketorolac 30 mg in adults undergoing haemorrhoidectomy is as efficacious as intravenous administration of the same dose as regards postoperative pain control, with fewer side effects.

Greenberg et al 2000

A new cyclooxygenase-2 inhibitor, rofecoxib (VIOXX), did not alter the antiplatelet effects of low-dose aspirin in healthy volunteers.

Greenberg HE, Gottesdiener K, Huntington M, Wong P, Larson P, Wildonger L, Gillen L, Dorval E, Waldm

J Clin Pharmacol 2000;40(12 Pt 2):1509–1515.

The present study examined whether rofecoxib (VIOXX), a new specific inhibitor of cyclooxygenase-2 (COX-2), would interfere with the desired antiplatelet effects of aspirin. Thus, the effects of rofecoxib on inhibition of ex vivo serum-generated thromboxane B2 (TXB2) and platelet aggregation by low doses (81 mg) of aspirin were examined in healthy volunteers. This was a double-blind, randomized, placebo-controlled, parallel study of two treatment groups (n=12 per group) in which subjects received 50 mg of rofecoxib or placebo for 10 days in a blinded fashion. Subjects also received 81 mg aspirin once on each of days 4 through 10 in an open-label fashion. Blood for measurement of serum TXB2 production and platelet aggregation studies was collected on day 1 (prior to rofecoxib/placebo), on day 4 (prior to aspirin), and on day 10 (before and 4 hours following the seventh dose of aspirin). Platelet-derived serum TXB2 (COX-1 assay) was measured in blood clotted for 1 hour at 37oC. Platelet aggregation was independently induced employing 1 mM arachidonic acid and 1 µg/ml collagen as agonists. Rofecoxib administered alone had no significant effect on serum TXB2 production or platelet aggregation (day 4). TXB2 production was inhibited 98.4% by aspirin coadministered with either rofecoxib or placebo (day 10). Similarly, platelet aggregation induced by arachidonic acid was inhibited 93.7% and 93.5% by aspirin coadministered with either rofecoxib or placebo, respectively (day 10). The comparable values for inhibition of collagen-induced platelet aggregation were 86.8% and 90.8%, respectively. No important clinical or laboratory adverse experiences were observed. In conclusion, rofecoxib alone (50 mg QD for 4 days) did not inhibit serum TXB2 production or platelet aggregation. In addition, rofecoxib (50 mg QD for 10 days) did not alter the antiplatelet effects of low-dose aspirin (inhibition of platelet aggregation and TXB2 production). Rofecoxib was generally well tolerated when administered alone or in combination with low-dose aspirin.

Aasboe 1998

Betamethasone reduces postoperative pain and nausea after ambulatory surgery.

Aasboe V, Raeder JC, Groegaard B.

Anesthesia and Analgesia 1998;87(2):319-23.

The aims of this study were to evaluate the effects of a single-dose glucocorticoid on the incidence and severity of pain and nausea and vomiting (PONV) after ambulatory surgery. Seventy-eight ASA physical status I-III patients scheduled for hemorrhoidectomy or hallux valgus correction were studied using a randomized, double-blind, placebo- controlled protocol. One group received 12 mg of betamethasone i.m. 30 min before the start of surgery (Group B), whereas the placebo group (Group P) received saline. General anesthesia was induced with propofol and fentanyl and maintained with isoflurane in both groups. Pain (measured using a visual analog scale, verbal score, and analgesic requirements), PONV, and other side effects were evaluated postoperatively. Patients in Group B experienced significantly less postoperative pain, less PONV, and better patient satisfaction during the first 24 h after surgery. In conclusion, a single dose of betamethasone (12 mg) seemed to produce analgesic and antiemetic effects after day-case surgery. Implications: In a placebo-controlled study, the use of corticosteroid prophylaxis (betamethasone) produced a significant reduction in both postoperative pain and nausea in outpatients who received the corticosteroid injection before ambulatory foot or hemorrhoid operations.

Liu 2000

Premedication with dextromethorphan provides posthemorrhoidectomy pain relief.

Liu ST, Wu CT, Yeh CC, Ho ST, Wong CS, Jao SW, Wu CC, Kang JC.

Diseases of the Colon and Rectum 2000;43(4):507-10.

PURPOSE: Previous studies have shown that N-methyl-D-aspartate receptor antagonists provide a preemptive analgesic effect in humans. This study was designed to examine whether premedication with dextromethorphan, an N-methyl-D-aspartate antagonist, also provided a preemptive analgesic effect that improved postoperative pain management. METHODS: Sixty patients who were American Society of Anesthesiologists status I and II scheduled for hemorrhoidectomy (modified Whitehead procedure) were included in the study. Patients were randomly assigned to the control and study groups. For the control group patients received chlorpheniramine maleate (20 mg), a component of the injection form of dextromethorphan, intramuscular injection 30 minutes before skin incision. In the study group dextromethorphan 40 mg containing 20 mg chlorpheniramine maleate (intramuscular) was given as premedication 30 minutes before skin incision. Pethidine (1 mg/kg, intramuscular) was given for pain relief as required postoperatively. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for 48 hours postoperatively. RESULTS: The times to first pethidine injection (mean +/- standard error of the mean) were 5.2 +/- 3 and 19.6 +/- 6 hours in the control and study groups, respectively. Total pethidine consumption was 140 +/- 11.3 and 63.5 +/- 11.8 mg in the control and study groups. The worst visual analog scale pain scores were 7.4 +/- 0.2 and 5.6 +/- 0.3 in the control and study groups during the two- day observation. The numbers of patients who required pethidine injection were 29 and 20 in the control and study groups, respectively. Two patients suffered pethidine-related side effects, such as nausea, vomiting, dizziness, and headache, in the control group, and no patient complained of any side effect in the study group. CONCLUSION: We found that dextromethorphan premedication provided a preemptive analgesic effect, thus producing reduced postoperative pain and pethidine requirement and improved recovery from hemorrhoidectomy.

Kilbride 1994

Transdermal fentanyl improves management of postoperative hemorrhoidectomy pain.

Kilbride M, Morse M, Senagore A.

Diseases of the Colon and Rectum 1994;37(11):1070-2.

PURPOSE: Outpatient postoperative hemorrhoidectomy pain remains a difficult problem. The purpose of this study is to evaluate the use of transdermal fentanyl for analgesia following hemorrhoidectomy. METHODS: Patients were prospectively randomized in a double-blind fashion to one of two groups, placebo or transdermal fentanyl. Forty- two patients were eligible for the study (placebo, 21; fentanyl, 17; 4 were excluded). A visual analog scale was used to evaluate postoperative pain (0 = no pain; 10 = worst pain). RESULTS: Fewer patients in the fentanyl group (10/17) required postoperative parental narcotics than the placebo group (21/21) (P < 0.05 Fisher's exact test). The amount of narcotics consumed postoperatively was significantly less in the fentanyl group (97.05 mg of meperidine +/- 23.27) than in the placebo group (236.19 +/- 30.46) (P < .05 Student's t-test). Pain scores in the fentanyl group were significantly lower (less pain) than in the placebo group (P < 0.05 Kruskal-Wallis). CONCLUSION: Results indicate that use of transdermal fentanyl provides an effective analgesic alternative that improves the transition to noninvasive outpatient pain management in the hemorrhoidectomy patient.

London 1987

Effect of four days of preoperative lactulose on posthaemorrhoidectomy pain: results of placebo controlled trial.

London NJ, Bramley PD, Windle R.

British Medical Journal (Clinical research ed.) 1987;295(6594):363-4.

The effect of four days of preoperative lactulose on posthaemorrhoidectomy pain was studied in a prospective double blind randomized trial. All patients received lactulose on admission to hospital, 20 received lactulose for four days before admission, and 22 received placebo. The preoperative lactulose treatment group suffered significantly less pain on defecation for the first four days that they opened their bowels (visual analogue scores in cm: day 1, 4.4 v 5.9; day 2, 4.1 v 6.3; day 3, 4.5 v 6.1; day 4, 4.6 v 6.5), suffered significantly less pain during the first two 24 hour periods after defecation (visual analogue scores in cm: day 1, 5.0 v 7.0; day 2, 3.9 v 6.1), and required significantly less analgesia daily after defecation (0.76 g paracetamol/day v 1.29 g paracetamol/day). These results show that lactulose given for four days preoperatively reduces pain after haemorrhoidectomy.

Roxas 2003

Double-blind, randomized, placebo-controlled trial to determine the efficacy of eutectic lidocaine/prilocaine EMLA cream for decreasing pain during local anaesthetic infiltration for out-patient haemo

Roxas M, Talip B, Crisostomo A.

Asian Journal of Surgery / Asian Surgical Association 2003;26(1):26-30.

OBJECTIVE: The study was undertaken to evaluate the efficacy of eutectic lidocaine/prilocaine (EMLA) cream for decreasing pain during local anaesthetic infiltration for outpatient haemorrhoidectomy. METHODS: Ninety-eight patients were randomly assigned either to receive EMLA or placebo. The creams were applied 45 minutes prior to injection of a lidocaine/bupivacaine mixture using a diamond-shaped perianal block. All participants were blinded to the specific medication received. They were asked to rate pain and levels of acceptability using a pre-validated pain scale and questionnaire. RESULTS: There were 49 patients in each group. The baseline characteristics between the two groups were similar. Forty patients (82%) in the EMLA group and 42 patients (86%) in the placebo group reported only mild pain during injection and infiltration of the lidocaine/bupivacaine mixture. The mean rank pain scores were 49.11 and 48.89, respectively (p = 0.886, not significant). CONCLUSION: While outpatient haemorrhoidectomy under local anaesthesia was generally well tolerated, there was no statistically significant difference between EMLA cream and placebo for decreasing pain during anaesthetic infiltration.

Morisaki 1996

Wound infiltration with lidocaine prolongs postoperative analgesia after haemorrhoidectomy with spinal anaesthesia.

Morisaki H, Masuda J, Fukushima K, Iwao Y, Suzuki K, Matsushima M.

Canadian Journal of Anaesthesia = Journal canadien d'anesthesie 1996;43(9):914-8.

PURPOSE: There are few clinical data examining whether sensitization of peripheral nerves contributes to postoperative pain when the entry of noxious impulses to the central nervous system is blocked. We hypothesized that wound infiltration with lidocaine would provide better postoperative analgesia than with normal saline following haemorrhoidectomy with spinal blockade. METHODS: In a randomized, placebo-controlled, blinded study, 168 adults undergoing haemorrhoidectomy were allocated to two groups. In Group L (n = 88) local infiltration was provided with lidocaine 1% and in Group S (n = 80) with normal saline. Following spinal anaesthesia with lidocaine 3%, the surgeon infiltrated 15 ml of either infiltration solution to the surgical area. Postoperative analgesia was obtained by continuous epidural administration of 90 mg eptazocine in normal saline for 48 hr. Supplemental analgesics were given on request. Postoperative pain control was assessed at rest and during coughing with a 10 cm VAS on the 1st, 2nd, and 3rd postoperative days (POD). RESULTS: The VAS scores at rest in Group L were lower than those in Group S throughout the postoperative period. During coughing, VAS scores in Group S were increased on the 3rd postoperative day, while those in Group L remained constant (4.42 +/- 0.27 vs 3.14 +/- 0.28, P < 0.05). Fewer patients in Group L than in Group S required supplemental analgesics. CONCLUSION: Preoperative lidocaine infiltration to the surgical area provided prolonged postoperative analgesia in patients receiving haemorrhoidectomy with spinal anaesthesia.

Brunat 2003

Posterior perineal block with ropivacaine 075% for pain control during and after hemorrhoidectomy.

Brunat G, Pouzeratte Y, Mann C, Didelot JM, Rochon JC, Eledjam JJ.

Regional Anesthesia and Pain Medicine 2003;28(3):228-32.

BACKGROUND AND OBJECTIVES: As perioperative pain management is a difficult challenge during hemorrhoidectomy, we tested the hypothesis that posterior perineal block (PPB) with local anesthetics alone is able to provide adequate pain control during and after surgery. METHODS: In a prospective, blinded, randomized study, we studied analgesic conditions and side effects of PPB in American Society of Anesthesiologists (ASA) I-II patients undergoing hemorrhoidectomy. Patients received general anesthesia (GA) either with PPB (0.75% ropivacaine, 40 mL (PPB group) or without PPB (control group). All patients received intravenous morphine patient-controlled analgesia (PCA) for postoperative pain control (morphine, 1.5 mg-boluses, 8- minute lockout interval). Intra- and postoperative opioids consumption was recorded, and pain assessments were performed at 1, 2, 4, 8, 12, and 24 hours using a visual analog scale (VAS). RESULTS: VAS scores were significantly lower during the first 8 postoperative hours in the PPB group as compared with the control group (P <.001). The PPB group required significantly less opioids during anesthesia (P <.001) and during the first postoperative day (P <.001) as compared with the control group. Time to first defecation and duration of hospitalization were identical in both groups. CONCLUSIONS: The present study shows that PPB with 40 mL 0.75% ropivacaine (300 mg) was a simple, effective, and safe method to provide better postoperative analgesia than PCA alone following surgical hemorrhoidectomy. In addition, PPB was shown to significantly reduce opioid consumption intraoperatively and during the first postoperative day.

Naja 2005

Nerve stimulator guided pudendal nerve block decreases posthemorrhoidectomy pain.

Naja Z, Ziade M, Loennqvist P.

Canadian Journal of Anaesthesia = Journal canadien d'anesthesie 2005;52(1):62-8.

PURPOSE: Based on our institution's initial results that reflected reduced postoperative pain using a modified pudendal nerve block technique, we conducted a prospective, randomized, double-blind study to investigate whether a combination of general anesthesia and bilateral nerve stimulator guided pudendal nerve blocks could provide better postoperative pain relief compared to general anesthesia alone or in combination with placebo nerve blocks. METHODS: Following Ethical Committee approval and informed consent 90 patients scheduled for hemorrhoidectomy were randomized to three different groups of 30 patients each: general anesthesia alone, general anesthesia plus nerve stimulator guided pudendal nerve block or general anesthesia plus placebo nerve blocks. Postoperative pain, the primary outcome variable of the study, was assessed by visual analogue scale scores at predetermined time intervals during the postoperative period. Total amount of analgesics, time to return to normal activities and patient satisfaction were also recorded. RESULTS: The pudendal nerve block group was found to have better postoperative pain-relief (P < 0.005), reduced need for analgesics (P < 0.05), and also a more rapid return to normal activities (P < 0.001) compared to general anesthesia alone or in combination with placebo blocks. The pudendal nerve block group was also associated with significantly higher patient satisfaction (P < 0.001) compared to the other two groups. CONCLUSION: A combination of general anesthesia and nerve stimulator guided pudendal nerve block showed significantly reduced postoperative pain, shortened hospital stay, and earlier return to normal activity. Thus, this technique deserves more widespread use in patients undergoing hemorrhoidectomy.

Luck 2000

Ischiorectal fossa block decreases posthemorrhoidectomy pain: randomized, prospective, double-blind clinical trial.

Luck AJ, Hewett PJ.

Diseases of the Colon and Rectum 2000;43(2):142-5.

PURPOSE: Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to assess the efficacy of a preemptive local anesthetic, ischiorectal fossa block, in the reduction of pain and analgesic requirements after hemorrhoidectomy. METHODS: All patients were suitable for an established day surgery hemorrhoidectomy protocol. Immediately before surgery patients were randomly assigned either to receive (Group 1) or not receive (Group 2) the local anesthetic block. All other aspects of surgery and anesthesia were standardized. Nursing staff assessed pain at 30 minutes and 2, 4, and 24 hours postoperatively using a visual analog scale (1-10, where 1 represented no pain and 10 represented the worst pain imaginable). Analgesic requirements also were recorded at these times. Both the patients and the nursing staff were blinded to which local anesthetic protocol had been used. RESULTS: Twenty patients were enrolled in the trial. Ten patients were randomly assigned to Group I and ten to Group 2. Mean pain scores for Group 1 (anal block) at 0.5, 2, 4, and 24 hours were 1.5, 1.8, 2.1, and 2.5, respectively, compared with Group 2, with mean pain scores of 3.4, 3.4, 3.9, and 5.1. These differences were statistically significant. Patients in Group 1 used less analgesia in the first 24 hours postoperatively than those in Group 2. CONCLUSION: The use of a preemptive local anesthetic, ischiorectal fossa block, is associated with a significant decrease in pain and analgesia requirements after hemorrhoidectomy.

Pybus 1983

Postoperative analgesia for haemorrhoid surgery.

Pybus DA, D BBE, Goulding G, Liberman H, Torda TA.

Anaesthesia and Intensive Care 1983;11(1):27-30.

Seventy patients undergoing haemorrhoidectomy under general anaesthesia were randomly allocated to one of five treatment groups in order to compare the effectiveness of various caudal agents in the control of postoperative pain. Four groups were given a caudal injection of either 2% lignocaine, 0.5% bupivacaine, 2% lignocaine + morphine sulphate 4 mg or normal saline + morphine sulphate 4 mg, while the fifth (control) group did not receive an injection. The number of patients requiring postoperative opiates was significantly higher in the lignocaine group than in the morphine (p less than 0.05) and morphine-lignocaine (p less than 0.05) groups. No agent significantly reduced the number requiring opiates. In those who received opiates, the mean analgesic period was 228 minutes in the control group, and was significantly longer following bupivacaine (577 min, p less than 0.01), morphine-lignocaine (637 min, p less than 0.05) and morphine (665 min, p less than 0.0). The mean analgesic period following lignocaine (349 min) was not significantly different from control. The incidence of catheterisation was lowest in those patients who did not receive caudal analgesia.

Pryn 1989

Postoperative analgesia for haemorrhoidectomy A comparison between caudal and local infiltration.

Pryn SJ, Crosse MM, Murison MS, McGinn FP.

Anaesthesia 1989;44(12):964-6.

This study compared the analgesic effectiveness of local infiltration of bupivacaine with caudal extradural bupivacaine in the first 48 hours after haemorrhoidectomy. Surgical and anaesthetic protocol was rigidly standardised. The caudal group had significantly less pain in the first 6 hours after haemorrhoidectomy, and on first bowel opening, when compared to those who received local infiltration of bupivacaine. There was no significant difference between the two groups with respect to further analgesic requirements, complications, time to first bowel action, and duration of hospital stay. The definite advantage of caudal extradural bupivacaine for haemorrhoidectomy must be balanced against the rare but potentially serious complications associated with its use.

Roxas 2006

Randomized controlled trial to determine the effectiveness of the Nivatvongs technique versus conventional local anaesthetic infiltration for outpatient haemorrhoidectomy.

Roxas M, Delima M.

Asian Journal of Surgery / Asian Surgical Association 2006;29(2):70-3.

BACKGROUND: Conventional local anaesthesia in outpatient haemorrhoidectomy, using a diamond-shaped perianal block, is reliable, safe and inexpensive. It allows for early ambulation and short hospital stay. However, without sedation, local infiltration is perceived to be both uncomfortable and painful. Nivatvongs described a technique in which the anaesthetic is injected intra-anally into the insensitive area above the dentate line, allegedly causing less pain. METHODS: This randomized, controlled, parallel-group, single- blind clinical trial compared the effectiveness of the conventional and Nivatvongs techniques in reducing the pain of anaesthetic infiltration in adult patients undergoing outpatient haemorrhoidectomy. A total of 112 patients were randomized into either treatment (n=57) or control groups (n=55). Assigned surgeon- anaesthetists performed the local anaesthetic infiltration. The Milligan-Morgan technique was used for haemorrhoidectomy. Pain was assessed using a standardized visual analogue scale. Patient and surgeon satisfaction were measured with a pre-validated questionnaire. RESULTS: Median scores for pain assessment during local anaesthetic infiltration were 2 and 3 in the control and treatment groups, respectively. Patient satisfaction with the method of anaesthetic infiltration and the procedure itself were 3 and 2, respectively, for both groups. The surgeon's overall satisfaction with the technique of anaesthetic infiltration was similar in the two groups. There was no significant difference in any of the outcomes measured. CONCLUSION: Both local anaesthetic techniques for outpatient haemorrhoidectomy were generally effective and well tolerated. The Nivatvongs technique did not confer any significant additional benefit.

Ong 2005

Ambulatory circular stapled haemorrhoidectomy under local anaesthesia versus circular stapled haemorrhoidectomy under regional anaesthesia.

Ong CH, Chee BFE, Keng V.

ANZ Journal of Surgery 2005;75(4):184-6.

BACKGROUND: The usage of circular stapled haemorrhoidectomy (CSH) has increased dramatically in recent years. Hitherto this has been performed using regional or general anaesthesia. The present study assesses the feasibility of performing CSH under local anaesthesia on an ambulatory basis and its acceptance by patients. METHODS: Sixty patients with symptomatic third or fourth degree haemorrhoids were randomized into two groups. Group A patients had CSH under regional anaesthesia (i.e spinal anaesthesia) and were discharged the next day and group B patients had CSH under local anaesthesia and were discharged on the same admission day. Both groups were assessed by visual analogue pain score. In addition, group B patients were asked questions regarding their satisfaction with the procedure. RESULTS: No significant differences in pain score and analgesic requirement were found between the two groups of patients. All patients in group B except for one, reported that they were satisfied to highly satisfied with their procedure. CONCLUSIONS: Circular stapled haemorrhoidectomy can be performed safely under local anaesthesia in an ambulatory care setting. The potential cost savings that may accrue would offset the cost of the stapler.

Kim 2005

The effect of pudendal block on voiding after hemorrhoidectomy.

Kim J, Lee D, Jang S, Shim M, Jee D.

Diseases of the Colon and Rectum 2005;48(3):518-23.

PURPOSE: Urinary retention in common benign anal surgery is a burden to ambulatory surgery. A pudendal nerve block was used in hemorrhoid surgery to reduce voiding complications. METHODS: The effects of a pudendal nerve block in anal surgery were compared with those of spinal anesthesia. In this prospective study, 163 consecutive patients who underwent elective hemorrhoids surgery by a single surgeon were randomized to receive pudendal nerve block (pudendal group) with 0.5 percent bupivacaine (n = 81) with 1:20,000 epinephrine or spinal anesthesia (spinal group) with 0.5 percentbupivacaine (n = 82). RESULTS: There were no statistically significant differences in the patient demographics, total amount of fluid administered, time to the onset of anesthesia, or intraoperative pain. All patients had a successful block during surgery. However, puborectalis muscle relaxation was not complete in the pudendal group. The time from the injection of the anesthetics to the first sensation of pain was longer in the pudendal group (9.1 vs. 3.1 hours; P < 0.001). Urinary catheterization was required in only 6 patients in the pudendal group compared with 57 patients in the spinal group (P < 0.001). The degree of pain was significantly lower in the pudendal group (2.7 vs. 5.2, Visual Analog Scale; P < 0.001). The amount of analgesics injected was significantly lower in the pudendal group (16/81 vs. 45/82; P < 0.001). CONCLUSIONS: A pudendal nerve block with bupivacaine results in fewer postoperative voiding complications and less pain compared with the traditional spinal anesthesia in a hemorrhoidectomy.

Amanor-Boadu 1992

Assessment of minidose intrathecal morphine for analgesia after hemorroidectomy.

Amanor-Boadu, SD.

West African journal of medicine 1992;11(2):146-9.

The efficacy of 0.5 kg intrathecal morphine was tested on 10 patients who had hemorrhoidectomy performed at the University College Hospital (UCH), Ibadan. They were anesthetized with 3 mls of 0.5% intrathecal bupivacine to which 0.5mg of morphine was added. Another 14 patients had intrathecal 3 mls of 0.5% bupivacine with normal saline. Post- operative analgesia was prolonged in the opiate group compared to the saline group up to 8th post-operative hour. Narcotic analgesic requirement was much less in the opiate group. There were no serious complications in either group. In view of the excellent analgesia in the immediate post-operative period and absence of delayed respiratory depression usually associated with higher doses of spinal opiates it is recommended that use of the technique be encouraged in similar surgical patients for pain relief.

Kim 2001

Intrathecal midazolam increases the analgesic effects of spinal blockade with bupivacaine in patients undergoing haemorrhoidectomy.

Kim MH, Lee YM.

British Journal of Anaesthesia 2001;86(1):77-9.

In the present double-blind study we aimed to evaluate the postoperative analgesic effects of intrathecal midazolam with bupivacaine following haemorrhoidectomy. Forty-five patients were randomly allocated to one of three groups: the control group received 1 ml of 0.5% heavy bupivacaine plus 0.2 ml of 0.9% saline intrathecally, group BM1 received 1 ml of 0.5% bupivacaine plus 0.2 ml of 0.5% preservative-free midazolam and group BM2 received 1 ml of 0.5% bupivacaine plus 0.4 ml of 0.5% midazolam. Time to first analgesia was significantly greater in the midazolam groups than in the placebo and significantly less in the BM1 group than in the BM2 group.

Davies 2003

Botulinum toxin botox reduces pain after hemorrhoidectomy: results of a double-blind, randomized study.

Davies J, Duffy D, Boyt N, Aghahoseini A, Alexander D, Leveson S.

Diseases of the Colon and Rectum 2003;46(8):1097-102.

PURPOSE: Pain after hemorrhoidectomy appears to be multifactorial and dependent on individual pain tolerance, mode of anesthesia, postoperative analgesia, and surgical technique. Spasm of the internal sphincter is believed to play an important role. The aim of this study was to assess the role of botulinum toxin in reducing pain after Milligan-Morgan hemorrhoidectomy. METHODS: This was a double- blind study of 50 consecutive patients undergoing Milligan-Morgan hemorrhoidectomy and assigned to an internal sphincter injection of 0.4 ml of solution containing either botulinum toxin (20 U; Botox) or normal saline. Patients were managed according to standardized perioperative analgesic and laxative regimens. Pain was assessed by use of daily visual analog scores and analgesia requirements for the first seven postoperative days. RESULTS: Patients randomized to receive botulinum toxin had lower daily average and maximal visual analog scores throughout the study period. The difference reached significance on both Day 6 (P < 0.05) and Day 7 (P < 0.05). There was no significant difference (P = 0.12) in morphine requirements in the first 24 hours (botulinum group, 16 (range, 6-27) mg; placebo arm, 22 (range, 13-41) mg). Patients who received Botox used 19 (range, 8-36) coproxamol tablets in the first seven days after surgery compared with 23 (range, 10-40) in the placebo arm (P = 0.63). CONCLUSIONS: Those patients who had botulinum toxin had significantly less pain toward the end of the first week after surgery. Reduction in spasm within the internal sphincter is the presumed mechanism of action. This is the first reported randomized, controlled trial using botulinum toxin in hemorrhoidectomy.

Patti 2005

Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection.

Patti R, Almasio PL, Muggeo VMR, Buscemi S, Arcara M, Matranga S, Di VG.

Diseases of the Colon and Rectum 2005;48(12):2173-9.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

Hosch 1998

Surgical treatment of piles: prospective, randomized study of Parks vs Milligan-Morgan hemorrhoidectomy.

Hosch SB, Knoefel WT, Pichlmeier U, Schulze V, Busch C, Gawad KA, Broelsch CE, Izbicki JR.

Diseases of the colon and rectum 1998;41(2):159-64.

PURPOSE: The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan-Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience. METHODS: Thirty-four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow-up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation. RESULTS: No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomy vs. 4.6 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively; P = 0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomy vs. 20.2 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively; P < 0.001) differed significantly between the Milligan-Morgan and Parks patients. Until two weeks after the operation, Milligan-Morgan hemorrhoidectomy patients experienced significantly more pain. CONCLUSIONS: Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.

Filingeri 2004a

A randomised trial comparing submucosal haemorrhoidectomy with radiofrequency bistoury vs diathermic haemorrhoidectomy.

Filingeri V, Gravante G, Baldessari E, Craboledda P, Bellati F, Casciani CU.

European Review for Medical and Pharmacological Sciences 2004a;8(2):79-85.

BACKGROUND: Haemorrhoid disease has become more and more frequent during the past years among western populations. Great attention has been paid in development of surgical procedures, in order to reduce post-operative pain (the main adverse effect of surgical treatment for haemorrhoids) and shorten execution time and hospital stay. This randomised clinical study compares the results obtained using submucosal haemorrhoidectomy with radiofrequency vs. diathermic haemorrhoidectomy. METHODS: Thirty-one patients were randomised to undergo submucosal haemorrhoidectomy with radiofrequency bistoury (16 patients, Group A) or diathermic haemorrhoidectomy (15 patients, Group B). The operating time, amount of pain and postoperative analgesic requirement, intra and post-operative complications and patient satisfaction were documented. RESULTS: The mean values for operative time have been 35.8 min for group A and 23.2 min for group B. According to pain score, patients' mean values for first day postoperative pain were 3.8 (A) and 5.8 (B). Pain at first evacuation 4.7 (A) and 6.5 (B). Pain at 7th postoperative day was 2.3 (A) and 3.7 (B). Patient's postoperative satisfaction rate was 6.0 (A) vs. 5.2 (B) at 3rd day and 6.7 (A) and 5.7 (B) at 6 months. CONCLUSIONS: In spite of relatively difficult execution and longer operating times, submucosal haemorrhoidectomy with radiofrequency bistoury appears to be the most precise and accurate treatment for IV degree haemorrhoids. Performing submucosal haemorrhoidectomy with radiofrequency bistoury allows us to reduce postoperative pain, bleeding and shorten hospital stay.

Mikuni 2002

A prospective randomized comparison between an open hemorrhoidectomy and a semi-closed semi-open hemorrhoidectomy.

Mikuni N, Oya M, Komatsu J, Yamana T.

Surgery Today 2002;32(1):40-7.

A semi-closed hemorrhoidectomy is a popular surgical procedure among Japanese coloproctologists because it is thought that the risk of postoperative bleeding is reduced, and postoperative pain is milder after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. However, no prospective randomized trial comparing an open and semi-closed hemorrhoidectomy has yet been published. We conducted a prospective randomized trial comparing both clinically and physiologically an open and semi-closed hemorrhoidectomy. Thirty- four consecutive patients undergoing a hemorrhoidectomy for third- degree hemorrhoids were randomized to receive either an open hemorrhoidectomy (n = 17) or a semi-closed hemorrhoidectomy (n = 17). Postoperative pain was evaluated using an analog scale by the patients themselves. An anorectal physiological study was performed before the operation and 2 months after the operation. Pain at 1 week after operation was significantly more severe after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. The postoperative physiological parameters including sphincter pressures did not differ between the two forms of hemorrhoidectomy. However, younger patients and patients having higher sphincter pressures preoperatively had more severe pain at 2 weeks after a semi-closed hemorrhoidectomy. Although both forms of hemorrhoidectomy appear to be almost equivalent, the degree of early postoperative pain may be less after an open hemorrhoidectomy in both young patients and in those patients having high preoperative anal sphincter pressures.

Boccasanta 2007

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse A randomized controlled trial.

Boccasanta P, Venturi M, Roviaro G.

International Journal of Colorectal Disease 2007;22(3):245-51.

PURPOSE: A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse. METHODS: Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography. RESULTS: At a mean follow-up of 8.1 +/- 2.0 and 7.9 +/- 1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p = 0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p = 0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p = 0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p = 0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse. CONCLUSIONS: STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.

Arroyo 2006

Prospective randomized clinical trial comparing two different circular staplers for mucosectomy in the treatment of hemorrhoids.

Arroyo A, Perez V, Miranda E, Sanchez A, Serrano P, Candela F, Oliver I, Calpena R.

World Journal of Surgery 2006;30(7):1305-10.

BACKGROUND: The main objections against circular stapled mucosectomy have been anal pain and rectal bleeding during the surgical procedure or in the immediate postoperative follow-up. To avoid these consequences, a new stapler (PPH33-03) has been developed. The aim of this trial was to compare the intraoperative and short-term postoperative morbidity of stapled mucosectomy with PPH33-01 versus PPH33-03 in the treatment of hemorrhoids. METHODS: We conducted a prospective randomized clinical trial comparing hemorrhoidectomy with PPH33-01 (group 1, n=30) versus PPH33-03 (group 2, n=30) for grade III-IV symptomatic hemorrhoids. For the follow-up, the patients underwent examination and proctoscopy at 4 weeks, 3 months, and 6 months. We recorded anal pain (linear analog scale from 0 to 10), intraoperative hemorrhage, postoperative bleeding, and continence (Wexner Continence Grading Scale). RESULTS: Demographic and clinical features showed no differences between the two groups. More patients required suture ligation to stop anastomotic bleeding at surgery when the PPH33-01 stapler was used (15 versus 4, P<0.05). Rectal bleeding during the first postoperative 4 weeks was similar (P>0.05). The postoperative pain scores during the first week were similar (P>0.05) . Patients with pain on defecation were fewer in the PPH-03 group (15 versus 2, P<0.05). Six patients from group 1 and none from group 2 (P<0.05) had granulomas along the line of staples at the sites of the reinforcing stitches; the granulomas were associated with postoperative anal discomfort and rectal bleeding. One patient in group 1 complained of persistent pain that resolved within 3 months. Of all the intraoperative or preoperative variables analyzed, only the presence of granuloma was associated with postoperative bleeding and anal discomfort. We have not found any recurrence or incontinence during the 6-month follow-up. CONCLUSIONS: Intraoperative bleeding along the stapled line and tenesmus or discomfort during defecation were less frequent after circular stapled mucosectomy with PPH33-03. Therefore, circular stapled mucosectomy with PPH33-03 decreases the risk of immediate complications and thus allows implantation with more safety as a day surgery procedure.

Perez-Vicente 2006

Prospective randomised clinical trial of single versus double purse- string stapled mucosectomy in the treatment of prolapsed haemorrhoids.

Perez-Vicente F, Arroyo A, Serrano P, Candela F, Sanchez A, Calpena R.

International Journal of Colorectal Disease 2006;21(1):38-43.

BACKGROUND AND AIMS: Despite the excellent results published on circular stapled mucosectomy (CSM), there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease, where a major prolapse may lead to insufficient resection and ensuing early recurrence. This study is aimed at comparing the outcomes after single purse-string CSM versus double purse-string CSM. PATIENTS AND METHODS: A prospective randomised clinical trial of single versus double purse-string CSM for grade III-IV symptomatic haemorrhoids was used. One hundred consecutive patients were randomised to single (group 1, N=50) versus double purse-string CSM (group 2, N=50). RESULTS: The mean age was 50.7 years, with a predominance of males (63 vs. 37). Haemorrhoids were classified as grade III in 59% and grade IV in 41% of the patients. Mean follow-up was 26 months. Demographic and clinical features showed no differences between the two groups. The size of the resected doughnut was greater in group 2 (4.95 vs. 3.55 cm; p<0.05), as was the distance of the suture from the dentate line (3.56 vs. 3.16 cm; p<0.05). Early postoperative pain was significantly less in group 2 (linear analogue scale from 0 to 10), 2.08 vs. 3.56 (p<0.001). Postoperative haemorrhage was absent or minimal in 79% of patients. Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months. There were two recurrences in group 1. CONCLUSION: Double purse-string CSM resects a greater doughnut, increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM. Larger series are necessary to assert whether recurrence is lower.

Chung 2002

Double-blind, randomized trial comparing Harmonic Scalpel (trademark) hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: Ligation technique.

Chung CC, Ha JPY, Tai YP, Tsang WWC, Li MKW.

Diseases of the Colon and Rectum 2002;45(6):789-794.

PURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel(trademark), bipolar scissors, and the conventional scissors excision-ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel(trademark) hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) post-operative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel(trademark) hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel (trademark) hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel(trademark) hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel(trademark) hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel(trademark) hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

Filingeri 2004b

Prospective randomized trial of submucosal hemorrhoidectomy with radiofrequency bistoury vs conventional Parks' operation.

Filingeri V, Gravante G, Baldessari E, Grimaldi M, Casciani CU.

Techniques in Coloproctology 2004b;8(1):31-6.

BACKGROUND: Postoperative pain has always been the main adverse effect of the surgical treatment for hemorrhoids. Surgical techniques evolved mainly to solve this problem as well as postoperative bleeding, stenosis and recurrence. This randomized study compared the results obtained using submucosal hemorrhoidectomy with radiofrequency bistoury with those of the conventional Parks' operation. METHODS: A total of 102 patients were randomized to undergo submucosal hemorrhoidectomy with radiofrequency bistoury (51 patients) or conventional Parks' haemorrhoidectomy (51 patients); loss of some patients at follow-up resulted in 49 and 45 patients available for analysis, respectively. The operating time, amount of pain (VAS scale, 1-10), postoperative analgesic requirement, intra- and postoperative complications, length of hospital stay and patient satisfaction were documented. RESULTS: In comparison to Parks' technique, use of radiofrequency bistoury reduced mean operating time (61.2 min vs. 37.4 min; p<0.05), first postoperative day pain score (5.9 vs. 4.0; p<0.05), pain score at first evacuation (5.7 vs. 4.2; p >0.05), postoperative stay (2.2 days vs. 1.3 days; p<0.05), and pain score on postoperative day 7 (3.6 vs. 2.8; p>0.05). Fecal incontinence was never observed. Incontinence to flatus with spontaneous resolution within 2-3 weeks was reported by 4 subjects in each surgical group. Urinary retention requiring catheterization occurred in 21 subjects in the radiofrequency bistoury group and in 18 patients in the control group. No complications nor recurrences were reported at the 6-month follow-up in either group. CONCLUSIONS: Performing submucosal hemorrhoidectomy with radiofrequency bistoury improves the results obtained with Parks' technique, allowing us to simplify the surgical procedure, reduce operating time, postoperative pain and bleeding, and shorten the hospital stay.

Pandini 2006

Surgical treatment of haemorrhoidal disease with CO(2) laser and Milligan-Morgan cold scalpel technique.

Pandini LC, Nahas SC, Nahas CSR, Marques CFS, Sobrado CW, Kiss DR.

Colorectal Disease 2006;8(7):592-595.

Objective:To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan- Morgan technique using either the CO(2) laser or cold scalpel. Methods: Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B) . Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption. Results: Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P = 0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction. Conclusion: There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction. © 2006 Blackwell Publishing Ltd.

Kanellos 2005

Usefulness of lateral internal sphincterotomy in reducing postoperative pain after open hemorrhoidectomy.

Kanellos I, Zacharakis E, Christoforidis E, Angelopoulos S, Kanellos D, Pramateftakis MG, Betsis D.

World Journal of Surgery 2005;29(4):464-8.

The aim of the present study was to evaluate the effect of lateral internal sphincterotomy on pain after open hemorrhoidectomy. From 1998 to 2003, seventy-eight (78) patients with fourth-degree hemorrhoids were included in this prospective randomized trial. The patients were randomized into two equal groups of 39 patients. Patients from group I underwent Milligan-Morgan hemorrhoidectomy. Patients from group II, quite apart from Milligan-Morgan hemorrhoidectomy, underwent lateral internal sphincterotomy up to the dentate line, in the left hemorrhoidectomy wound. One surgeon from the Department, who did not know to which group the patients belonged, evaluated the postoperative course in all the patients. After the first bowel movement, there were three (7.7%) patients who did not experience any pain in the internal sphincterotomy group, while in the non-internal sphincterotomy group all patients experienced mild or moderate pain. There were also more patients who experienced excruciating pain in the non-internal sphincterotomy group than in the internal sphincterotomy group (25 vs. 18); these differences were statistically significant (p = 0.034). There was no significant difference in the Wexner Incontinence Scale between the groups (p = 0.228). The addition of lateral internal sphincterotomy to open hemorrhoidectomy seems to have a positive effect on reducing postoperative pain in a few patients, without affecting the postoperative complications rate.

Galizia 2000

Lateral internal sphincterotomy together with haemorrhoidectomy for treatment of haemorrhoids: A randomised prospective study.

Galizia G, Lieto E, Castellano P, Pelosio L, Imperatore V, Pignatelli C.

European Journal of Surgery 2000;166(3):223-228.

Objective: To investigate anorectal manometric findings in patients with haemorrhoids and to evaluate the clinical effects and physiological consequences of adding a lateral internal sphincterotomy (LIS) to haemorrhoidectomy. Design: Randomised prospective study. Setting: Teaching hospital, Naples. Patients: 48 consecutive patients with prolapsed piles who had anorectal manometry; 10 healthy volunteers served as controls. Interventions: Resting and squeeze pressures, sphincter length and rectoanal inhibitory reflex were recorded. 6 patients were excluded because anal pressures were not raised, so 42 patients were randomised. 22 patients had haemorrhoidectomy plus LIS; and 20 had haemorrhoidectomy alone. Main outcome measures: Morbidity, continence, and anorectal manometry. Results: Sphincter anomalies were found in 87.5% (n = 42) of patients. Haemorrhoidectomy alone did not affect anal pressures, which returned to the normal ranges after sphincterotomy. Those who had LIS did better postoperatively than those who had did not. 4 patients who did not have a sphincterotomy developed anal strictures. No patient who had LIS developed incontinence of faeces. Conclusions: High anal pressures are common in patients with haemorrhoids suggesting that they may have a pathogenetic role; anorectal manometry is useful in the investigation of anal pressure patterns; and when indicated, lateral sphincterotomy avoids pain, urinary retention, and stenosis, and is safe.

Khubchandani 2002

Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study.

Khubchandani IT.

Diseases of the Colon and Rectum 2002;45(11):1452-7.

PURPOSE: Pain after hemorrhoidectomy is universal. Several attempts have been made to reduce or alleviate the pain after excisional hemorrhoidectomy. The origin of pain is undetermined. Current theories propose that the pain is mediated through the internal sphincter. This prospective, randomized study was performed to assess the degree of discomfort in patients with and without a sphincterotomy when performing a closed hemorrhoidectomy. METHODS: Between December 1999 and September 2001, 42 patients (22 males), median age 52 (range, 30-80) years, who underwent excisional hemorrhoidectomy were randomly chosen to have an internal sphincterotomy in the base of the left lateral wound. RESULTS: Thirty-nine patients were available for the study. Parameters elicited in the study were pain, postoperative bleeding, urinary retention, impairment of continence by day and by night, and day the patient returned to work. There was no statistical difference in the postoperative pain in each of the two categories at four hours after surgery, after the first bowel movement, or four days after surgery. CONCLUSIONS: Results showed no difference in the perception of pain after hemorrhoidectomy in patients who had an internal sphincterotomy compared with those who did not. Both groups were equally likely to have difficulty with control of gas and soiling.

Mathai 1996

Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy.

Mathai V, Ong BC, Ho YH.

British Journal of Surgery 1996;83(3):380-382.

A prospective trial was conducted to compare haemorrhoidectomy alone (control, group 1) with haemorrhoidectomy plus lateral internal sphincterotomy (group 2) for prolapsed piles. Some 33 patients (18 men, 15 women) of mean (s.e.m.) age 40 (2.3) years were randomized, 16 to group 1 and 17 to group 2. There were no significant differences in postoperative pain scores. Mean resting and maximum anal squeeze pressures, studied 6 weeks and 3 months after operation, were generally lower in group 2, but were not significantly different. Two patients in group 2 were distressed by incontinence to liquid faeces which persisted in one after 1 year. There were no other complications in either group after a mean (s.e.m.) follow-up of 11 (0.4) months. The addition of lateral internal sphincterotomy to routine haemorrhoidectomy is unnecessary and carries the added risk of incontinence.

Ho 2001

Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy.

Ho YH, Seow CF, Tsang C, Eu KW.

The British Journal of Surgery 2001;88(11):1449-55.

BACKGROUND: Conventional stapled haemorrhoidectomy involves the use of a large circular anal dilator (DL technique), which may cause anal sphincter injuries. This study compared whether the procedure can be effectively performed without this dilator (ND technique), with better sphincter preservation. METHODS: Fifty-eight patients with symptomatic prolapsed irreducible haemorrhoids were randomized to DL (n = 29) and ND (n = 29) groups. Preoperative continence scoring, anorectal manometry and endoanal ultrasonography were performed. These were repeated at up to 14 weeks after operation, with additional pain scores, analgesic requirements and quality of life assessments. RESULTS: DL haemorrhoidectomy took significantly longer to perform (P = 0.02). However, there were fewer residual skin tags (P = 0.044) and less perianal pruritis (P = 0.007) at 2 weeks, although such symptoms subsided to an equivalent level in both groups afterwards. Internal anal sphincter fragmentation persisting to at least 14 weeks was found in four patients after DL, but not after ND haemorrhoidectomy (P = 0.038). However, these were asymptomatic and no differences were found in continence scores and anal pressures. The pain scores, satisfaction scores, quality of life assessments and time off work were similar. CONCLUSION: The large circular anal dilator used for stapled haemorrhoidectomy increased the risk of anal sphincter injuries, which may become problematic with ageing.

Madsen 1987

Comparison of diflunisal with acetaminophen plus codeine in posthemorrhoidectomy bowel function and analgesic efficacy.

Madsen JJ, Dipiro JT, Angaran DM, Hooks IVH, Bowden JTA, Rothenberger DA, Buls JG.

Current Therapeutic Research - Clinical and Experimental 1987;42(2):319-323.

No abstract available

Chang 1999

Postoperative intramuscular dextromethorphan injection provides postoperative pain relief and decreases opioid requirement after hemorrhoidectomy.

Chang FL, Wu CT, Yeh CC, Lin TC, Ho ST, Wong CS.

Acta Anaesthesiologica Sinica 1999;37(4):179-83.

BACKGROUND: Previous studies have shown that dextromethorphan (DM) produces an analgesic/antihyperalgesic effect. This study was designed to examine whether postoperative DM intramuscular (i.m.) injection could reduce post-hemorrhoidectomy pain. METHODS: At the end of the surgery, patients in the study group (n = 30) were given an intramuscular injection of 40 mg DM and 20 mg chlorpheniramine (CPM) while in the study group (n = 30), the patients were given intramuscular 20 mg CPM only. Pethidine (1 mg/kg, i.m.) was prescribed for postoperative pain relief if required. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for 48 h postoperatively. RESULTS: The time from the end of operation to the first pethidine injection was 5.4 +/- 1.6 h and 17.8 +/- 3.7 h (P = 0.006) in the control group and the study group, respectively. Total pethidine consumption was 139.5 +/- 11.5 mg and 77.5 +/- 12.2 mg (P < 0.001) in the control group and the study group, respectively. The worst VAS score was 7.5 +/- 0.2 and 7.1 +/- 0.2 (P = 0.09) in the control and the study groups, respectively. The number of patients who required pethidine injection was 29 and 21 (P < 0.005) in the control and the study groups, respectively. The number of patients who suffered pethidine-related side effects was 7 and 1 (P < 0.025) in the control and the study groups, respectively. CONCLUSIONS: We found that intramuscular DM given at the end of operation could provide good postoperative pain relief and decrease the pethidine requirement after hemorrhoidectomy.

Patti 2006

Botulinum toxin vs topical glyceryl trinitrate ointment for pain control in patients undergoing hemorrhoidectomy: a randomized trial.

Patti R, Almasio PL, Arcara M, Sammartano S, Romano P, Fede C, Di VG.

Diseases of the Colon and Rectum 2006;49(11):1741-8.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound healing and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mmHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

Di Vita 2003

Milligan-Morgan haemorrhoidectomy with ultrasonic scalpel.

Di Vita G, Patti R, Petrone R, Arcara M, Sieli G.

Il Giornale di chirurgia 2003;24(11-12):422-7.

INTRODUCTION: Milligan-Morgan haemorrhoidectomy is considered the best treatment for hemorrhoidal disease. Although this, many patients complaint post-operative pain that remain the worse complication. For this reason different are the trials performed in order to reduce his intensity. In this report we want to evaluate if the use of ultrasonic scalpel to perform Milligan-Morgan hemorrhoidectomy, compared with conventional surgery, could reduce post-operative pain. MATERIALS AND METHODS: 30 patients with III and IV degree of haemorrhoids were included in this study and divided in two groups. In the first group Milligan-Morgan haemorrhoidectomy was performed with conventional instruments, while in the second group the some procedure was performed with ultrasonic scalpel. The duration of intervention, time hospitalization, the time to open alvus to stools, the time to return to normal activity, the complications, pain and the amount of analgesic consumption were evaluated. RESULTS: In the II group's patients, it was observed a reduced time to healing with reduced spread of necrosis and inflammatory pattern, associated with reduced post-operative pain and the lower analgesic consumption. CONCLUSIONS: The use of ultrasonic scalpel to perform Milligan-Morgan haemorrhoidectomy, compared with conventional instruments, reduce post-operative pain making a more short time to healing and a precocious time to return to normal activity. For this reason we believe that the use of ultrasonic scalpel, although a more elevated costs, seems to be advantageous.

Ho 1997a

Randomized controlled trial of trimebutine anal sphincter relaxant for pain after haemorrhoidectomy.

Ho YH, Seow CF, Low JY, Tan M, Leong AP.

The British Journal of Surgery 1997a;84(3):377-9.

BACKGROUND: Anal sphincter spasm may aggravate pain after haemorrhoidectomy. The aims of this study were to investigate whether a trimebutine suppository (Proctolog) reduced anal resting pressure and, subsequently, to test its efficacy in relieving pain after haemorrhoidectomy. METHODS: Ten patients underwent anal manometry before and 4 h after Proctolog application. A controlled randomized trial was then conducted on 160 consecutive patients. A standard haemorrhoidectomy was performed. Eighty patients were then randomized to receive an application of Proctolog immediately after the procedure (group 1). The remaining 80 did not receive a suppository (controls, group 2). An independent, blinded observer determined the pain scores. RESULTS: Proctolog resulted in a mean 35 per cent reduction in resting anal pressure (P < 0.001). However, there were no differences in the pain score at 4 h after haemorrhoidectomy, maximum pain during the first 24 h, maximum pain during the second postoperative day, ketoprofen requirement or need for intramuscular pethidine injections between groups 1 and 2. CONCLUSION: Although Proctolog reduced mean resting anal pressure at 4 h after application, this did not affect pain after haemorrhoidectomy.

Silverman 2005

A randomized, prospective, double-blind, placebo-controlled trial of the effect of a calcium channel blocker ointment on pain after hemorrhoidectomy.

Silverman R, Bendick PJ, Wasvary HJ.

Diseases of the Colon and Rectum 2005;48(10):1913-6.

PURPOSE: Spasm of the internal sphincter plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. We have evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. METHODS: After hemorrhoidectomy, 18 patients were randomly assigned to receive 2 percent diltiazem ointment (n = 9) or a placebo ointment (n = 9). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate (Vicodin) to take as needed. The type and number of prescribed or nonprescribed medications taken during the postoperative period were recorded. Patients maintained a log to measure postoperative pain daily and perceived benefit of the ointment, using a Visual Analog Scale ranging from 0 to 10. Any postoperative morbidity noted during the follow-up period was recorded. RESULTS: Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week. Postoperative pain scores in the placebo group averaged 8.8 +/- 1.2 early and diminished to 5.2 +/- 1.7 at the end of one week, compared to the diltiazem group of 5.2 +/- 2.4 early and 2.3 +/- 1.2 at the end of one week (P < 0.001, both time periods). Perceived benefit in the placebo group averaged 2.7 +/- 1.2 vs. 5.6 +/- 1.4 in the diltiazem group (P < 0.001). Total and daily narcotic use was higher in the placebo group, but this was not statistically significant (P = 0.13). No differences in the frequency of use of nonsteroidal anti- inflammatory drugs and acetaminophen were seen between the two groups, and there were no differences in morbidity between the two groups. CONCLUSIONS: Perianal application of 2 percent diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity. Patients using a placebo ointment tend to take more prescription narcotics for pain relief postoperatively, with a similar usage of nonsteroidal anti-inflammatory drugs and acetaminophen, although differences were not significant.

Ingram 1998

A prospective randomized study of calcium alginate Sorbsan versus standard gauze packing following haemorrhoidectomy.

Ingram M, Wright TA, Ingoldby CJ.

Journal of the Royal College of Surgeons of Edinburgh 1998;43(5):308-9.

Post-haemorrhoidectomy pain is problematical but may be reduced by using less bulky haemostatic dressings in the anal canal. Fifty consecutive patients undergoing haemorrhoidectomy were prospectively randomized to receive either paraffin gauze/cotton gauze roll on calcium alginate (Sorbsan) roll as a post-operative pack. Post- operative pain was assessed at 6 h, on removal of rectal packing and at first bowel action. Haemorrhage was monitored at 6 h and removal of pack. There was no difference in the hospital stay between the two groups. Pain was significantly reduced at the time of removal /spontaneous discharge of rectal packing (P < 0.0001) and first post- operative bowel action (P = 0.0008) in the calcium alginate group. There was no significant difference in post-operative haemorrhage between the two groups. Calcium alginate dressings following haemorrhoidectomy effectively reduce post-operative pain compared to more bulky anal packs.

Chester 1990

Analgesic benefit of locally injected bupivacaine after hemorrhoidectomy.

Chester JF, Stanford BJ, Gazet JC.

Diseases of the Colon and Rectum 1990;33(6):487-9.

The analgesic efficacy of locally injected bupivacaine was studied in 40 patients undergoing hemorrhoidectomy. After a standard Milligan- Morgan hemorrhoidectomy, 40 age- and sex-matched patients were randomized to receive either 0.5 percent bupivacaine (1.5 mg/kg) in adrenaline solution (1:200,000) injected into the perianal area, or equivalent volumes of adrenaline solution. Intramuscular opiate was available on demand during the postoperative period, and the amount and timing of analgesia given was recorded. All patients noted their pain on a daily basis using a linear analogue scale, and all patients answered a questionnaire assessing analgesic efficacy. Although the median time interval between surgery and first analgesic demand was nearly four times greater for patients receiving bupivacaine compared with adrenaline solution, there was no difference in the levels of pain recorded or in the overall opiate requirements. Local injection of bupivacaine after hemorrhoidectomy provides initial pain relief, but patients do not obtain an overall analgesic benefit.

Marsh 1993

Bupivacaine infiltration after haemorrhoidectomy.

Marsh GD, Huddy SP, Rutter KP.

Journal of the Royal College of Surgeons of Edinburgh 1993;38(1):41-2.

The effect of a locally infiltrated solution of bupivacaine was studied in 30 patients undergoing haemorrhoidectomy. A standard Milligan-Morgan haemorrhoidectomy, with preoperative infiltration of adrenaline solution (1:200,000), was performed. The patients were randomized to receive local four quadrant perianal infiltration of 20 ml of 0.5% bupivacaine or normal saline. Analgesia was available on demand postoperatively. There was no significant difference between the groups with respect to visual analogue pain scores, analgesic requirement, time to first bowel action or duration of hospital stay. Bupivacaine as a local infiltration in this situation does not confer analgesic effect into the postoperative period.