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Xue P, Zhang Q, Xiang J, Yang H, Wang D, Jia Q, Chen L, Liu Y, Wu J. Effect of Pressure and Nonpressure Dressings on Postoperative Complications in Patients With Mixed Hemorrhoids: A Single-blind Controlled Study. J Perianesth Nurs 2024:S1089-9472(24)00053-4. [PMID: 38864797 DOI: 10.1016/j.jopan.2024.02.006] [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: 09/21/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE To compare the clinical effects of nonpressure and pressure dressings on the postoperative complications of modified Milligan-Morgan hemorrhoidectomy. DESIGN Randomized controlled trial. METHODS A total of 186 patients with grade II to III mixed hemorrhoids who had been excluded from cardiovascular and cerebrovascular diseases and anorectal surgery were included and randomly assigned to the nonpressure dressings group and the pressure dressings group by random number table. The incidence of acute urinary retention and medical adhesive-related skin injury, pain, hemostatic effect, anal distension, anal edema, use of analgesics, length of hospital stay, and hospitalization costs were compared between the two groups. The Consolidated Standards of Reporting Trials checklist for randomized controlled trials was used in this study. FINDINGS The incidence of acute urinary retention in both men and women was significantly lower in the nonpressure dressing group (relative risk [RR] = 0.20, 95% confidence interval [CI] [0.13, 0.37], P = .002); (RR = 0.47, 95% CI [0.22, 0.76], P = .015). The postoperative pain at 6 hours/18 hours/25 hours was significantly lower in the nonpressure dressing group (P < .001, P = .004 < 0.05, P = .009). The anal distension at 6 hours and the number of patients who used analgesics were significantly lower in the nonpressure dressing group (P < .001). The incidence of medical adhesive-related skin injuries was significantly lower in the nonpressure dressing group (RR = 0.061, 95% CI [0.020, 0.189], P < .001). No primary bleeding was observed in both groups. However, there were no significant differences between both groups in terms of anal edema scores, length of stay, or hospitalization expenses. No adverse events were reported in either group during the study period. CONCLUSIONS Nonpressure dressings can effectively reduce the incidence of acute urinary retention and medical adhesion-related skin injury after surgery for grade III to IV mixed hemorrhoids. They can also safely relieve pain and distension.
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Affiliation(s)
- Ping Xue
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qin Zhang
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jueying Xiang
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Huan Yang
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Dan Wang
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qinghua Jia
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ling Chen
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yiling Liu
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jing Wu
- Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Division of Surgery, Institute of Integrated Traditional Chinese and Western Medicine, Chengdu Shang Jin Nan Fu Hospital of West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Soto Sánchez A, Cano Valderrama O, Vilela Ferrer I, Díaz Jiménez N, Hernández Barroso M, Bravo García PL, Hernández Hernández G, Balanzá JJ. Protocol of a clinical trial on the effectiveness of pudendal nerve block with and without neurostimulation in reducing posthemorroidectomy pain. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00100-8. [PMID: 38821379 DOI: 10.1016/j.redare.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/24/2023] [Accepted: 11/19/2023] [Indexed: 06/02/2024]
Abstract
INTRODUCTION Hemorrhoidal pathology is the most frequent proctological problem with a prevalence of 44% of the adult population. The most effective treatment is surgery but it also has the highest postoperative pain rate with moderate to severe pain rates of 30-40% during the first 24-48 hours. Here lies the importance of seeking measures to improve this situation, such as the pudendal nerve block with local anesthetic. However, the variability of the pudendal nerve sometimes makes its blockade ineffective and for this reason nerve location methods are sought to achieve a higher rate of success. The main aim of the study is to compare pain in the immediate postoperative period (24 h) after hemorrhoidectomy in patients with pudendal nerve block guided by anatomical references and guided by neurostimulation. METHODS The present project proposes the performance of a single-center, triple-blind, randomized clinical trial of efficacy, carried out under conditions of routine clinical practice. Patients over 18 years old with hemorrhoids refractory to medical treatment, symptomatic grade III-IV and grade II hemorrhoids that do not respond to conservative procedures in a third level hospital in Spain and that are subsidiaries of surgery in major ambulatory surgery will be included. Demographic variables, variables on hemorrhoidal pathology, details of surgery, verbal numeric pain scale in the preoperative period and surgical complications will be collected. RESULTS Not avaliable until the end of the study. CONCLUSIONS The pudendal nerve block guided by anatomical landmarks has been shown to be useful in postoperative pain control after hemorrhoidectomy although the use of the neurostimulator has not been well studied and we believe it may improve outcom.
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Affiliation(s)
- A Soto Sánchez
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain.
| | - O Cano Valderrama
- Departamento de Cirugía, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - I Vilela Ferrer
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - N Díaz Jiménez
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - M Hernández Barroso
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - P L Bravo García
- Departamento de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - G Hernández Hernández
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - J J Balanzá
- Departamento de Cirugía, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
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Albrecht PJ, Liu Y, Houk G, Ruggiero B, Banov D, Dockum M, Day A, Rice FL, Bassani G. Cutaneous targets for topical pain medications in patients with neuropathic pain: individual differential expression of biomarkers supports the need for personalized medicine. Pain Rep 2024; 9:e1119. [PMID: 38375092 PMCID: PMC10876238 DOI: 10.1097/pr9.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/30/2023] [Accepted: 11/07/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction Numerous potential cutaneous targets exist for treating chronic pain with topically applied active pharmaceutical ingredients. This preliminary human skin tissue investigation was undertaken to characterize several key biomarkers in keratinocytes and provide proof-of-principle data to support clinical development of topical compounded formulations for peripheral neuropathic pain syndromes, such as postherpetic neuralgia (PHN). Objectives The study intended to identify objective biomarkers in PHN skin on a patient-by-patient personalized medicine platform. The totality of biopsy biomarker data can provide a tissue basis for directing individualized compounded topical preparations to optimize treatment efficacy. Methods Referencing 5 of the most common actives used in topical pain relief formulations (ketamine, gabapentin, clonidine, baclofen, and lidocaine), and 3 well-established cutaneous mediators (ie, neuropeptides, cannabinoids, and vanilloids), comprehensive immunolabeling was used to quantify receptor biomarkers in skin biopsy samples taken from ipsilateral (pain) and contralateral (nonpain) dermatomes of patients with PHN. Results Epidermal keratinocyte labeling patterns were significantly different among the cohort for each biomarker, consistent with potential mechanisms of action among keratinocytes. Importantly, the total biomarker panel indicates that the enriched PHN cohort contains distinct subgroups. Conclusion The heterogeneity of the cohort differences may explain studies that have not shown statistical group benefit from topically administered compounded therapies. Rather, the essential need for individual tissue biomarker evaluations is evident, particularly as a means to direct a more accurately targeted topical personalized medicine approach and generate positive clinical results.
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Affiliation(s)
| | - Yi Liu
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - George Houk
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Beth Ruggiero
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Daniel Banov
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Marilyn Dockum
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - A.J. Day
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Frank L. Rice
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Gus Bassani
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
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Tsai KM, Kiu KT, Yen MH, Yen YC, Tam KW, Chang TC. Comparison the effect of gelatin sponge and epinephrine-soaked gauze for hemostasis and pain control after hemorrhoidal surgery. Sci Rep 2023; 13:18010. [PMID: 37865694 PMCID: PMC10590443 DOI: 10.1038/s41598-023-45380-0] [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] [Received: 05/14/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023] Open
Abstract
Post-operative pain and bleeding are the main complications following hemorrhoidal surgery. This study aimed to investigate whether an absorbable gelatin sponge is a superior hemostatic and analgesic agent compared to gauze soaked in epinephrine for post-hemorrhoidal surgery care. A retrospective study was conducted using data from a single institute. Data were collected from the electronic medical record database and outpatient patient questionnaire archive. The study encompassed 143 patients who received gauze soaked in epinephrine as the hemostatic agent after hemorrhoidal surgery and 148 patients who received an absorbable gelatin sponge. Most patients underwent stapled hemorrhoidopexy, with 119 (83.2%) in epinephrine group and 118 (79.7%) in gelatin sponge group. The primary outcome measurements were postoperative pain score, oral analgesic dosage and complications. Patients in the absorbable gelatin sponge group reported significantly lower pain scores from 8 h after their hemorrhoidal surgery (postoperative day 0) through postoperative day 2. The average pain scores in the absorbable gelatin sponge group and gauze soaked in epinephrine group were 5.3 ± 3.2 and 6.2 ± 3.2 (p = 0.03) on postoperative 8 h; 4.7 ± 3.0 and 5.8 ± 2.9 (p ≤ 0.01) on postoperative day one; and 4.4 ± 2.8 and 5.3 ± 2.9 (p = 0.01) on postoperative day two, respectively. There were no significant differences in postoperative recovery or complication rates between the two groups. Our study revealed that absorbable gelatin sponges provide more effective pain relief to patients during the initial postoperative days after hemorrhoidal surgery, without any adverse impact on patient outcomes. Consequently, absorbable gelatin sponges are recommended as a replacement for gauze soaked in epinephrine following hemorrhoidal surgery.
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Affiliation(s)
- Kun-Min Tsai
- Department of General Medicine, Shuang Ho Hospital, Taipei Medical University, No. 901, Zhonghua Road, Yongkang District, Tainan City, New Taipei City, 71004, Taiwan
| | - Kee-Thai Kiu
- Division of Colorectal Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City 235, Taiwan
| | - Min-Hsuan Yen
- Division of Colorectal Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City 235, Taiwan
| | - Yu-Chun Yen
- Biostatistics Center, Office of Data Science, Taipei Medical University, No. 172-1, Sec. 2, Keelung Road, Taipei City 106, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Taipei Medical University - Shuang Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City 235, Taiwan
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei City, Taiwan
| | - Tung-Cheng Chang
- Division of Colorectal Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City 235, Taiwan.
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan.
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Perivoliotis K, Chatzinikolaou C, Symeonidis D, Tepetes K, Baloyiannis I, Tzovaras G. Comparison of ointment-based agents after excisional procedures for hemorrhoidal disease: a network meta-analysis of randomized controlled trials. Langenbecks Arch Surg 2023; 408:401. [PMID: 37837466 DOI: 10.1007/s00423-023-03128-4] [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] [Received: 08/09/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Efficient postoperative pain control is important after hemorrhoidal surgery. Although several locally applied medications have been used, current evidence regarding the optimal strategy is still conflicting. This network meta-analysis assessed analgesic efficacy and safety of the various topical medications in patients submitted to excisional procedures for hemorrhoids. METHODS The present study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The last systematic literature screening was performed at 15 June 2023. Comparisons were based on a random effects multivariate network meta-analysis under a Bayesian framework. RESULTS Overall, 26 RCTs and 2132 patients were included. Regarding postoperative pain, EMLA cream (surface under the cumulative ranking curve (SUCRA) 80.3%) had the highest ranking at 12-h endpoint, while aloe vera cream (SUCRA 82.36%) scored first at 24 h. Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation. Lidocaine (SUCRA 87.9%) displayed the best performance regarding overall morbidity rates. CONCLUSIONS Due to the inconclusive results and several study limitations, further RCTs are required.
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Affiliation(s)
| | | | - Dimitrios Symeonidis
- Department of Surgery, University Hospital of Larissa Viopolis, 41110, Larissa, Greece
| | - Konstantinos Tepetes
- Department of Surgery, University Hospital of Larissa Viopolis, 41110, Larissa, Greece
| | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa Viopolis, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa Viopolis, 41110, Larissa, Greece
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Verdiner R, Khurmi N, Choukalas C, Erickson C, Poterack K. Does adding muscle relaxant make post-operative pain better? a narrative review of the literature from US and European studies. Anesth Pain Med (Seoul) 2023; 18:340-348. [PMID: 37919918 PMCID: PMC10635846 DOI: 10.17085/apm.23055] [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: 04/25/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 11/04/2023] Open
Abstract
Centrally acting skeletal muscle relaxants (CASMR) are widely prescribed as adjuncts for acute and chronic pain. Given the recent interest in multimodal analgesia and reducing opioid consumption, there has been an increase in its use for perioperative/postoperative pain control. The mechanism of action, pharmacodynamics, and pharmacokinetics of these drugs vary. Their use has been studied in a wide range of operative and non-operative settings. The best evidence for the efficacy of CASMRs is in acute, nonoperative musculoskeletal pain and, in the operative setting, in patients undergoing total knee arthroplasty and abdominal surgery, including inguinal herniorrhaphy and hemorrhoidectomy. The risk of complications and side effects, coupled with the limited evidence of efficacy, should prompt careful consideration of individual patient circumstances when prescribing CASMRs as part of perioperative pain management strategies.
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Affiliation(s)
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Christopher Choukalas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Colby Erickson
- Midwestern Osteopathic Medical School, Glendale, CA, USA
| | - Karl Poterack
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
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Comella A, Mogridge E, Arachchi A. A rare presentation of large bowel obstruction post haemorrhoidectomy: a case report. J Med Case Rep 2023; 17:394. [PMID: 37717034 PMCID: PMC10505309 DOI: 10.1186/s13256-023-04125-3] [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] [Received: 07/04/2022] [Accepted: 08/13/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Hemorrhoidal disease is a common anorectal pathology. Complications post hemorrhoidectomy are rare. Postoperative complications following hemorrhoidectomy include bleeding (2%), infection (0.4-8%), urinary retention (15%), and constipation (15-30%). CASE PRESENTATION A 40-year-old of Asian background female presented to a tertiary colorectal service with large bowel obstruction post hemorrhoidectomy. This is the first case in the surgical literature describing large bowel obstruction secondary to extrinsic compression from urinary retention following hemorrhoidectomy. The patient developed urinary retention and obstructed defecation in setting of inadequate analgesia post hemorrhoidectomy. The patient required indwelling catheter insertion and aggressive constipation management to resolve symptoms. Histopathology from the hemorrhoidectomy did not reveal a malignancy. CONCLUSION Anesthetic choice and postoperative analgesia are important factors to avoid the development of complications. A missed malignancy diagnosis must always be excluded with patients presenting post hemorroidectomy with bowel obstruction.
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Affiliation(s)
- Assia Comella
- Department of Surgery, Monash Health, 246 Clayton Rd., Clayton, VIC 3168 Australia
| | - Emily Mogridge
- Department of Surgery, Monash Health, 246 Clayton Rd., Clayton, VIC 3168 Australia
| | - Asiri Arachchi
- Department of Surgery, Monash Health, 246 Clayton Rd., Clayton, VIC 3168 Australia
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Long Q, Li J, Li Y. Analgesic effect of subcutaneous injection of different concentrations of methylene blue after hemorrhoidectomy: A retrospective study. Front Surg 2023; 10:1132277. [PMID: 37077863 PMCID: PMC10106721 DOI: 10.3389/fsurg.2023.1132277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
ObjectiveSubcutaneous injection of methylene blue around the anus may help reduce postoperative pain. However, the concentration of methylene blue is still controversial. Therefore, Our study aims to investigate the efficacy and safety of different methylene blue injected concentrations subcutaneously in pain treatment after hemorrhoidectomy.MethodsA total of 180 consecutive patients with grade III or IV hemorrhoids from March 2020 to December 2021 were reviewed. All patients underwent hemorrhoidectomy under spinal anesthesia and were divided into three groups. Group A received subcutaneous injection of 0.1% methylene blue after hemorrhoidectomy, group B received subcutaneous injection of 0.2% methylene blue, and Group C did not received subcutaneous injection of methylene blue. The primary outcome measures were the visual analog scale (VAS) pain score on postoperative days 1, 2, 3, 7, 14, and total analgesic consumption within 14 days. Secondary outcomes were complications after hemorrhoidectomy, including acute urinary retention, secondary bleeding, perianal incision edema, and perianal skin infection, and the Wexner scores used to assess the level of anal incontinence at one and three months after surgery.ResultsThere was no significant difference among three groups in sex, age, course of the disease, hemorrhoid grade and the number of incisions, and there was no significant difference in the volume of methylene blue injected between group A and group B. The VAS pain score and total analgesics consumption within 14 days in group A and group B were significantly lower than those in group C, but the differences between group A and group B were not statistically significant. The Wexner scores of group B were significantly higher than those of group A and group C one month after the operation, but the differences between group A and group C were not statistically significant. In addition, the Wexner score among three groups decreased to zero at three months after operation. There was no significant difference in the incidence of other complications among three groups.ConclusionThe perianal injection of 0.1% methylene blue and 0.2% methylene blue have a similar analgesic effect in pain treatment after hemorrhoidectomy, but 0.1% methylene blue has higher safety.
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Affiliation(s)
- Qing Long
- Department of Traditional Chinese Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jun Li
- Department of Traditional Chinese Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Li
- Department of Dermatology, Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University, Luzhou, China
- Correspondence: Yan Li
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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: 5.5] [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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Romito JW, Turner ER, Rosener JA, Coldiron L, Udipi A, Nohrn L, Tausiani J, Romito BT. Baclofen therapeutics, toxicity, and withdrawal: A narrative review. SAGE Open Med 2021; 9:20503121211022197. [PMID: 34158937 PMCID: PMC8182184 DOI: 10.1177/20503121211022197] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022] Open
Abstract
Baclofen is an effective therapeutic for the treatment of spasticity related to multiple sclerosis, spinal cord injuries, and other spinal cord pathologies. It has been increasingly used off-label for the management of several disorders, including musculoskeletal pain, gastroesophageal reflux disease, and alcohol use disorder. Baclofen therapy is associated with potential complications, including life-threatening toxicity and withdrawal syndrome. These disorders require prompt recognition and a high index of suspicion. While these complications can develop following administration of either oral or intrathecal baclofen, the risk is greater with the intrathecal route. The management of baclofen toxicity is largely supportive while baclofen withdrawal syndrome is most effectively treated with re-initiation or supplementation of baclofen dosing. Administration of other pharmacologic adjuncts may be required to effectively treat associated withdrawal symptoms. This narrative review provides an overview of the historical and emerging uses of baclofen, offers practical dosing recommendations for both oral and intrathecal routes of administration, and reviews the diagnosis and management of both baclofen toxicity and withdrawal.
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Affiliation(s)
- Jia W Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
- Department of Neurological Surgery, The
University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology, The University
of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emily R Turner
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - John A Rosener
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Landon Coldiron
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Ashutosh Udipi
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Linsey Nohrn
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Jacob Tausiani
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
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Maloney J, Pew S, Wie C, Gupta R, Freeman J, Strand N. Comprehensive Review of Topical Analgesics for Chronic Pain. Curr Pain Headache Rep 2021; 25:7. [PMID: 33534003 DOI: 10.1007/s11916-020-00923-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Topical analgesics are a non-opioid option for the treatment of chronic pain conditions including neuropathic pain, musculoskeletal pain, and osteoarthritis. There are many topical medications available; however their efficacy is variable. This article reviews the various topical analgesics, their mechanisms of action, and their efficacy. RECENT FINDINGS Studies have found topical NSAIDs are useful in treating acute musculoskeletal pain syndromes (strains and sprains) and show some efficacy in treating hand and knee osteoarthritis (Derry et al. Cochrane Database Syst Rev 5:CD008609, 2017). Topical capsaicin 8% has been shown to be efficacious in the treatment of postherpetic neuralgia, painful diabetic peripheral neuropathy, and HIV-neuropathy (Derry et al. Cochrane Database Syst Rev 1:CD007393, 2017). Topical lidocaine has been widely studied and found to reduce pain in patients with postherpetic neuralgia (Knezevic et al. Pain Manag 7:537-58, 2017). Although many other topical analgesics are available, there is limited data to support the efficacy of other agents. Topical analgesics are a relatively benign treatment for chronic pain conditions including neuropathic pain, musculoskeletal, and myofascial pain. There is evidence to support the use of topical NSAIDs, high concentration topical capsaicin, and topical lidocaine for various painful conditions.
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Affiliation(s)
- Jillian Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Scott Pew
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Christopher Wie
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ruchir Gupta
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - John Freeman
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic of Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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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: 2.3] [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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Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials. Int J Colorectal Dis 2020; 35:181-197. [PMID: 31897645 DOI: 10.1007/s00384-019-03497-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Post-operative pain following excisional haemorrhoidectomy poses a particular challenge for patient recovery, as well as a burden on hospital resources. There appears to be an increasing role for topical agents to improve this pain, but their efficacy and safety have not been fully assessed. This systematic review aims to assess all topical agents used for pain following excisional haemorrhoidectomy. METHODS The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently assessed MEDLINE, EMBASE, and CENTRAL databases to 27 June 2019. All randomised controlled trials (RCTs) in English that investigated topical agents following excisional haemorrhoidectomy were included. Meta-analysis was performed using Review Manager, version 5.3. RESULTS A total of 3639 records were identified. A final 32 RCTs were included in the qualitative analysis. Meta-analysis was performed on 9 RCTs that investigated glyceryl trinitrate (GTN) (5 for diltiazem, 2 for metronidazole and 2 for sucralfate). There were mixed significant changes in pain for GTN compared with placebo. Diltiazem resulted in significant reduction of pain on post-operative days 1, 2, 3 and 7 (p < 0.00001). Metronidazole resulted in significant reduction of pain on days 1 (p = 0.009), 7 (p = 0.002) and 14 (p < 0.00001). Sucralfate resulted in signification reduction of pain on days 7 and 14 (both p < 0.00001). CONCLUSION Topical diltiazem, metronidazole and sucralfate appear to significantly reduce pain at various timepoints following excisional haemorrhoidectomy. GTN had mixed evidence. Several single trials identified other promising topical analgesics.
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