Haemorrhoidectomy 2016

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Diclofenac suppositories administered immediately postoperatively reduced pain scores on the evening of surgery and the morning after and reduced analgesic consumption versus control (n=60; all patients had SA) (Rahimi 2012, LoE 1)

PROSPECT Recommendations

• Based on procedure-specific evidence of analgesic efficacy (LoE 1), systemic NSAIDs/COX-2-selective inhibitors are recommended (Grade A), in the absence of contraindications
• The recommendation has been strengthened since the previous review, which stated:
  • Postoperative systemic conventional NSAIDs are recommended (Grade B) based on transferable evidence showing analgesic efficacy (LoE 1)

Haemorrhoidectomy-Specific Evidence

Arguments for…

• There were no procedure-specific studies evaluating paracetamol in this review or the last review

PROSPECT Recommendations

• Paracetamol is recommended, given its safety and established role in baseline pain management, despite a lack of procedure-specific evidence (Grade B)
• The previous review stated:
  • Postoperative paracetamol is recommended (Grade B), based on transferable evidence (LoE 1) showing efficacy for low-moderate pain (VAS <50 mm)
  • Paracetamol alone is not recommended for high-intensity pain (VAS >/=50 mm) (Grade B), based on transferable evidence (LoE 1) showing a lack of analgesic efficacy

Haemorrhoidectomy-Specific Evidence

• No studies on opioids were identified since the last review

PROSPECT Recommendations

• Because opioids can cause constipation, nausea, vomiting and urinary retention, non-opioid analgesics should be used in preference (Grade B), with opioids reserved for rescue
• The recommendation is consistent with the previous review, which stated:
  • Strong opioids are recommended for moderate-to-high intensity postoperative pain (VAS>/= 30 mm) (Grade B), to supplement oral paracetamol and conventional NSAIDs/COX-2-selective inhibitors, based on transferable evidence for analgesic efficacy (LoE 1)
  • Weak opioids are recommended for low-to-moderate intensity postoperative pain (VAS<50 mm) (Grade B), to supplement oral paracetamol and conventional NSAIDs/COX-2-selective inhibitors, based on transferable evidence for analgesic efficacy (LoE 1)

Haemorrhoidectomy-Specific Evidence

Arguments for…

• One week of postoperative diosmin 500mg reduced pain at rest and on passing bowel motion for up to two weeks (n=86; all patients had SA) (Ba-bai-ke-re 2011, LoE 1)
• Another study comparing diosmin to paracetamol alone showed a reduction in pain at day 3 postoperatively but not at day 1 or 9 (n=60) (De Luca 2012, LoE 2)

Arguments against…

• Quercetin 200mg and hesperidin 50mg in combination with resveratrol, bromelain, folic acid, vitamins C and E, did not reduce pain compared with control (n=26) (Filingeri 2014, LoE 2)

PROSPECT Recommendations

• Diosmin is recommended as an adjunct to non-opioid analgesia (Grade A) based on procedure-specific evidence of a reduction in postoperative pain (LoE 1 and 2)
• The recommendation has been updated since the previous review, which stated: Flavonoids are not recommended (Grade D, LoE 4) because of limited and inconclusive procedure-specific evidence

Haemorrhoidectomy-Specific Evidence

Arguments for…

• No additional studies on laxatives were identified since the last review
• Relevant evidence from the previous review:
  • VAS pain scores on defecation were significantly lower with lactulose (15 ml three times daily for four days prior to haemorrhoidectomy; n=22) compared with placebo (n=20) on days 2 (p=0.025) and 4 (p=0.02), but not on days 1, 3 and 5, and significantly lower in the first two 24 h periods after defecation (p=0.005) (London 1987; LoE 1). VRS pain scores on defecation were significantly lower with lactulose compared with placebo on days 1 (p=0.03), 2 (p=0.025) and 3 (p=0.04), but not on days 4 and 5, and significantly lower in the first 24 h period after defecation (p=0.03). Patients in both groups received 15 ml lactulose three times daily from admission until discharge
  • VAS pain scores on defecation were significantly lower with Plantago ovata (a laxative herb, administered postoperatively, two sachets of 3.26 g per day for 20 days) compared with control (glycerine oil) (p<0.001) (Kecmanovic 2006; LoE 2)

PROSPECT Recommendations  

• Laxatives are recommended (Grade A), started in the days prior to surgery, as an adjunct to analgesic therapy, based on procedure-specific evidence (LoE 1 and 2)
• This is consistent with the previous review, which stated: Laxatives are recommended (Grade A) in the days prior to surgery, as an adjunct to analgesic therapy, based on procedure-specific evidence (LoE 1 and 2)

Haemorrhoidectomy-Specific Evidence  

Arguments for…

• Oral metronidazole for 7 days after surgery reduced pain, analgesia requirement and time to resumption of daily activities (n=44; all patients received SA) (Solorio-Lopez 2015, LoE 2)
• The previous review found:
  • Three out of four studies (all LoE 1) demonstrated a reduction in pain scores with metronidazole compared with placebo/no treatment (Data table)

PROSPECT Recommendations

• Oral metronidazole is recommended (Grade A) as an adjunct to analgesic therapy based on procedure-specific evidence (LoE 1)
• The recommendation for oral metronidazole is strengthened since the previous review by additional procedure-specific evidence of analgesic benefit

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Topical application of 2% lidocaine plus 0.2% GTN reduced pain scores on days 1 to 4 postoperatively, and analgesic requirements on days 1 to 3 versus either 2% lidocaine or 0.2% GTN alone. Topical 2% lidocaine reduced pain scores compared with 0.2% GTN on day 2 (n=210; all patients had SA or GA) (Khan 2014a; LoE 1)
• GTN ointment (0.4%) applied for 6 weeks reduced postoperative pain during the first postoperative week, reduced time to return to work, and significantly improved time to complete wound healing versus control (n=203; all patients received LA) (Franceschilli 2013, LoE 1)

Arguments against…

• Headache is reported as a side effect of GTN (Khan 2014a, LoE 1; Franceschilli 2013, LoE 1)

PROSPECT Recommendations

• The combination of topical 2% lidocaine and 0.2% GTN, or 0.4% GTN on its own, is recommended post-operatively (Grade A), based on procedure-specific evidence of analgesic efficacy (LoE 1 and 2)
• This recommendation has been updated based on new procedure-specific evidence. The previous review stated: Topical glyceryl trinitrate is not recommended (Grade D, LoE 4) due to inconsistent procedure-specific data

Haemorrhoidectomy-Specific Evidence

Arguments against…

• Diltiazem gel did not reduce pain or analgesic requirement compared with placebo (n=62; all patients had SA) (Sugimoto 2013; LoE 1)

PROSPECT Recommendations

• Topical diltiazem is not recommended (Grade A) as procedure-specifice evidence shows it does not reduce pain (LoE 1)
• The previous review made no recommendation regarding topical diltiazem as no evidence was identified

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Cholestyramine ointment (15%) reduced pain in one study on days 1 and 2, and pain with bowel motions up to 4 weeks after surgery, and reduced analgesic consumption (n= 91; all patients had GA) (Ala 2013a; LoE 1)

PROSPECT Recommendations

• Topical cholestyramine is recommended post-operatively (Grade A) based on procedure-specific evidence of analgesic efficacy (LoE 1)
• The previous review made no recommendation regarding topical cholestyramine as no evidence was identified

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Topical sucralfate ointment was associated with a reduction in pain and analgesic consumption for 2 weeks (n=48; all patients had GA) (Ala 2013b; LoE 1)
• Topical sucralfate ointment was associated with a reduction in pain scores up to 14 days after surgery (n=116) (Gupta 2008, LoE 1)

PROSPECT Recommendations  

• Topical sucralfate ointment is recommended (Grade A) as procedure-specific evidence shows a reduction in pain scores (LoE 1)
• The previous review made no recommendation regarding topical sucralfate ointment as no evidence was identified

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Topical EMLA applied at the end of surgery reduced pain in the very short term after surgery in three studies (n= 60, 30 and 60, respectively) (Rahimi 2012, LoE 1; Shiau 2008, LoE 1; Shiau 2007, LoE 2)

PROSPECT Recommendations

• Topical EMLA is recommended (Grade A) but it only reduced pain in the very short term in procedure-specific studies (LoE 1 and 2)
• This recommendation has been updated since the previous review, which stated:
  • Topical EMLA is not recommended (Grade B) based on limited procedure-specific evidence (LoE 1) showing a lack of analgesic benefit

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Topical nifedipine decreased pain at 6h and 7 days after surgery, with no effect on analgesic use (n=270; SA in both groups) (Perrotti 2010, LoE 1)

PROSPECT Recommendations

• Topical nifedipine is recommended (Grade A) but it only reduced pain in the very short term in procedure-specific studies (LoE 1)
• The previous review made no recommendation regarding topical nifedipine as no evidence was identified

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Topical metronidazole ointment reduced pain up to day 14, and analgesic requirements up to day 7, postoperatively (n=47) (Ala 2008, LoE 2)

PROSPECT Recommendations

• Topical metronidazole is not recommended (Grade D) as procedure-specific evidence of analgesic benefit is limited (LoE 2)
• The previous review made no recommendation regarding topical metronidazole as no evidence was identified

Haemorrhoidectomy-Specific Evidence

Arguments for…

• Non-surgical gloves filled with warm water and applied locally for 15 min sessions reduced pain at 24h and 72h and reduced analgesic consumption (n= 40; all patients underwent SA) (Balta 2015, LoE 2)

PROSPECT Recommendations

• Application of a warm bag is not recommended (Grade D) as procedure-specific evidence of benefit is limited (LoE 2)
• The previous review made no recommendation regarding application of a warm bag as no evidence was identified