Haemorrhoidectomy 2016
PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.
Grades of recommendation (GoR) and levels of evidence (LoE)
GoRs are assigned according to the overall LoE on which the recommendations are based, which is determined by the quality and source of evidence: Relationship between quality and source of evidence, levels of evidence and grades of recommendation
Recommended pre- and intra-operative interventions
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NSAIDs/COX-2-selective inhibitors | 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, administered in time to provide sufficient early post-operative analgesia |
Paracetamol | Paracetamol is recommended, given its safety and established role in baseline pain management, despite a lack of procedure-specific evidence (Grade B), and it should be administered in time to provide sufficient early post-operative analgesia |
Parenteral glucocorticoids | Pre-operative parenteral glucocorticoids are recommended (Grade B), based on procedure-specific evidence (LoE 1 and 2) for analgesic efficacy |
Laxatives | 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) |
Oral metronidazole | Oral metronidazole is recommended (Grade A) as an adjunct to analgesic therapy based on procedure-specific evidence (LoE 1) |
Pudendal nerve block as an analgesic adjunct or anaesthetic intervention | Pudendal nerve block under GA or LA is recommended as there is some evidence that it is more effective than perianal infiltration of local anaesthetic (Grade B, LoE 2) |
Pudendal block, with or without GA, is recommended as the anaesthetic modality of choice (Grade A) based on procedure-specific evidence of analgesic benefit over spinal anaesthesia (LoE 1) | |
Operative techniques | Closed haemorrhoidectomy (Grade B) or open haemorrhoidectomy with electrocoagulation of the pedicle (Grade A) is recommended as the primary procedure for grade 3 and 4 haemorrhoids, based on:
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Recommended post-operative interventions
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NSAIDs/COX-2-selective inhibitors | 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 |
Paracetamol | Paracetamol is recommended, given its safety and established role in baseline pain management, despite a lack of procedure-specific evidence (Grade B) |
Opioids | 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 |
Laxatives | 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) |
Oral metronidazole | Oral metronidazole is recommended (Grade A) as an adjunct to analgesic therapy based on procedure-specific evidence (LoE 1) |
Topical lidocaine/GTN | 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) |
Diosmin | 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) |
Topical cholestyramine | Topical cholestyramine is recommended post-operatively (Grade A) based on procedure-specific evidence of analgesic efficacy (LoE 1) |
Topical EMLA | Topical EMLA is recommended (Grade A) but it only reduced pain in the very short term in procedure-specific studies (LoE 1 and 2) |
Topical nifedipine | Topical nifedipine is recommended (Grade A) but it only reduced pain in the very short term in procedure-specific studies (LoE 1) |
Topical sucralfate | Topical sucralfate ointment is recommended (Grade A) as procedure-specific evidence shows a reduction in pain scores (LoE 1) |
Perioperative pain treatment for haemorrhoidectomy should include, unless contraindicated: | |
Pre-/intra-operative |
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Operative technique |
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Postoperative |
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