Annals of Coloproctology

Reviews

Benign proctology, Functional outcomes

Still a Case of “No Pain, No Gain”? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020: Kheng-Seong Ng, Melanie Holzgang, Christopher Young; Ann Coloproctol. 2020;36(3):133-147. Published online June 30, 2020; DOI: https://doi.org/10.3393/ac.2020.05.04

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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.

Citations

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Benign proctology

Metronidazole in the Management of Post-Open Haemorrhoidectomy Pain: Systematic Review: Angelina Di Re, James Wei Tatt Toh, Jonathan Iredell, Grahame Ctercteko; Ann Coloproctol. 2020;36(1):5-11. Published online February 29, 2020; DOI: https://doi.org/10.3393/ac.2020.01.08

5,742 View
159 Download
7 Web of Science
6 Citations

Abstract PDF

Purpose
Open haemorrhoidectomy is associated with significant postoperative pain. Metronidazole is commonly prescribed in the postoperative period as an adjunct to analgesia in pain management.
Methods
In our systematic review, studies were identified using PubMed/MEDLINE, Embase/Ovid and Cochrane Register of Controlled Trials databases. Studies were included if they were randomised controlled trials (RCTs) involving interventions with oral metronidazole at any dose over any time period. The primary outcome was pain score (visual analogue scale, VAS) after open haemorrhoidectomy. Secondary outcomes included time to return to normal daily activities, additional analgesia usage, and postoperative complications.
Results
Of 14 RCTs reviewed, 4 met inclusion criteria and were selected. The studies comprised 336 study subjects and 169 subjects were randomised to metronidazole while 167 were in the control group. There was a significant reduction in VAS across all time points, with maximal reduction seen on day 5 posthaemorrhoidectomy (mean difference, -2.28; 95% confidence interval, -2.49 to -2.08; P < 0.001). There was no difference in incidence of complications (P = 0.13). The Cochrane Risk of Bias Tool showed 3 of 4 of the studies had a risk of bias.
Conclusion
Metronidazole may be associated with decreased pain but there is insufficient evidence from RCTs to provide a strong grade of recommendation. Further RCTs are required.

Citations

Citations to this article as recorded by

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Varut Lohsiriwat, Romyen Jitmungngan
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Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial
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Treatment of Hemorrhoid in Unusual Condition-Pregnancy
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