Haemorrhoid Surgery 2006

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PROSPECT Haemorrhoid Surgery Subgroup

For each review, a Subgroup of the prospect Working Group performs an initial evaluation of the evidence and also drafts clinical practice statements and recommendations, which are then discussed by the whole Working Group before a final consensus is reached. The Subgroup may sometimes include a non-Working Group member, to provide additional expertise in the procedure being reviewed. For the haemorrhoid surgery review, the Subgroup members were:

• Professor Girish Joshi (PROSPECT Working Group member)
• Professor Edmund Neugebauer (PROSPECT Working Group member)

Grades of Recommendation

Recommendations are graded according to the overall level of evidence (LoE) on which the recommendations are based, which is determined by the quality and source of evidence: Levels of evidence and grades of recommendation in PROSPECT reviews (from 2006) 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.

Summary Recommendations

Pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following haemorrhoid surgery. Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision, ‘intra-operative’ refers to interventions applied after incision and before wound closure, ‘postoperative’ refers to interventions applied at or after wound closure. After haemorrhoid surgery, pain is not only related to the early postoperative period, but is also a problem after 2–3 days, around the time of first defecation. The following peri-operative interventions for haemorrhoid surgery have been reviewed:

• Pre-operative recommendations for Haemorrhoid Surgery
• Intra-operative recommendations for Haemorrhoid Surgery
• Postoperative recommendations for Haemorrhoid Surgery
• Not recommended for Haemorrhoid Surgery

See Overall PROSPECT recommendations for the overall strategy for managing pain after haemorrhoid surgery.

PROSPECT overall recommendations for postoperative pain management following haemorrhoid surgery:

Recommended for postoperative analgesia:

Overall PROSPECT Recommendations for Haemorrhoid Surgery

Not recommended for postoperative analgesia:

Not recommended for Haemorrhoid Surgery

Description of studies

Literature search

• Systematic review of the literature from 1966–June 2006 using MEDLINE and EmBASE, following the protocol of the Cochrane Collaboration Haemorrhoid Surgery June 2006 Search Terms
• Inclusion of randomised studies in English, assessing analgesic interventions in haemorrhoid surgery in adults, and reporting pain on a linear analogue, verbal or numerical rating scale
  • Primary outcome measure: postoperative pain scores
  • Secondary outcome measures: supplemental analgesic requirements, other recovery outcomes (adverse effects, functional recovery)
• Identification of 207 studies of peri-operative interventions for postoperative pain following haemorrhoid surgery
• 106 studies included Haemorrhoid Surgery June 2006 Included References
• 101 studies excluded Haemorrhoid Surgery June 2006 Excluded References
• The most common reasons for exclusion were that the method of haemorrhoid removal was not surgical (35 studies), or pain scores were not reported (24 studies), or the study was not a randomised controlled trial (29 studies; see Table 1 below) Haemorrhoid Surgery June 2006 Reasons for Exclusion

Study quality assessments, levels of evidence and grades of recommendation

Recommendations are graded according to the overall level of evidence (LoE) on which the recommendations are based, which is determined by the quality and source of evidence: Levels of evidence and grades of recommendation in PROSPECT reviews (from 2006)

Click here for quality scores and levels of evidence for included procedure-specific studies: Haemorrhoid Surgery June 2006 Quality Scoring + Levels of Evidence

Quantitative analyses

No meta-analyses were performed due to a limited number of studies of homogeneous design that reported similar outcome measures. Therefore, the procedure-specific evidence was only assessed qualitatively.

Transferable evidence

Transferable evidence of analgesic efficacy from comparable procedures (e.g. anorectal surgery) or evidence of other outcomes, such as adverse effects, has been included to support the procedure-specific evidence where this is insufficient to formulate the recommendations. Several studies that were identified in the literature search reported data pooled from patients undergoing mixed surgical procedures including haemorrhoid surgery. Such studies are excluded from the procedure-specific systematic review, but have been used as additional transferable evidence in cases where the Working Group considered it appropriate.

Descriptions of haemorrhoid surgery

Operative techniques

• Open (Milligan-Morgan technique): dissection of the haemorrhoid and ligation of the vascular pedicle, wounds are left open to heal naturally
• Closed
  • Conventional closed (Ferguson’s technique): the wound is closed with a continuous suture to promote healing
  • Stapled: reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane above the dentate line, using a specific circular stapling device. This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. May also be referred to as stapled haemorrhoidopexy or stapled anopexy
  • Submucosal (Park’s technique): removes the vascular pedicle corresponding to every haemorrhoidal nodule and preserves the overlying mucosa, which is then accurately reconstructed

Dissection techniques

• Conventional scissors
• Diathermy: uses high current bipolar electrocautery for cutting and haemostasis
  • Ligasure™ vessel sealing system: complete haemostasis is achieved by reforming the collagen and elastin in vessel walls to form an autologous seal
• Harmonic Scalpel: ultrasonically-activated scalpel, associated with decreased thermal damage to tissue and facilitated dissection within tissue planes
• Radiofrequency bistoury: cuts and coagulates tissues in an atraumatic manner, using radio waves (maximum temperature 80 °C). Eliminates diffuse bleeding because all vessels of 1.5–2 mm diameter are coagulated on the sectioning line, thus haemostasis is controlled
• Laser: concentrates the energy from electromagnetic radiation into a narrow beam that can be used for cutting, and causes very little damage to the surrounding tissue. It has a coagulative haemostatic effect that allows a dry operative field and obviates the need for ligation or diathermy

Adjuncts to surgery

• Sphincterotomy: part of the internal sphincter muscle is cut, which relieves the tension of the muscle
• Anal dilator: widens the anal canal if it has become narrowed because of tightness or spasm in the muscles (anal sphincters) that control the opening and closing of the anus

Topics for future research

In certain circumstances, recommendations for a type of treatment cannot be made due to limited or conflicting evidence. Areas which have been identified as requiring further investigation in the future are listed:

• Gabapentinoids
• Ketamine
• Flavonoids
• Botulinum toxin injection
• Topical therapies, including glyceryl trinitrate (GTN) and calcium channel blockers, and haemostatic dressings, including calcium alginate dressing

Abbreviations

CPM	chlorpheniramine maleate
EMLA	Eutectic Mixture of Local Anaesthetic
GA	general anaesthetic
GTN	glyceryl trinitrate
IM	intramuscular
Intra-op	intra-operatively
IV	intravenous
LA	local anaesthetic
LIS	lateral internal sphincterotomy
MFF	micronized flavonoid fraction
MPFF	micronized purified flavonoid fraction
NRS	numerical rating scale
PACU	post-anaesthesia care unit
PCA	patient-controlled analgesia
POD	postoperative day
PONV	postoperative nausea and vomiting
Postop	postoperatively
Pre-op	pre-operatively
VAS	visual analogue scale
VIS	visual intensity scale
VRS	verbal rating scale

Pre-operative studies

To ensure an adequate analgesic effect in the immediate postoperative period, it may be necessary to administer analgesic medication prior to the postoperative period.

Data in this section are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that assessed pre-operative analgesia versus the same analgesia given postoperatively (to examine the concept of pre-emptive – or preventive – analgesia).

A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids (Ong 2005b). A previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures — such as orthopaedic, dental, gynaecological and abdominal — has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002).

Intra-operative analgesia

To ensure an adequate analgesic effect in the immediate postoperative period, it may be necessary to administer analgesic medication prior to the postoperative period, e.g. conventional NSAIDs, COX-2-selective inhibitors, paracetamol

Postoperative studies 

Data in this section are available from studies that assessed postoperative analgesia versus postoperative placebo, as well as those that assessed postoperative analgesia versus the same analgesia given pre-operatively or intra-operatively.