Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review.

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.

Rectovaginal fistula after low anterior resection: Prevention and management.

Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon's experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.

Enhanced recovery after surgery in emergency resection for obstructive colorectal cancer: a systematic review and meta-analysis.

PURPOSE: Enhanced recovery after surgery (ERAS) improves outcomes after elective colorectal operations. Whether it is beneficial for emergency colorectal surgery is unclear. This study aimed to systematically review and summarize evidence from all studies comparing ERAS versus conventional care in patients having emergency colectomy and/or proctectomy for obstructive colorectal cancer. METHODS: EMBASE, MEDLINE, and PUBMED from 1981 to December 2019 were systematically searched. Any studies comparing our primary outcome of interest (length of hospitalization) among patients having emergency resection for obstructive colorectal cancer who received ERAS versus conventional care were selected. Primary outcome was length of hospitalization. Secondary outcomes were gastrointestinal recovery, postoperative complication, 30-day readmission and mortality, and time to start adjuvant therapy. RESULTS: Three cohort studies with 818 participants (418 received ERAS and 400 received conventional care) were included. Length of hospitalization (mean reduction 3.07 days; 95% CI, - 3.91 to - 2.23) and risk of overall complication (risk ratio 0.78; 95% CI, 0.63 to 0.97) were significantly lower in ERAS than in conventional care. ERAS was also associated with quicker time to gastrointestinal recovery, a lower incidence of ileus, and a shorter interval between operation and commence of adjuvant chemotherapy. There was no significant difference in the rates of anastomotic leakage, surgical site infection, reoperation, readmission, and mortality within 30 days after surgery between groups. CONCLUSIONS: ERAS had advantages over conventional care in patients undergoing emergency resection for obstructive colorectal cancer-including a shorter length of hospitalization, a lower incidence of overall complication, and a quicker gastrointestinal recovery.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices.

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.