Analgesic effect of local anaesthetic in haemorrhoid banding: systematic review and meta-analysis.

PURPOSE: Rubber band ligation of haemorrhoids can be,painful and there is no consensus regarding the optimal analgesic strategy. This study aims to determine whether there is a difference in post-procedural pain in adults undergoing haemorrhoid banding who have received local anaesthetic, a pudendal nerve block or no regional or local analgesia. METHODS: MEDLINE, Embase, Google Scholar and clinical trial registries were searched for randomised trials of local anaesthetic or pudendal nerve block use in banding. Primary outcomes were patient-reported pain scores. The quality of the evidence was assessed using the GRADE approach. RESULTS: Seven studies were included in the final review. No articles were identified that studied pudendal nerve blocks. The difference in numerical pain scores between treatment groups favoured the local anaesthetic group at all timepoints. The mean difference in scores on a 10-point scale was at 1 h,-1.43 (95% CI-2.30 to-0.56, p < 0.01, n = 342 (175 in treatment group)); 6 h,-0.52 (95% CI-1.04 to 0.01, p = 0.05, n = 250 (130 in treatment group)); and 24 h,-0.31 (95% CI-0.82 to 0.19, p = 0.86, n = 247 (127 in treatment group)). Of reported safety outcomes, vasovagal symptoms proceeded to meta-analysis, with a risk ratio of 1.01 (95% CI 0.64-1.60). The quality of the evidence was rated down to 'low' due to inconsistency and imprecision. CONCLUSION: This review supports the use of LA for reducing early post-procedural pain following haemorrhoid banding. The evidence was limited by small sample sizes and substantial heterogeneity across studies. REGISTRATION: PROSPERO (ID CRD42022322234).

Does complete pathological response increase perioperative morbidity risk in rectal cancer?

AIM: The optimal management of patients with clinical complete response after neoadjuvant treatment for rectal cancer is controversial. The aim of this study is to compare the morbidity between patients with locally advanced rectal cancer who have had a pathological complete response (pCR) or not after neoadjuvant chemoradiotherapy (NCRT) and total mesorectal excision (TME). The study hypothesis was that pCR may impact the surgical complication rate. METHOD: A retrospective cohort study was conducted of a prospectively maintained database in Australia and New Zealand, the Binational Colorectal Cancer Audit, that identified patients with locally advanced rectal cancer (<15 cm from anal verge) from 1 January 2007 to 31 December 2019. Patients were included if they had locally advanced rectal cancer and had undergone NCRT and proceeded to surgical resection. RESULTS: There were 4584 patients who satisfied the inclusion criteria, 65% being male. The mean age was 63 years and 11% had a pCR (ypT0N0). TME with anastomosis was performed in 67.8% of patients, and the majority of the cohort received long-course radiotherapy (81.7%). Both major and minor complications were higher in the TME without anastomosis group (17.3% vs. 14.7% and 30.6% vs. 20.8%, respectively), and the 30-day mortality was 1.31%. In the TME with anastomosis group, pCR did not contribute to higher rates of surgical complications, but male gender (p < 0.0012), age (p < 0.0001), preoperative N stage (p = 0.0092) and American Society of Anesthesologists (ASA) score ≥3 (p < 0.0002) did. In addition, pCR had no significant effect (p = 0.44) but male gender (p = 0.0047) and interval to surgery (p = 0.015) contributed to higher rates of anastomotic leak. In the TME without anastomosis cohort, the only variable that contributed to higher rates of complications was ASA score ≥3 (p = 0.033). CONCLUSION: Patients undergoing TME dissection for rectal cancer following NCRT showed no difference in complications whether they had achieved pCR or not.

Use of pudendal nerve blocks in rubber band ligation of haemorrhoids: an Australia-wide cross-sectional analysis.

BACKGROUND: Surgeons vary in their approach to preventing pain post rubber band ligation (RBL) of haemorrhoids, with pudendal nerve blocks (PNB) being one analgesic strategy. No data exists on how commonly PNBs are used in RBL in Australia, and whether use varies by year and patient and hospital characteristics. METHODS: Aggregate data from the National Hospital Morbidity Database was obtained for all admissions for RBL in Australia from 2012 to 2021, with and without a PNB, overall and in relation to sex, age group, hospital remoteness, hospital sector, and year of procedure. Adjusted relative risks (adj. RR) of PNB were estimated using Poisson regression, mutually adjusting for all variables. RESULTS: Of the 346 542 admissions for RBL, 14013 (4.04%) involved a PNB. The proportion of patients receiving a PNB increased between 2012-2013 and 2020-2021, from 1.62% to 6.63% (adj. RR 3.99, CI 3.64-4.36). Patients most likely to receive a PNB were female (adj. RR 1.10; CI 1.07-1.14) aged 25-34 years (adj. RR 1.13; CI 1.01-1.26); in major-city (adj. RR 1.25 CI 1.20-1.30) and private hospitals (adj. RR 3.28 CI 3.13-3.45). CONCLUSION: This is the first published analysis of the use of PNB in RBL. Pudendal nerve block use has increased over time, with substantial variation in practice. Blocks were more than three times as likely to be used in private compared to public hospitals. If evidence supporting PNB use is established, equitable access to the procedure should be pursued.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial).

INTRODUCTION: Rubber band ligation ('banding') is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the optimal analgesic strategy. In practice, patients may receive submucosal local anaesthetic, pudendal nerve block or routine periprocedural analgesia. The aim of this study is to compare the efficacy of submucosal local anaesthetic, pudendal nerve block and routine analgesia for postprocedural pain in patients undergoing haemorrhoid banding. METHODS AND ANALYSIS: This is a multicentre, prospective, three-arm, double-blind randomised controlled trial of adults booked for haemorrhoid banding. Participants will be randomised to one of three groups in a 1:1:1 ratio: (1)submucosal bupivacaine injection; (2) pudendal nerve ropivacaine injection and (3) no local anaesthetic. The primary outcome is patient reported postprocedural pain (scored 0-10) from 30 min to 2 weeks. Secondary outcomes include postprocedural analgesia use, time to discharge, patient satisfaction, time to return to work and complications. A sample size of 120 patients is required to achieve statistical significance. ETHICS AND DISSEMINATION: This study received Human Research Ethics Approval from the Austin Health Human Research Ethics Committee (March 2022). Trial results will be submitted to a peer-reviewed journal, and presented at academic meetings. A summary of the trial results will be made available to study participants on request. TRIAL REGISTRATION NUMBER: ACTRN12622000006741p.