Exploration of the mechanism underlying the therapeutic effect of electroacupuncture at chengshan acupoint on post-hemorrhoidectomy anal pain: Insights from the mAChRs/IP3-Ca2+-CaM signaling pathway.

OBJECTIVE: In the context of postoperative anal pain, understanding the intricate mechanisms and effective interventions is paramount. This study investigates the role of Muscarinic Acetylcholine Receptors (mAChRs) and the IP3-Ca2+-CaM signaling pathway in a rat model of postoperative anal pain, exploring the potential analgesic effects of electroacupuncture. METHODS: Comprehensive approaches involving mechanical sensitivity assays, Western blotting, immunohistochemistry, and intracellular calcium concentration measurement were used. RESULTS: The authors found elevated mAChRs expression in the postoperative pain model. Antagonizing mAChRs reduced pain sensitivity and attenuated the IP3-Ca2+-CaM pathway. Remarkably, electroacupuncture treatment further mitigated pain, potentially by suppressing this signaling cascade. INTERPRETATION: These findings reveal a novel connection between mAChRs and the IP3-Ca2+-CaM pathway in postoperative anal pain and suggest electroacupuncture as a promising avenue for pain relief through these mechanisms, offering insights into innovative strategies for postoperative pain management.

[The effectiveness of flavonoids in the postoperative treatment of patients with hemorrhoids]. / Effektivnost' flavonoidov v posleoperatsionnom vedenii patsientov s gemorroem.

OBJECTIVE: Evaluation of the effectiveness of flavonoids in the postoperative management of patients with hemorrhoids. MATERIAL AND METHODS: A single-center randomized controlled clinical trial was conducted. Patients with stage III and IV hemorrhoids aged over 18 years who patients who underwent hemorrhoidectomy were included.The patients were divided into 2 groups - main and control. Patients in the main group were recommended to use a purified micronized flavonoid fraction - 65 patients. In the control group (70 patients), the use of this group of drugs was not expected.The observation period was 60 days. After discharge from the hospital, 5 patient visits were scheduled: on the 3rd, 7th, 21st, 40th and 60th day after surgery. Patients independently assessed the intensity of symptoms - pain, tenesmus, itching and bleeding.The randomization procedure was carried out using the method of simple randomization using envelopes. RESULTS: 135 patients were randomized. There were no patients who dropped out of the study. The number of participants whose data were included in the analysis was 65 patients in the main group and 70 patients in the control group.Assessment of symptoms in the first 3 days of the postoperative period did not show a significant difference in the condition of the patients. Over time, we found significant changes in the dynamics of complaints between groups. After 7, 21, 40 and 60 days, a statistically significant lower severity of pain, bleeding and tenesmus was revealed among patients in the main group compared to the control group. This trend was not detected in the assessment of itching. There were no undesirable effects. CONCLUSION: The use of purified micronized flavonoid fraction in the postoperative management of patients with hemorrhoids can significantly reduce the degree and duration of pain, bleeding and tenesmus.

[Anorectal melanoma: Clinical case]. / Melanoma anorrectal: un caso clínico.

Background: Anorectal melanoma (AM) is a rare and aggressive type of tumor, with varied and inconclusive scientific information. Its preoperative diagnosis is challenging due to its rarity and similarity to other anorectal conditions. It represents only 1.3% of melanomas and affects more women than men. Approximately 20-30% of AM cases are amelanotic, complicating endoscopic detection and leading to misdiagnoses. AM is often confused with hemorrhoids, polyps, and rectal cancer in two thirds of patients due to similar symptoms. The causes and risk factors of AM are not well understood, but they are suspected to differ from cutaneous and ocular melanomas. Diagnosis is performed through biopsy and immunohistochemical staining. Colonoscopy helps to characterize the lesions, and histological examination is crucial for definitive diagnosis. Clinical case: 50-year-old woman with rectal bleeding and proctalgia. AM was diagnosed through colonoscopy, and transanal resection with hemorrhoidectomy was performed. Conclusions: Management of AM is complicated by the lack of randomized trials. Resection surgery is the standard treatment, but there is no established protocol. Wide local excision may be an option for limited cases. Further research is needed to improve the management and treatment of AM. Early detection and complete surgical removal are crucial for enhancing survival in these patients.

Introducción: el melanoma anorrectal (MA) es un tipo raro y agresivo de tumor, cuya información científica es variada y poco concluyente. Su diagnóstico preoperatorio es un desafío debido a su rareza y a su similitud con otras afecciones anorrectales. Representa solo el 1.3% de los melanomas y afecta más a mujeres que a hombres. Aproximadamente el 20-30% de los casos de MA son amelanóticos, lo que complica su detección endoscópica y conduce a diagnósticos erróneos. El MA se confunde con hemorroides, pólipos y cáncer de recto en dos tercios de los pacientes debido a síntomas similares. Las causas y factores de riesgo del MA aún no se conocen bien, pero se sospecha que son diferentes de los melanomas cutáneos y oculares. El diagnóstico se realiza mediante biopsia y tinción inmunohistoquímica. La colonoscopía permite caracterizar las lesiones y el examen histológico es crucial para el diagnóstico definitivo. Caso clínico: mujer de 50 años con rectorragia y proctalgia. Se diagnosticó MA mediante colonoscopía y se realizó una resección transanal con hemorroidectomía. Conclusiones: el manejo del MA es complicado por la falta de ensayos aleatorizados. La cirugía de resección es el tratamiento habitual, pero no hay un protocolo establecido. La escisión local amplia puede ser una opción para casos limitados. Se necesita más investigación para mejorar el manejo y tratamiento del MA. La detección temprana y la extirpación quirúrgica completa son cruciales para mejorar la supervivencia en estos pacientes.

Topical metronidazole after haemorrhoidectomy to reduce postoperative pain: a systematic review.

Excisional haemorrhoidectomy is the gold standard for operating haemorrhoids, but it is accompanied by a significant problem: postoperative pain. Several strategies have been adopted to minimize this condition. Oral metronidazole has been proven to reduce postoperative pain but with some complications. This systematic review was conducted to investigate the effects and general efficacy of topical metronidazole administration and to evaluate its potential superiority over the oral formula. A systematic review of the literature was carried out. Randomized controlled trials published until September 2023 on PubMed, Central, and Web of Science were considered. The primary outcome considered was postoperative pain, which was evaluated using visual analogue scores. The secondary outcomes were analgesic use, return to work, and complications. Six randomized controlled trials were included, with a total of 536 patients. Topical metronidazole was compared with placebo in two studies, with oral formula in three studies, and with placebo and oral administration in one study. Topical metronidazole was found to be effective for treating postoperative pain when compared to a placebo but had no significant advantage over the oral formula. No complications were reported in the studies. Topical and oral metronidazole are effective solutions for postoperative pain after excisional haemorrhoidectomy. No superiority was demonstrated based on the route of administration, and complications were marginal for both formulas. Further studies are required to determine the best metronidazole solution.

Carlos passou por uma cirurgia no Hospital Dia (HD) Vila Prudente

Acometido por uma hemorroida, o técnico de farmácia Carlos Roberto Rocha, relata o tratamento cirúrgico pelo qual passou até a hemorroidectomia, sob as mãos da cirurgiã geral e proctologista, Paola Meinicke, o mesmo declara os preconceitos superados quanto ao assunto e seus cuidados.

Comparison of Post-Hemorrhoid Surgery Pain Profiles in Older and Younger Adults.

INTRODUCTION: Older and younger adults are offered similar analgesic options after hemorrhoid surgery (HS), but the differences in pain between the two populations are unknown. This study aims to compare postoperative pain outcomes after HS in older and younger individuals. METHODS: This is a retrospective analysis of electronic medical records of patients who underwent HS between 2018 and 2023. Patients were excluded if additional anorectal procedures were performed at the time of HS. Data related to pain-related outcomes were compiled: (1) need for narcotic prescription refills; (2) documentation of a pain-related phone call within 30 d; (3) urgent postoperative office visit before regular scheduled follow-up; and (4) pain-related postoperative emergency department visits. Associations between age and pain-related outcomes were tested using Fisher's exact test, chi-square test, and covariate adjusted logistic regression modeling. RESULTS: There were a total of 249 patients, 60 older adults, and 189 younger adults. Compared to younger patients, older adults demonstrated a reduced frequency of pain-related phone calls (10.3 versus 32.1%, P < 0.01) and opioid refills (0 versus 14.4%, P < 0.01). After adjusting for confounders, older age remained inversely associated with pain-related postoperative phone calls (odds ratio = 0.25, 95% confidence interval = [0.1-0.6], P = 0.003). CONCLUSIONS: Older adults had better pain outcomes after HS in comparison to younger patients. These findings suggest that the postoperative analgesic needs of older patients after HS are lower than those of younger patients. Decisions regarding opioid prescription in older adults recovering from HS should be tailored to avoid narcotic-related complications.

Analysis of Two Treatment Modalities for Post-surgical Pain after Hemorrhoidectomy.

Background: This non-randomized study aimed to compare the efficacy of two pharmacological treatments, "around-the-clock" analgesic treatment (ACAT) and "on-demand" analgesic treatment (ODAT), for managing postoperative pain following hemorrhoidectomy. Material and Methods: The study, conducted from July 2016 to December 2020, included 5335 hemorrhoidectomy patients. Participants were divided into ACAT (3767) and ODAT (1568) groups. The study was registered at clinicaltrials.gov (NCT04953182). Results: Patients had a mean age of 47.47 years, with 59.98% males. Postoperatively, 14.13% reported severe pain, 36.49% moderate, 34.28% mild, and 15.09% no pain. ACAT group's maximum pain was 3.04 (VAS), ODAT 4.95 (p; average pain was 0.79 (ACAT) and 1.45 (ODAT). Discharge pain was 0.42 (ACAT) and 0.63 (ODAT) VAS. The ACAT group consistently reported lower levels of pain across all measured instances. Higher BMI and younger age were pain risk factors (p=.049, p .001 respectively). ACAT administration resulted in reduced opioid usage, with meperidine showing a 68.38% decrease, morphine 43.57% less, tramadol 46.82% less, oxycodone reduced by 38.74%, and codeine by 53.40%. Additionally, the use of non-opioid analgesics was notably lower in the ACAT group, ranging from 16% to 59% less compared to the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain, with only 14% experiencing severe pain. A fixed schedule multimodal pain regimen, regardless of procedure and anesthesia type, reduces pain from moderate to mild post-hemorrhoidectomy. This approach also decreases opioid and non-opioid analgesic requirements. Higher BMI and younger age are identified as risk factors for elevated postoperative pain.

Hemorrhoidal laser ablation procedure: a minimally invasive treatment for grades II, III, and IV using a 1470 nm diode laser.

<b>Indroduction:</b> Hemorrhoids often cause pain, and achieving painless outcomes through surgery is challenging. Hemorrhoidal Laser Ablation, a method for treating severe hemorrhoids, has limited documentation in clinical trials.</br> <br><b>Aim:</b> This retrospective study aimed to present our experience with Hemorrhoidal Laser Ablation in symptomatic grade II, III, and IV internal hemorrhoids and evaluate the efficacy and safety of this relatively recent technique.</br> <br><b>Material and methods:</b> The cohort included 138 patients with symptomatic hemorrhoids who underwent Hemorrhoidal Laser Ablation at three different medical centers in 2017-2022. Patients were treated with a 1470 nm diode laser. Data were collected on clinical and perioperative characteristics and outcomes.</br> <br><b>Results:</b> No evidence of intraoperative complications occurred. There was no rectal tenesmus or alteration of defecation habits. Early mild postoperative symptoms were observed for an average of one week after the operation. The plateau of symptom resolution and downgrading of hemorrhoid size reached approximately six months post-procedure. The short- -term recurrence rate was 0.8% within roughly a month after the laser surgery, while the long-term recurrence rate was 5% over up to five years of follow-up. The overall satisfaction rate was 95% with symptomatic relief.</br> <br><b>Conclusions:</b> Hemorrhoidal Laser Ablation is a painless outpatient technique that does not require general anesthesia. It is an easy-to-perform, convenient, safe, and efficient modality in reducing symptoms and complications of grades II, III, and IV internal hemorrhoids. Hemorrhoidal Laser Ablation limits postoperative discomfort and allows the patient to return to daily routines quickly.</br>.

A systematic review comparing the efficacy of 980 nm vs. 1470 nm wavelengths in laser hemorrhoidoplasty.

BACKGROUND: Laser Hemorrhoidoplasty (LHP) is a minimally invasive surgical option for the management of hemorrhoidal disease that has been increasingly adopted by surgeons over the last decade. Two wavelengths; 980 nm and 1470 nm have been employed in LHP. However, no data exist comparing the effects of these two wavelengths for this indication. This systematic review investigates both wavelengths for the management of hemorrhoids via the LHP procedure. METHODS: This systematic analysis and meta-analysis was performed following the PICOS and PRISMA guidelines. A systematic research of MEDLINE, Scopus, Clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials, CENTRAL and Google Scholar databases from inception until March 2024 was performed. RESULTS: Overall, 19 studies including seven randomized control trials (RCT) and 12 non-randomized control trials with a total of 2492 patients were included in this systematic review and meta-analysis. The duration of LHP with both wavelengths was significantly shorter compared to open hemorrhoidectomy, postoperative pain and the rate of postoperative complications were significantly lower following LHP. There was no statistically significant difference in the rate of recurrence between LHP with the 980-nm wavelength and open hemorrhoidectomy. However, LHP with 1470-nm wavelength resulted in significantly higher recurrence rate compared to hemorrhoidectomy. CONCLUSION: Although no direct studies have compared the two wavelengths used in LHP, the outcomes of LHP seem to be independent of the wavelength used. Both wavelengths, when correctly used provide similar results, which are mostly better compared to open hemorrhoidectomy in terms of postoperative complications and postoperative pain, but not in terms of recurrence, where at least for the 1470-nm wavelength, LHP seems to show a higher recurrence rate when compared to open hemorrhoidectomy. Although a direct comparison of both wavelengths was not possible, technical issues regarding number of shots and energy per pile represent relevant parameters for recurrence after LHP.

Clinical outcomes of laser hemorrhoidoplasty with feeding vessels suture ligation: a retrospective study in a single center.

BACKGROUND: Laser hemorrhoidoplasty has demonstrated significant therapeutic effectiveness. To diminish postoperative bleeding and enhance overall outcomes, we have additionally adopted suture ligating the feeding vessels. This study aimed to understand the treatment outcomes and any associated complications. METHODS: This study comprised patients with symptomatic grade II-III hemorrhoids who underwent laser hemorrhoidoplasty with feeding vessel suture ligation and Milligan-Morgan hemorrhoidectomy between 1 September 2020, and 31 August 2022. Surgical-related details, postoperative pain, discomfort after discharge, hemorrhoid recurrence, and any complications were collected from inpatient records, outpatient follow-ups, and telephone interviews. Initially, we will analyze the distinctions between the laser group and the traditional group, followed by an investigation into complications and satisfaction within the laser surgery subgroup. RESULTS: The study included 323 patients, with 173 undergoing laser hemorrhoidoplasty (LHP) and 150 undergoing Milligan-Morgan hemorrhoidectomy. Regarding pain assessment, the LHP group exhibited superior performance compared to traditional surgery at postoperative 4 h, before discharge, and during the first and second outpatient visits, with statistically significant differences. Additionally, the LHP group had a lower rate of urinary retention and experienced significantly less pain, with statistically significant differences. CONCLUSIONS: Laser hemorrhoidoplasty with feeding vessels suture ligation has been shown to reduce postoperative pain and appears to be a promising minimally invasive treatment option for symptomatic grade II and III hemorrhoids.

Flavonoids and post haemorrhoidectomy recovery: a systematic review and meta-analysis.

BACKGROUND: Haemorrhoidectomy is the gold standard for definitive treatment of high-grade symptomatic haemorrhoids but is often associated with substantial pain. This systematic review aims to explore the potential of flavonoids in alleviating the postoperative symptom burden following excisional haemorrhoidectomy. METHODS: A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42023472711). Randomized controlled trials (RCTs) published PubMed, MEDLINE, Embase, and Scopus from inception to 1st December 2023 were retrieved. The primary outcome investigated was post-operative pain. Meta-analysis was performed using Review Manager version 5.4.1. RESULTS: Ten articles with 775 patients were included. The meta-analysis identified statistically significant decreases in post-operative pain in favour of the flavonoid groups (Standardized Mean Difference -0.66 [95% confidence intervals (CI) -0.82, -0.52]; P < 0.00001), and bleeding (Odds Ratio 0.13 [95% CI 0.09, 0.19]; P < 0.00001). CONCLUSION: Flavonoids show promise as a means of reducing pain associated with excisional haemorrhoidectomy. Further research is required to investigate topical routes of administration and standardize regimes.

Rectal perforation after laser hemorrhoidoplasty: a case report.

This case report outlines the intricate management of rectal perforation following laser hemorrhoidoplasty in a 31-year-old female, leading to an acute abdomen, sepsis, and multiorgan failure. Urgent laparoscopic exploration and the establishment of a double-loop colostomy were undertaken, marking the beginning of a complex course characterized by relapsed pelvic sepsis. Laser hemorrhoidoplasty has gained widespread acceptance for its minimally invasive approach in treating hemorrhoids. Remarkably, to our knowledge, the case we present is the first major complication reported after laser hemorrhoidoplasty, likely attributed to collateral thermic and mechanical tissue damage.

Evaluating the efficacy and safety of perianal injection of liposomal ropivacaine HR18034 for postoperative analgesia following hemorrhoidectomy: A multicenter, randomized, double-blind, controlled phase II clinical trial.

STUDY OBJECTIVE: HR18034, composed of the ropivacaine encapsulated in multi-lamellar, concentric circular structure liposomes as the major component and a small amount of free ropivacaine, has performed well in animal experiments and phase I clinical trials. This trial was to investigate the efficacy, safety, pharmacokinetic profile and the minimum effective dose of HR18034 for postoperative analgesia after hemorrhoidectomy compared with ropivacaine. DESIGN: A multicenter, randomized, double-blind trial. SETTING: 19 medical centers in China. PATIENTS: 85 patients undergoing hemorrhoidectomy between October 2022 to November 2022. INTERVENTIONS: Patients were randomly divided into HR 18034 190 mg group, 285 mg group, 380 mg group and ropivacaine 75 mg group, receiving single local anesthetic perianal injection for postoperative analgesia. MEASUREMENTS: The primary outcome was the area under the resting state NRS score -time curve within 72 h after injection. The second outcomes included the proportion of patients without pain, the proportion of patients not requiring rescue analgesia, cumulative morphine consumption for rescue analgesia, etc. Safety was evaluated by adverse events incidence and plasma ropivacaine concentrations were measured to explore the pharmacokinetic characteristics of HR18034. MAIN RESULTS: The areas under the NRS score (at rest and moving states)-time curve were significantly lower in HR 18034 380 mg group than ropivacaine 75 mg at 24 h, 48 h, and 72 h after administration. However, this superiority was not observed in HR18034 190 mg group and 285 mg group. There was no difference in cumulative morphine consumption for rescue analgesia between HR 18034 groups and ropivacaine group. CONCLUSIONS: HR 18034 380 mg showed superior analgesic efficacy and equivalent safety compared to ropivacaine 75 mg after hemorrhoidectomy, thus preliminarily determined as minimum effective dose.

Gold Standard yet Inconspicuous- Our Experience of Conventional Haemorrhoid Surgeries in a Peripheral Free of Cost Hospital of Bangladesh.

Recent advancement in surgical treatment of haemorrhoidal disease is not accessible by low socio-economic group of patient in a peripheral hospital of an underdeveloped country, where we aimed to evaluate the outcome of conventional surgeries. This descriptive, prospective, observational study was performed from diagnosis of haemorrhoidal disease to surgical intervention and followed up 12 months post operatively. Clinico-pathological data and outcome in the form of complications and recurrence within follow-up period was studied. Total 64 adult patients with mean age 38.6 years and male female ratio 1.7:1 were included in this study. Mean duration of symptoms was 13 months, reflects late presentation. Two (2) piles mass was seen most frequent in 36(56.3%) cases and most of the patients i.e. 44(68.8%) had haemorrhoids only on primary sites (3, 7 and 11 o'clock) of anal canal, but 18(28.1%) had mixed primary and secondary position of haemorrhoids. Similarly among those who had more than one haemorrhoid, grade 4 was commonest 35(53.1%) followed by only grade 3 in 15(23.4%) cases but mixed grade 3 and 4 was seen in 10(15.6%) patient. Complication less recovery was seen in 56(87.5%) cases, where delayed wound healing and pain was reported in 2(3.6%) patient each, followed by 1(1.6%) each reported urinary retention, anal sepsis, primary bleeding and reactionary bleeding. Mean hospital stay was 4 days. Conventional surgeries are equally efficacious and cost effective option for management of operable haemorrhoidal disease at any setup.

A Randomized Controlled Trial of Topical Analgesia Posthemorrhoidectomy (TAPH Trial).

BACKGROUND: Postoperative pain remains the greatest problem after hemorrhoidectomy. Pain is hypothesized to arise from bacterial infection, sphincter spasm, and local inflammation. OBJECTIVE: This trial was conducted to assess the effects of metronidazole, diltiazem, and lidocaine on posthemorrhoidectomy pain. DESIGN: A double-blinded randomized controlled factorial trial. SETTINGS: This multicenter trial was conducted in Auckland, New Zealand. PATIENTS: A total of 192 participants were randomly assigned (1:1:1:1) into 4 parallel arms. INTERVENTIONS: Participants were randomly assigned into 1 of 4 groups receiving topical treatment with 10% metronidazole, 10% metronidazole + 2% diltiazem, 10% metronidazole + 4% lidocaine, or 10% metronidazole + 2% diltiazem + 4% lidocaine. Participants were instructed to apply treatment to the anal verge 3 times daily for 7 days. MAIN OUTCOME MEASURES: The primary outcome was pain on the visual analog scale on day 4. The secondary outcomes included analgesia usage, pain during bowel movement, and functional recovery index. RESULTS: There was no significant difference in the pain and recovery scores when diltiazem or lidocaine was added to metronidazole (score difference between presence and absence of diltiazem in the formulation: -3.69; 95% CI, -13.3 to 5.94; p = 0.46; between presence and absence of lidocaine: -5.67; 95% CI, -15.5 to 3.80; p = 0.24). The combination of metronidazole + diltiazem + lidocaine did not further reduce pain. Secondary analysis revealed a significant difference between the best (metronidazole + lidocaine) and worst (metronidazole + diltiazem + lidocaine) groups in both pain and functional recovery scores. There were no significant differences in analgesic usage, complications, or return to work between the groups. No clinically important adverse events were reported. The adverse event rate did not change in the intervention groups. LIMITATIONS: Topical metronidazole was used in the control group rather than a pure placebo. CONCLUSIONS: There was no significant difference in pain when topical diltiazem, lidocaine, or both were added to topical metronidazole. See Video Abstract . CLINICALTRIALSGOV IDENTIFIER: NCT04276298. ENSAYO CONTROLADO ALEATORIZADO DE ANALGESIA TPICA POSTERIOR A HEMORROIDECTOMA ENSAYO TAPH: ANTECEDENTES:El dolor postoperatorio sigue siendo el mayor problema tras hemorroidectomía. La hipótesis es que el dolor se debe a infección bacteriana, el espasmo esfínteriano e inflamación local.OBJETIVO:Se realizó un ensayo factorial aleatorizado y controlado para evaluar los efectos del metronidazol, el diltiazem y la lidocaína en el dolor posthemorroidectomía.DISEÑO:Ensayo factorial controlado aleatorizado doble ciego.ESCENARIO:Se realizó un ensayo multicéntrico en Auckland, Nueva Zelanda.PACIENTES:Se aleatorizó a 192 participantes (1:1:1:1) en cuatro brazos paralelos.INTERVENCIONES:Los participantes se asignaron aleatoriamente a uno de los cuatro grupos que recibieron tratamiento tópico con metronidazol al 10% (M), metronidazol al 10% + diltiazem al 2% (MD), metronidazol al 10% + lidocaína al 4% (ML), o metronidazol al 10% + diltiazem al 2% + lidocaína al 4% (MDL). Se indicó a los participantes que lo aplicaran en el margen anal 3 veces al día durante 7 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el dolor en la escala analógica visual en el día 4. Los resultados secundarios incluyeron el uso de analgesia, el dolor al defecar y el índice de recuperación funcional.RESULTADOS:No hubo diferencias significativas en las puntuaciones de dolor y recuperación cuando se añadió diltiazem o lidocaína al metronidazol (diferencia de puntuación entre la presencia y la ausencia de D en la formulación: -3.69; IC del 95%: -13.3; 5.94; p = 0.46; entre la presencia y la ausencia de L: -5.67; IC del 95%: -15.5; 3.80; p = 0.24). La combinación de MDL no redujo más el dolor. El análisis secundario reveló una diferencia significativa entre los grupos mejor (ML) y peor (MDL) tanto en las puntuaciones de dolor como en las de recuperación funcional. No hubo diferencias significativas en el uso de analgésicos, las complicaciones o la reincorporación al trabajo entre los grupos. No se notificaron eventos adversos clínicamente importantes. La tasa de eventosadversos no cambió en los grupos de intervención.LIMITACIONES:Se utilizó metronidazol tópico en el grupo de control, en lugar de un placebo puro.CONCLUSIONES:No hubo diferencias significativas en el dolor cuando se añadió diltiazem tópico o lidocaína, o ambos, al metronidazol tópico. ( Traducción-Dr. Jorge Silva Velazco )Identificador de registro del ensayo clínico:NCT04276298.

Pycnogenol® supplementation to relieve symptoms after hemorrhoidectomy.

BACKGROUND: Hemorrhoids are a common problem associated with symptoms, like swelling, local thrombosis and generally with a decreased quality of life, often in otherwise healthy subjects. Hemorrhoids can be classified by grades (I to IV) according to their severity. In this registry study subjects treated with excisional hemorrhoidectomy (EH) for the first time, were included. After surgery, edema tends to complicate surgical areas causing relevant symptoms. Most hemorrhoids symptoms are related to alterations in bowel habits. Increase in diet fibers to avoid constipation, exercise, and limiting straining reduce recurrence after surgery. METHODS: The aim of the registry study was to evaluate the effects of Pycnogenol® (Horphag Research, Geneva, Switzerland) on relieving postoperative symptoms following hemorrhoidectomy. Pycnogenol® 150 mg/day was used between one month before surgery up to one month after surgery. The main postoperative symptoms were scored. RESULTS: Thirty-eight subjects completed the 60-day supplement registry study. Eighteen subjects were supplemented with Pycnogenol® in addition to the standard management (SM) and 20 subjects only received SM and were considered as controls. The two groups were comparable for age, sex and main symptoms distribution and for their clinical characteristics at inclusion. No other disease was present. The scores for pain, discomfort, and constipation were significantly lower with the supplement compared to controls (P<0.05) 10 and 30 days after surgery. In addition, the quality-of-life score was higher with Pycnogenol® (P<0.05) while bleeding (minimal, not clinically evaluable) and a possible residual anal stenosis (requiring a longer period of observation) were barely observed. A satisfactory return to activity was observed 30 days after surgery in the 18 subjects using Pycnogenol®, and in only 15 out of 20 patients (75%) in the control group (P<0.05). All Pycnogenol® subjects were able to drive and perform daily tasks in comparison with 14 out of 20 subjects in the control group. The proportion of patients that took pain medication from day 10 to 30 post-surgery was significantly lower in the Pycnogenol® group than in controls (P<0.05). CONCLUSIONS: In this post-surgical pilot, registry study, Pycnogenol® was effective in preventing and controlling postoperative symptoms after hemorrhoidectomy. To confirm the results, more cases are needed, including different surgical methods and clinical conditions. Mucosal and cutaneous edema and perianal swelling - generally seen after surgery - seem to be clearly reduced with Pycnogenol® and the supplement intake was associated with a more regular and pain-controlled convalescence and healing.

Protocol of a clinical trial on the effectiveness of pudendal nerve block with and without neurostimulation in reducing posthemorroidectomy pain.

INTRODUCTION: Hemorrhoidal pathology is the most frequent proctological problem with a prevalence of 44% of the adult population. The most effective treatment is surgery but it also has the highest postoperative pain rate with moderate to severe pain rates of 30-40% during the first 24-48 hours. Here lies the importance of seeking measures to improve this situation, such as the pudendal nerve block with local anesthetic. However, the variability of the pudendal nerve sometimes makes its blockade ineffective and for this reason nerve location methods are sought to achieve a higher rate of success. The main aim of the study is to compare pain in the immediate postoperative period (24 h) after hemorrhoidectomy in patients with pudendal nerve block guided by anatomical references and guided by neurostimulation. METHODS: The present project proposes the performance of a single-center, triple-blind, randomized clinical trial of efficacy, carried out under conditions of routine clinical practice. Patients over 18 years old with hemorrhoids refractory to medical treatment, symptomatic grade III-IV and grade II hemorrhoids that do not respond to conservative procedures in a third level hospital in Spain and that are subsidiaries of surgery in major ambulatory surgery will be included. Demographic variables, variables on hemorrhoidal pathology, details of surgery, verbal numeric pain scale in the preoperative period and surgical complications will be collected. RESULTS: Not avaliable until the end of the study. CONCLUSIONS: The pudendal nerve block guided by anatomical landmarks has been shown to be useful in postoperative pain control after hemorrhoidectomy although the use of the neurostimulator has not been well studied and we believe it may improve outcom.

Is routine histopathological analysis of hemorrhoidectomy specimens necessary? A systematic review and meta-analysis.

BACKGROUND: Hemorrhoidectomy is a common procedure used to treat symptomatic hemorrhoids. However, the necessity and cost-effectiveness of routinely conducting histopathological analysis on excised tissue samples are uncertain. METHODS: A systematic review was conducted using MEDLINE and EMBASE up to December 2023 for studies assessing the histopathological outcomes of hemorrhoidectomy specimens. Meta-analysis was performed on articles with combinable results to determine the pooled proportions of cancer and anal intraepithelial neoplasia (AIN) using the random effects model. RESULTS: From 2974 initial search results, 12 studies were included in the review, with 48,365 resected specimens from hemorrhoidectomy. Among these, there were 11 retrospective studies and one prospective study. A meta-analysis of 11 studies revealed that the prevalence of anal cancer was low, at 0.13% (95% CI: 0.05%-0.31%). The prevalence of anal cancer and AIN combined was 1.16% (95% CI: 0.53%-2.52%). CONCLUSION: This literature review estimated the probability of malignancy detection in hemorrhoid specimens sent for histopathological evaluation. The low incidence of malignant findings implies that routine analysis of hemorrhoidectomy samples may not be cost-effective. However, existing studies have yet to establish definitive risk factors for abnormal histological diagnoses to aid in the selection of specimens for selective histopathology.