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Post-hemorrhoidectomy pain: can surgeons reduce it? A systematic review and network meta-analysis of randomized trials

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Hemorrhoidectomy remains the gold standard treatment for grade III–IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery, post-operative pain has been a limitation to the widespread inclusion of this condition in day surgery programs.

The aims of the study were to analyze and compare the post-operative pain of conventional open hemorrhoidectomy, considered the reference technique, against other surgical procedures such as closed hemorrhoidectomy, open hemorrhoidectomy using bipolar or ultrasonic sealant, hemorrhoidopexy, or HAL-RAR, when performed exclusively as outpatients.

Methods

A systematic review and meta-analysis was conducted according to PRISMA methodology. All prospective and randomized studies of patients operated on for hemorrhoids in day surgery and specifying the value of post-operative pain, using a validated scale, were included. Conventional meta-analyses and a random-effects network meta-analysis were carried out.

Results

Twenty-nine studies were included (3309 patients). None of the procedures described severe pain in the post-operative period. Hemorrhoidopexy was the least painful. Conventional open hemorrhoidectomy was the most painful on the first and seventh post-operative days. Pain was reduced after closed hemorrhoidectomy technique and when bipolar or harmonic scalpel was used. Furthermore, transfixive ligation of the hemorrhoidal pedicle was associated with increased post-operative pain.

Conclusion

Hemorrhoidal surgery is feasible in day surgery units and post-operative pain can be adequately managed in an outpatient setting. Hemorrhoidopexy was the least painful; however, data should be carefully evaluated by the high rate of long-term recurrence described in literature. Closed hemorrhoidectomy, performed with bipolar or ultrasonic sealing, avoiding transfixive ligation of the hemorrhoidal pedicle, may improve post-operative pain control.

Trial registration

CRD42020185160

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Data availability

Yes.

Code available

None.

Abbreviations

OH:

Conventional open hemorrhoidectomy or Milligan-Morgan technique

CH:

Close hemorrhoidectomy or Ferguson technique

BH:

Open hemorrhoidectomy using bipolar sealant

UH:

Open hemorrhoidectomy using ultrasonic sealant

PPH:

Hemorrhoidopexy or Longo technique

HAL-RAR:

Echo-Doppler-guided hemorrhoidal desarterialization and mucopexy

MD:

Mean differences

THD:

Transanal hemorrhoidal desarterialization

References

  1. Sammour T, Barazanchi AW, Hill AG (2017) PROSPECT group (Collaborators). Evidence-based management of pain after excisional haemorrhoidectomy surgery: a PROSPECT review update. World J Surg 41(2):603–614. https://doi.org/10.1007/s00268-016-3737-1

  2. Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP (2015) Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg 102(13):1603–1618. https://doi.org/10.1002/bjs.9913

  3. Moher D, Liberati A, Tetzlaff J et al (2010) Preferred reporting items for systematic reviews and meta-analysis: the PRISMA statement. Int J Surg 8:336–341

    Article  Google Scholar 

  4. Shea BJ, Reeves BC, Wells G et al (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. Sep 21;358:j4008

  5. Higgins JPT (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

  6. Bucher HC, Guyatt GH, Griffith LE et al (1997) The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials. J Clin Epidemiol 50:683–691

    Article  CAS  Google Scholar 

  7. Catalá-López F et al (2014) Conceptos básicos del metaanálisis en red. Aten Primaria 46(10):573–658

    Article  Google Scholar 

  8. Stolfi VM, Sileri P, Micossi C et al (2008) Treatment of hemorrhoids in day surgery: stapled hemorrhoidopexy vs Milligan-Morgan hemorrhoidectomy. J Gastrointest Surg 12(5):795–801. https://doi.org/10.1007/s11605-008-0497-8

    Article  PubMed  Google Scholar 

  9. Mehigan BJ, Monson JR, Hartley JE (2000) Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet 355(9206):782–785. https://doi.org/10.1016/S0140-6736(99)08362-2

    Article  CAS  PubMed  Google Scholar 

  10. Watson AJM. Hudson J. Wood J (2016) Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 388(10058):2375–2385

  11. Helmy MA (2000) Stapling procedure for hemorrhoids versus conventional haemorrhoidectomy. J Egypt Soc Parasitol 30:951–958

    CAS  PubMed  Google Scholar 

  12. Shalaby R, Desoky A (2001) Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 88:1049–1053

    Article  CAS  Google Scholar 

  13. Tan JJ, Seow-Choen F (2001) Prospective, randomized trial comparing diathermy and Harmonic Scalpel hemorrhoidectomy. Dis Colon Rectum 44(5):677–679. https://doi.org/10.1007/BF02234565

    Article  CAS  PubMed  Google Scholar 

  14. Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O’Riordain DS (2002) Randomized clinical trial of Ligasure versus conventional diathermy for day case hemorrhoidectomy. Br J Surg 89(4):428–432

    Article  CAS  Google Scholar 

  15. Palazzo FF, Francis DL, Clifton MA (2002) Randomized clinical trial of Ligasure versus open hemorrhoidectomy. Br J Surg 89(2):154–157

    CAS  PubMed  Google Scholar 

  16. Cheetham MJ, Cohen CR, Kamm M et al (2003) A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up. Dis Colon Rectum 46:491–497

  17. Franklin EJ, Seetharam S, Lowney J et al (2003) Randomized, clinical trial of Ligasure vs conventional diathermy in hemorrhoidectomy. Dis Colon Rectum 46(10):1380–1383

    Article  Google Scholar 

  18. Arroyo A, Pérez F, Miranda E et al (2004) Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study. Int J Colorectal Dis 19:370–373

    Article  CAS  Google Scholar 

  19. Kairaluoma M, Nuorva K, Kellokumpu I (2003) Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome. Dis Colon Rectum 46:93–99

  20. Palimento D, Picchio M, Attanasio U et al (2003) Stapled and open hemorrhoidectomy: randomized controlled trial of early results. World J Surg 27:203–207

    Article  Google Scholar 

  21. You SY, Kim SH, Chung CS, Lee DK. Open vs. closed hemorrhoidectomy. Dis Colon Rectum 2005; 48: 108–113.

  22. Jóhannsson HO, Påhlman L, Graf W (2006) Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy. Br J Surg 93(10):1208–1214. https://doi.org/10.1002/bjs.5408

    Article  PubMed  Google Scholar 

  23. Gaj F, Trecca A, Crispino P (2007) Transfixed stitches technique versus open haemorrhoidectomy. Results of a randomised trial. Chir Ital 59:231–235

  24. Muzi MG, Milito G, Nigro C et al (2007) Amabile D et al. Randomized clinical trial of LigaSure™ and conventional diathermy haemorrhoidectomy. Br J Surg 94: 937–942

  25. Tan EK, Cornish J, Darzi AW et al (2007) PP. Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure™ vs conventional hemorrhoidectomy. Arch Surg 142:1209–1218

  26. Pokharel N, Chhetri RK, Malla B, Joshi HN, Shrestha RK (2009) Haemorrhoidectomy: Ferguson’s (closed) vs Milligan Morgan’s technique (open). Nepal Med Coll J 11:136–137

    CAS  PubMed  Google Scholar 

  27. Abo-hashem AA, Sarhan A, Aly AM (2010) Harmonic Scalpel compared with bipolar electro-cautery hemorrhoidectomy: a randomized controlled trial. Int J Surg 8:243–247

    Article  CAS  Google Scholar 

  28. Shaikh AR, Dalwani AG, Soomro N (2013) An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad. Pakistan Pak J Med Sci 29(1):122–127. https://doi.org/10.12669/pjms.291.2858

    Article  PubMed  Google Scholar 

  29. Elmér SE, Nygren JO, Lenander CE (2013) A randomized trial of transanal hemorrhoidal dearterialization with anopexy compared with open hemorrhoidectomy in the treatment of hemorrhoids. Dis Colon Rectum 56(4):484–490. https://doi.org/10.1097/DCR.0b013e31827a8567

    Article  PubMed  Google Scholar 

  30. Kim JS, Vashist YK, Thieltges S et al (2013) Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial. J Gastrointest Surg 17(7):1292–1298. https://doi.org/10.1007/s11605-013-2220-7

    Article  PubMed  Google Scholar 

  31. Ozer MT, Yigit T, Uzar AI et al (2008) A comparison of different hemorrhoidectomy procedures. Saudi Med J 29(9):1264–1269

    PubMed  Google Scholar 

  32. Talha A, Bessa S, Abdel WM (2017) Ligasure, Harmonic Scalpel versus conventional diathermy in excisional haemorrhoidectomy: a randomized controlled trial. ANZ J Surg 87(4):252–256. https://doi.org/10.1111/ans.12838

    Article  PubMed  Google Scholar 

  33. Onur Gülseren M, Dinc T, Özer V, Yildiz B, Cete M, Coskun F (2015) Randomized controlled trial comparing the effects of vessel sealing device and Milligan Morgan technique on postoperative pain perception after hemorrhoidectomy. Dig Surg 32(4):258–261. https://doi.org/10.1159/000381754

    Article  PubMed  Google Scholar 

  34. Carvajal López F, Hoyuela Alonso C, Juvany Gómez M et al (2019) Prospective randomized trial comparing HAL-RAR versus excisional hemorrhoidectomy: postoperative pain, clinical outcomes, and quality of life. Surg Innov 26(3):328–336. https://doi.org/10.1177/1553350618822644

    Article  PubMed  Google Scholar 

  35. Trenti L, Biondo S, Kreisler Moreno E et al (2019) Short-term outcomes of transanal hemorrhoidal dearterialization with mucopexy versus vessel-sealing device hemorrhoidectomy for grade III to IV hemorrhoids: a prospective randomized multicenter trial. Dis Colon Rectum 62(8):988–996. https://doi.org/10.1097/DCR.0000000000001362

    Article  PubMed  Google Scholar 

  36. Rørvik HD, Campos AH, Styr K et al (2020) Minimal open hemorrhoidectomy versus transanal hemorrhoidal dearterialization: the effect on symptoms: an open-label randomized controlled trial. Dis Colon Rectum 63(5):655–667. https://doi.org/10.1097/DCR.0000000000001588

    Article  PubMed  Google Scholar 

  37. Romaguera VP, Sancho-Muriel J, Alvarez-Sarrdo E, Millan M, Garcia-Granero A, Frasson M (2021) Postoperative complications in hemorrhoidal disease and special conditions. Rev Recent Clin Trials 16(1):67–74. https://doi.org/10.2174/1574887115666200406114218 (PMID: 32250228)

    Article  PubMed  Google Scholar 

  38. Bhatti MI, Sajid MS, Baig MK (2016) Milligan-Morgan (open) versus Ferguson haemorrhoidectomy (closed): a systematic review and meta-analysis of published randomized, controlled trials. World J Surg 40(6):1509–1519. https://doi.org/10.1007/s00268-016-3419-z

    Article  PubMed  Google Scholar 

  39. Milito G, Cadeddu F, Muzi MG, Nigro C, Farinon AM (2010) Haemorrhoidectomy with Ligasure vs conventional excisional techniques: meta-analysis of randomized controlled trials. Colorectal Dis 12(2):85–93. https://doi.org/10.1111/j.1463-1318.2009.01807.x

    Article  CAS  PubMed  Google Scholar 

  40. Nienhuijs SW, de Hingh IH (2010) Pain after conventional versus Ligasure haemorrhoidectomy. A meta-analysis Int J Surg 8(4):269–273. https://doi.org/10.1016/j.ijsu.2010.04.001

    Article  CAS  PubMed  Google Scholar 

  41. Kwok SY, Chung CC, Tsui KK, Li MK (2005) A double-blind, randomized trial comparing Ligasure and Harmonic Scalpel hemorrhoidectomy. Dis Colon Rectum 48(2):344–348. https://doi.org/10.1007/s10350-004-0845-z (PMID: 15616753)

    Article  CAS  PubMed  Google Scholar 

  42. Mushaya CD, Caleo PJ, Bartlett L, Buettner PG, Ho YH (2014) Harmonic scalpel compared with conventional excisional haemorrhoidectomy: a meta-analysis of randomized controlled trials. Tech Coloproctol 18(11):1009–1016. https://doi.org/10.1007/s10151-014-1169-1

    Article  CAS  PubMed  Google Scholar 

  43. Gallo G, Martellucci J, Sturiale A et al (2020) Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease. Tech Coloproctol 24(2):145–164. https://doi.org/10.1007/s10151-020-02149-1

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Laughlan K, Jayne DG, Jackson D, Rupprecht F, Ribaric G (2009) Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review. Int J Colorectal Dis 24(3):335–344. https://doi.org/10.1007/s00384-008-0611-0

    Article  CAS  PubMed  Google Scholar 

  45. Emile SH (2019) Evidence-based review of methods used to reduce pain after excisional hemorrhoidectomy. J Coloproctol (Rio J) 39(1):81–89

    Article  Google Scholar 

  46. Bessa SS (2011) Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation. Dis Colon Rectum 54(11):1405–1411. https://doi.org/10.1097/DCR.0b013e318222b5a9

    Article  PubMed  Google Scholar 

  47. Kendirci M, Şahiner İT, Şahiner Y, Güney G (2018) Comparison of effects of vessel-sealing devices and conventional hemorrhoidectomy on postoperative pain and quality of life. Med Sci Monit 24:2173–2179. Published 2018 Apr 12. https://doi.org/10.12659/msm.909750.

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Authors and Affiliations

  1. Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/ San Clemente n° 12, 46015, Valencia, Spain

    Zutoia Balciscueta & Natalia Uribe

  2. Department of General and Digestive Surgery, La Ribera University Hospital, Alzira, Valencia, Spain

    Izaskun Balciscueta

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  1. Zutoia Balciscueta
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Contributions

Study conception design, data acquisition, and data analysis and interpretation: Zutoia Balciscueta, Izaskun Balciscueta, and Natalia Uribe. Drafting the article and critical revision: Zutoia Balciscueta, Izaskun Balciscueta, and Natalia Uribe. Final approval of the manuscript: Zutoia Balciscueta, Izaskun Balciscueta, and Natalia Uribe.

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Correspondence to Zutoia Balciscueta.

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Balciscueta, Z., Balciscueta, I. & Uribe, N. Post-hemorrhoidectomy pain: can surgeons reduce it? A systematic review and network meta-analysis of randomized trials. Int J Colorectal Dis 36, 2553–2566 (2021). https://doi.org/10.1007/s00384-021-04013-6

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