Improving Outcomes Following Excisional Haemorrhoidectomy

Abstract

Aim: To determine the burden of disease of haemorrhoids and investigate methods of improving outcomes from haemorrhoidectomy. Methods:

A population-based cross-sectional study on the incidence of newly diagnosed haemorrhoids and haemorrhoidectomies performed in New Zealand public hospitals from 2007–2016 to establish the burden of disease. Retrospective cohort studies performed on the Counties Manukau District Health Board population were used to determine the rate of readmission and differences between inpatient and day-stay performed haemorrhoidectomies. Regression analyses were performed to investigate potentially modifiable risk factors for patient re-presentation. Systematic reviews were performed to investigate topical analgesics following haemorrhoidectomy, as well as investigate metronidazole specifically. A systematic review was conducted investigating the optimal anaesthetic regimen for haemorrhoidectomy. A prospective, randomised, double-blinded, controlled trial was performed to compare topical versus oral administration of metronidazole following haemorrhoidectomy. Findings: New Zealand has seen an increasing rise in annual incidence rates of presentations with haemorrhoids and haemorrhoidectomies. There is a peak prevalence of disease in the fifth decade of life, with females and New Zealand Europeans being the largest groups affected. In Counties Manukau, there is a 12.8% readmission rate following surgery with pain being the most common presenting complaint. Day stay haemorrhoidectomy has similar readmission rates as those performed as an inpatient. Males and use of non-diathermy energy devices resulted in increased risk of readmission. Topical metronidazole, diltiazem and sucralfate were found to significantly reduce pain at various timepoints with glyceryl trinitrate having mixed evidence. Metronidazole in both topical and oral routes reduced pain. Haemorrhoidectomies performed under local anaesthesia alone may be considered as an alternative to regional anaesthesia. The randomised controlled trial evaluating topical versus oral metronidazole showed no significant difference in postoperative pain between them, although patients preferred the topical route of administration. Conclusions: Haemorrhoids and excisional haemorrhoidectomies are an increasing burden in New Zealand, with a rising incidence rate. Several topical medications were identified to reduce post-haemorrhoidectomy pain, including metronidazole. Metronidazole in both oral and topical routes reduce pain. Although patients preferred to use the topical route, this did not confer any significant clinical difference.