Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial

Abstract

BACKGROUND: Pain management after hemorrhoidectomy continues to be challenging. OBJECTIVE:The aim of this study was to evaluate the effectiveness of infiltration of bupivacaine hydrochloride and triamcinolone acetonide in surgical wounds of Milligan-Morgan hemorrhoidectomy for postoperative pain relief. DESIGN:A double-blind randomized controlled clinical trial was conducted between May 2015 and June 2019. SETTINGS:This study was carried out in a secondary referral hospital center in Spain. PATIENTS:Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included. INTERVENTIONS:Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone and patients allocated in the control group did not receive any intervention. MAIN OUTCOMES MEASURES:The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay. Secondary end points were pain at follow-up, pain during defecation, analgesic requirements, wound healing rate, and complications.RESULTS: A total of 128 patients were randomly assigned (64 in each group). The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different (p < 0.05). No differences were observed regarding pain during defecation. Morphine requirements were significant lower in the intervention group (6.3% vs 21.9% patients; p = 0.01; 5 vs 23 cumulative doses; p = 0.01). Wound healing and complication rates were similar in both groups.LIMITATIONS: Use of placebo was not considered in the control group ("intervention group" vs "control group" clinical trial). Data regarding pain or other complications at 48 hours postoperatively were pooled and expressed as median of values. CONCLUSIONS: Infiltration of surgical wounds with bupivacaine and triamcinolone decreases postoperativeFunding/Support: This was an investigator-initiated study supported by internal funding.

The effect of bupivacaine on analgesia and safety in patients undergoing hemorrhoidectomy: a meta-analysis

“…Furthermore, 65 irrelevant studies and 1 non-English study were excluded based on full-text reading. Finally, 18 eligible studies were included in our meta-analysis ( Jirasiritham et al, 2004 ; Naja et al, 2005 ; Ng et al, 2006 ; Imbelloni et al, 2007 ; Gorfine et al, 2011 ; Haas et al, 2012 ; Rajabi et al, 2012 ; Moreira et al, 2014 ; Sim and Tan, 2014 ; Farag and Esmat, 2016 ; Shashikala and Prathibha, 2016 ; Ruiz-Castro et al, 2017 ; Chitty et al, 2022 ; Cui et al, 2022 ; Hatami et al, 2022 ; Medina-Gallardo et al, 2022 ; Steen et al, 2022 ; Shahrokhzadeh et al, 2023 ). The characteristics of the 18 eligible studies are shown in Table 1 .…”

“…Postoperative pain remains a significant problem in hemorrhoidectomy because up to 40% of patients experience severe pain ( Medina-Gallardo et al, 2022 ). Preemptive analgesia is a simple method to decrease the level and duration of postoperative pain ( Van Backer et al, 2018 ).…”

“…A study has shown that preemptive analgesia with perianal infiltration of 0.5% bupivacaine can better alleviate pain after hemorrhoidectomy ( Jirasiritham et al, 2004 ). Medina et al found that bupivacaine-combined triamcinolone acetonide achieved better post-hemorrhoidectomy pain relief at 48 h than the blank group ( Medina-Gallardo et al, 2022 ). Accordingly, the results of our meta-analysis showed a significant pain reduction at 48 h in the bupivacaine-combined other drug group than in the other drug group.…”

Milligan-Morgan hemorrhoidectomy combined with non-Doppler hemorrhoidal artery ligation for the treatment of grade III/IV hemorrhoids: A single centre retrospective study

“…At present, many treatment methods are available for hemorrhoids, including conservative treatment, instrument treatment, and surgical treatment, such as hemorrhoidectomy, stapler hemorrhoidectomy (SH), and Doppler-guided/-assisted hemorrhoid artery ligation (HAL) [14][15][16]. Although MMH has obvious postoperative pain, secondary bleeding, long recovery period, and other shortcomings, MMH is still the preferred surgical method for patients with grade III/IV hemorrhoids because of its exact curative effect, low recurrence rate, and cost-effectiveness [17][18][19].…”

Pain After Hemorrhoidectomy

“…In this issue of the journal, Medina-Gallardo et al 2 report the results of a double-blinded randomized clinical trial in open excisional hemorrhoidectomy (Milligan-Morgan technique). Patients in the intervention group received a single infiltration of a mixture of 1 mL of triamcinolone acetonide (40 mg) and 9 mL of 0.50% bupivacaine hydrochloride (45 mg) at the end of the procedure.…”