Carapeti E A, Kamm M A, McDonald P J, Phillips R K
Department of Surgery, St Mark's Hospital, Middlesex, UK.
Lancet. 1998 Jan 17;351(9097):169-72. doi: 10.1016/S0140-6736(97)09003-X.
Haemorrhoidectomy is commonly an inpatient procedure because patients and doctors worry about postoperative pain. Day-case haemorrhoidectomy (DCH) is possible if patient anxiety is addressed and postoperative pain and bowel function are managed. Pain sometimes increases a few days after haemorrhoidectomy, possibly because of secondary infection. We studied the effect of metronidazole on pain after DCH.
We randomly assigned 40 consecutive patients admitted for DCH metronidazole 400 mg (n = 20) or placebo (n = 20) three times daily, both for 7 days. All patients received lactulose from 2 days before surgery for 2 weeks. Diathermy DCH was performed without pedicle ligature or anal-canal dressing, and a diclofenac suppository was administered at the end of the procedure. Patients were discharged on the same day with diclofenac, 0.2% glyceryl-trinitrate ointment, lactulose, a telephone number to call for queries in emergencies, and an outpatient appointment. Patients took paracetamol or Co-dydramol (dihydrocodeine and paracetamol) as required; they completed linear analogue charts every day and completed questionnaires on satisfaction at 1 and 6 weeks.
34 patients had all three major piles excised, of whom seven had additional division and reconstruction of the posterior skin bridge. Overall, both groups of patients experienced less pain than expected, except on days 3 and 4. Patients in the metronidazole group had significantly less pain than those in the placebo group on days 5, 6, and 7 (p = 0.004, p = 0.02, and p = 0.006). Median time to return to work or normal activity was 15 days (range 12-28) in the metronidazole group and 18 days (7-34) in the placebo group (p = 0.009). The patient satisfaction score was higher in the metronidazole group than in the placebo group at 1 week (p = 0.005).
Prophylactic metronidazole in diathermy DCH suppressed secondary pain around days 5-7 and increased patient satisfaction and earlier return to work.
痔切除术通常是一种住院手术，因为患者和医生担心术后疼痛。如果能解决患者的焦虑情绪，并对术后疼痛和肠道功能进行管理，日间痔切除术（DCH）是可行的。痔切除术后疼痛有时会在几天后加重，可能是由于继发感染。我们研究了甲硝唑对DCH术后疼痛的影响。
我们将40例连续接受DCH的患者随机分为两组，一组每日3次服用400mg甲硝唑（n = 20），另一组每日3次服用安慰剂（n = 20），均持续7天。所有患者在手术前2天开始服用乳果糖，持续2周。采用无蒂结扎或肛管敷料的透热DCH，并在手术结束时给予双氯芬酸栓剂。患者在同一天出院时携带双氯芬酸、0.2%硝酸甘油软膏、乳果糖、紧急情况咨询电话号码和门诊预约。患者根据需要服用对乙酰氨基酚或可待因（二氢可待因和对乙酰氨基酚）；他们每天完成线性模拟量表，并在1周和6周时完成满意度问卷。
34例患者切除了所有三个主要痔核，其中7例还进行了后皮肤桥的额外分离和重建。总体而言，两组患者除在第3天和第4天外，疼痛均比预期轻。甲硝唑组患者在第5、6和7天的疼痛明显低于安慰剂组（p = 0.004、p = 0.02和p = 0.006）。甲硝唑组恢复工作或正常活动的中位时间为15天（范围12 - 28天），安慰剂组为18天（7 - 34天）（p = 0.009）。甲硝唑组在1周时的患者满意度得分高于安慰剂组（p = 0.005）。
透热DCH中预防性使用甲硝唑可抑制第5 - 7天左右的继发疼痛，提高患者满意度并使患者更早恢复工作。
