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MULTIDISCIPLINARY MULTIMODAL ANALGESIC THERAPY FOLLOWING HEMORRHOID SURGERY: A PILOT STUDY
Vanessa Boosahda
*, Doron Ben-Dov, Michael Gardyn, Dilip Baral, Christopher D'Adamo, Joseph Wetherell, Matthew Zeller, Jessica Felton, Joshua H. Wolf
Colorectal Surgery, Sinai Hospital, Baltimore, MD
Background: Hemorrhoid surgery (HS) has a high incidence of severe postoperative pain, often leading to prolonged recovery and excessive opioid usage. Conventional analgesic strategies have not yielded improved outcomes, and the use of more integrative approaches have been underutilized and untested. In this study, we devised a multi-disciplinary, multimodal analgesic therapy (MMAT) in which patients were co-managed by an integrative pain specialist (IPS) perioperatively. The study aimed to assess patient satisfaction and feasibility with this novel approach.
Methods: This was a retrospective telephone survey study of patients over a 14 month period. Patients were included if they had either excisional hemorrhoidectomy (EH) or transanal hemorrhoidal dearterialization (THD), and if they were referred preoperatively to an IPS for consultation. IPS recommendations included the application of transcutaneous electrical neurostimulation (TENS), and topical cream containing cannabidiol (CBD) derivatives. Patients were also managed with standard analgesics including intraoperative pudendal and anal blocks, intravenous ketorolac and dexamethasone. Postoperatively, patients were given short prescriptions for oxycodone and were advised to use over-the-counter analgesics and Sitz baths PRN. The telephone survey consisted of 11 questions related to satisfaction (scored on a 5-point Likert scale), and postoperative pain (0-10 numerical rating scale) at 4 time points (preop, 1 day, 1 week, and 2 weeks).
Results: 18 of 27 patients completed the survey (66.7%). Mean age was 51.6 ± 12.0 years, with an equal sex distribution (9 female, 9 male). In terms of type of HS, 44% underwent THD, and 56% underwent EH. Mean postoperative pain rose sharply on POD1 compared to preop (6.5 ± SD 3.2 vs. 3.3 ± 3.1) and then decreased steadily at 1 week (5.5 ± 3.4) and 2 weeks (4.2 ± 3.7)(Figure 1). The majority of patients reported using TENS frequently, either daily (56%) or multiple times per week (11%). Use of topical CBD-derivatives was more limited (27% daily). Mean responses to questions related to patient satisfaction included neutral (3 questions), favorable (7), and strongly favorable (1) results. There were no patient satisfaction questions with unfavorable mean Likert scores (Figure 2). There were no adverse events related to the MMAT pathway.
Conclusions: MMAT is a novel collaborative approach to post-operative pain management that was a feasible option for patients undergoing HS, resulting in satisfaction with most aspects of the program. Use of TENS was more prevalent than that of topical CBD cream. Followup studies are in progress to compare pain outcomes in HS between MMAT and conventional analgesia. Based on our preliminary findings, we anticipate that MMAT can result in decreased post-operative pain and reduced opioid consumption.
Figure 1. Pain After Hemorrhoid Surgery in MMAT Patients
Figure 2. Survey Questions with Mean Likert Scale Results
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