The Effect of Metronidazole on Post-Operative Pain After Hemorrhoidectomy Operations

Abstract

Background: Pain after open “Morgan-Milligan” hemorrhoidectomy is a significant problem both for the patient and the surgeon. It increases analgesics need, prolongs the hospital stay, delay first act, hindered early return to usual daily activities and causes a significant anxiety to the patient and family. Aim of the study: To evaluate effectiveness of oral Metronidazole therapy in the decreasing pain after open hemorrhoidectomy. Patients and methods: A prospective controlled study was set in the Department of Surgery/Al-Yarmouk Teaching Hospital. The study included adult patients who undergone elective opened “Morgan-Milligan” hemorrhoidectomy for grade III and IV disease. Data collection was completed over the period from the 1st of June 2017 to 15th of January 2019. The total number of patients after exclusion was 64 patients (32 patients in each group). Patients who are discharged in the first operative day were allocated in to two groups; those who received oral Metronidazole course (group A; study group) and those who did not received the therapy (group B; control group). The main parameter studied was pain. Other parameters include frequency of analgesic doses required, time for first bowel motion, time for return for usual daily activities and evidences of Surgical Site Infection. The method for pain assessment was Visual Analogue Scale (VAS) of 10 grades. A scale sheet was supplied for each patient (in native language) and patients were informed clearly how to fill the required information. At the end of the first week, the attendance of the patients and delivery of the VAS sheet is considered the date for termination of assessment. Patients who are lost to follow up or discontinued therapy due to drug intolerance, were excluded from analysis. Data tabulated and appropriately displayed and statistically analyzed using Statistical Package for Social Sciences (SPSS) version 25. A P-Value less than 0.05 was considered significant. Ethical aspects and official approval were appropriately considered. Results: The overall age range was 18 - 55 years (a mean of 32.37 years and a standard deviation of ± 10.06 years). Female gender predominates in both groups (22 in group A, 18 in group B). The majority in both group A and B have Grade III hemorrhoid (81.3% and 87.5% respectively). There were no statistically significant differences between the two groups regarding age and gender. Postoperatively, the mean of VAS in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (5.46 versus 6.71, P= 0.011; 5.31 versus 7.81, P= 0.001; 4.46 versus 6.25, P= 0.001; and 4.06 versus 6.56, P= 0.001; respectively). There was no statistically significant difference (P = 0.104) between study groups in mean of VAS in the 2nd day. The mean of doses of analgesia required in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (2.75 versus 3.37, P= 0.001; 2.75 versus 3.37, P= 0.002; 2.37 versus 3, P= 0.016; and 3.43 versus 3.93, P= 0.001; respectively). Again; no statistically significant difference (P = 0.162) between study groups regarding mean doses of analgesia on the 2nd day. No statistically significant difference (P= 0.11) was reported between study groups regarding mean time for 1st bowel motion. Returning to usual daily activities was significantly earlier in group A patients compared with patients in Group B (5.68 versus 7.12 days, P= 0.028). At the end of first week; a total of 7 (11%) patients demonstrated signs of Surgical Site Infection. This was statistically insignificant when compared between both groups (P = 0.229). Conclusions: There are evidences that oral Metronidazole therapy after open hemorrhoidectomy can play a role in reduction of pain intensity.