Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief.

AIM: Conventional haemorrhoidectomy is still considered the reference standard for the management of severe or recurrent haemorrhoids. Pain is reported by patients to be the most common postoperative complication. Although the literature lacks a consensus on its effectiveness, metronidazole is often used to reduce postoperative pain. We have performed a meta-analysis of all randomized controlled trials (RCTs) that investigated the use of metronidazole for pain relief after haemorrhoidectomy. METHOD: A systematic review was undertaken in accordance with the PRISMA protocol using the MESH headings 'haemorrhoidectomy', 'hemorhoidectomy', 'hemorrhoidectomy', 'haemorrhoid', 'metronidazole', 'Flagyl® ' 'antibiotic' and 'pain'. The search returned 421 articles of which eight were RCTs suitable for inclusion in the review with a total population of 437 patients. The outcomes of interest were postoperative pain intensity on days 1, 2 and 7 and on first defaecation as measured using a visual analogue scale. RESULTS: The meta-analysis demonstrated a significant reduction in postoperative pain for patients treated with metronidazole with a reduced mean difference for the metronidazole group on day 1 of -1.42 (95% CI: -2.14 to -0.69, P = 0.0001), on day 2 of -1.43 (95% CI: -2.45 to -0.40, P = 0.006) and on day 7 of -2.40 (95% CI: -3.10 to -1.71, P < 0.00001). Pain on first defaecation was likewise reduced with a mean difference of -1.38 (95% CI: -2.15 to -0.60, P = 0.0005). Limitations of this study include variation in the grade of haemorrhoids treated and variability in the quality of included studies. CONCLUSION: Metronidazole is a cheap, safe and effective intervention for reducing postoperative pain following conventional haemorrhoidectomy.

Meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair.

BACKGROUND: Laparoscopic incisional and ventral hernia repair (LIVHR) is being used increasingly, with reported outcomes equivalent to those of open hernia repair. Closure of the fascial defect (CFD) is a technique that may reduce seroma formation and bulging after LIVHR. Non-closure of the fascial defect makes the repair of larger defects easier and reduces postoperative pain. The aim of this systematic review was to determine whether CFD affects the rate of adverse outcomes, such as recurrence, pseudo-recurrence, mesh eventration or bulging, and the rate of seroma formation. METHODS: A systematic search was performed of PubMed, Ovid, the Cochrane Library, Google Scholar and Scopus to identify RCTs that analysed CFD with regard to rates of adverse outcomes. A meta-analysis was done using fixed-effect methods. The primary outcome of interest was adverse events. Secondary outcomes were seroma, postoperative pain, mean hospital stay, mean duration of operation and surgical techniques employed. RESULTS: A total of 16 studies were identified involving 3638 patients, 2963 in the CFD group and 675 in the non-closure of facial defect group. Significantly fewer adverse events were noted following CFD than non-closure (4·9 per cent (79 of 1613) versus 22·3 per cent (114 of 511)), with a combined risk ratio (RR) of 0·25 (95 per cent c.i. 0·18 to 0·33; P < 0·001). CFD resulted in a significantly lower rate of seroma (2·5 per cent (39 of 1546) versus 12·2 per cent (47 of 385)), with a combined RR of 0·37 (0·23 to 0·57; P < 0·001), and shorter duration of hospital stay. No significant difference was noted in postoperative pain. CONCLUSION: CFD during LIVHR reduces the rate of seroma formation and adverse hernia-site events.

Percutaneous management of pulmonary metastases arising from colorectal cancer; a systematic review.

BACKGROUND: Radiofrequency ablation (RFA) is a well-established treatment modality for colorectal hepatic metastases, the success of which has prompted its use to treat other lesions such as colorectal pulmonary metastases (CRPM). Our aim was to perform a systematic review of the evidence and to assess the safety and effectiveness of ablative techniques in the management of CRPM. METHOD: A literature search was performed using PubMed, Embase, Cochrane Library, CINAHL and Google scholar databases to identify studies, which analysed ablative techniques and their effectiveness in the management of CRPM. The primary outcome measures were overall survival, local recurrence rates and disease free survival. Secondary outcome measures were complication (major/minor), chest drain insertion rates and follow up duration. RESULTS: Eight studies were included in the review with a total of 903 patients and all of which used RFA for ablation. Mortality from ablation was <1% with overall survival ranging from 31 to 67 months. 1, 3 and 5 year survival ranges of 84-95%, 35-72% and 20-54% respectively. Local progression following ablation ranged from 9 to 21%. Major complication rates were noted in 0.5%-8% of patients with minor complications ranging between 7% and 33%. 23% of patients required chest drain insertion post procedure. CONCLUSION: s: RFA is a safe and effective technique for the management of CRPM. However, in the absence of large randomised controlled trials it is unclear where RFA should sit in the treatment algorithm for patients with CRPM.