The Effect of Botulinum Toxin Injection After Hemorrhoidectomy in Pain Control.
Condition: Pain; Haemorriodectomy; Anal Sphincterotomy
Study type: Interventional

Summary: 
      Hemorrhoids are a common disease in the general population. Its prevalence is estimated to be
      5-36 % and more prevalent in western countries . Half of people older than 50 years of age
      will suffer from hemorrhoids in a period of their life, of which only 5-10% will require
      surgical intervention while most of the remainders become asymptomatic and improved with the
      conservative treatment.

      Conservative treatment in the form of diet modification as well as some medical treatment, is
      usually effective. On the other hand, a few patients require surgical intervention. Surgery
      is indicated for those not responding to conservative management, those with grade III, and
      grade IV hemorrhoids.

      Surgical treatment is the only curative method for hemorrhoidal disease and indicated for
      advanced and complicated disease. The most radical operations with the best results are the
      Milligan-Morgan and Ferguson hemorrhoidectomy .

      However, the major concern of hemorrhoidectomy is the post-operative pain that occurs in
      20-40 % of patients and it is considered the main cause of refusing surgery. The cause of
      postoperative pain is multifactorial, including the type of anesthesia , hemorrhoidectomy
      technique. and spasm of the internal anal sphincter (IAS) that becomes exposed after
      hemorrhoidectomy. The spasm of the IAS is considered the target to relieve pain post
      operatively. Lateral internal sphincterotomy (LIS) is widely used as an adjunct to relieve
      pain post hemorrhoidectomy as it release the spasm of the sphincter and subsequently relieve
      pain. However, this procedure is not accepted by many surgeons due to its recorded
      complications as bleeding and mild degree of fecal incontinence, so its role following
      hemorrhoidectomy is still controversial.

      On the other hand, the spasm of the anal sphincter can be abolished by injection of the
      botulinum toxin which acts on the acetylcholine receptor and consequently temporary muscle
      paralysis occurs that is followed by decreased pain and wound healing.

      Our hypothesis is botulinum toxin relaxes the internal sphincter, so prevent its spasm and so
      reducing the pain and promoting wound healing more rapidly.
    

Detailed description: 
      many procedures have been described to decrease the pain post hemorridectomy. Internal
      sphincterotomy Botox Injection giving strong analgesics

      We aim to evaluate the efficacy of Botox and internal sphincterotomy in pain relief after
      hemorridectomy.
    

Intervention name(s): Botox Injectable Product; Internal sphincterotomy
Intervention type(s): Procedure; Procedure
Intervention description(s): one group will have botox injection in the internal sphincter; this group will have internal sphincterotomy
Other intervention name(s): Botulonium toxin injection; lateral internal sphincterotomy
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: post hemorridectomy pain; sphincterotomy; botox injection