Modified Multimodal Local Infiltration versus Liposomal Bupivacaine for Early Pain Control and Recovery after Mixed Hemorrhoid Surgery: A Randomized Trial
In a randomized trial of 360 patients undergoing mixed hemorrhoid surgery, a modified multimodal local infiltration cocktail demonstrated modest advantages over liposomal bupivacaine in reducing early movement- and defecation-related pain, rescue analgesic use, and opioid consumption within 24 hours, while showing no significant differences in later pain or most other recovery outcomes.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Pain after surgery is a universal human experience, but for one specific and very common procedure, it can be particularly sharp and lingering. Hemorrhoids are swollen veins in the lower rectum and anus, a condition affecting a vast portion of the global population. While mild cases can be managed with diet and medication, severe cases often require surgical removal. The surgery itself is effective, but the recovery is notoriously difficult. The area is rich in nerve endings, and the simple act of walking, sitting, or having a bowel movement can trigger intense pain. This discomfort often keeps patients still, disrupts sleep, and creates a fear of using the bathroom, which can actually slow down healing. To manage this, doctors rely on local anesthesia—injecting numbing medicine directly into the tissue around the wound to block pain signals before they reach the brain.
For years, surgeons have debated the best way to deliver this relief. One popular option is a specialized, slow-release drug called liposomal bupivacaine. Imagine a tiny, protective bubble that holds the medicine and releases it gradually over several days, like a time-release capsule for pain. This approach has been shown to work well, but the drug is expensive. On the other side of the equation is a "cocktail" of standard, inexpensive medicines mixed together right before the surgery. This mixture typically includes a local anesthetic to numb the area, a steroid to reduce swelling, and other additives that might help the medicine work faster or last longer. While doctors have used similar mixes for knee and hip surgeries, no one had rigorously tested whether this cheaper, custom-made mix could match the performance of the expensive, slow-release drug specifically for hemorrhoid surgery.
A team of researchers at West China Hospital in Chengdu, China, set out to answer this question with a large, carefully controlled experiment. They recruited 360 patients who were scheduled for surgery to remove mixed hemorrhoids. The patients were randomly assigned to one of two groups. One group received the slow-release liposomal bupivacaine, while the other received the custom-mixed cocktail containing ropivacaine, dexamethasone, magnesium sulfate, and sodium bicarbonate. To ensure fairness, neither the patients nor the doctors evaluating their recovery knew which treatment each patient received. All patients underwent the same standardized surgery and received the same follow-up pain medication plan, with the only variable being the initial injection given just before the wound was closed.
The results revealed a clear pattern of timing. In the first few hours after surgery, the patients who received the custom cocktail felt noticeably better. When asked to rate their pain while moving, those in the cocktail group reported lower scores at six and twelve hours compared to the group that received the slow-release drug. This early advantage translated into real-world benefits: fewer patients in the cocktail group needed extra pain medication within the first 24 hours, and those who did need it took smaller doses. Consequently, the cocktail group was able to start walking around sooner, a key milestone in recovery. The pain they felt during their first bowel movement was also significantly lower than that of the other group.
However, the story changes as time goes on. After the first day, the difference between the two groups faded. By 24 hours post-surgery, the pain levels for both groups were nearly identical, and this similarity held true through the seventh day. Neither group had a clear advantage in terms of how quickly their bowels returned to normal, how well their wounds healed, or their overall sense of well-being a week later. The slow-release drug did not provide a "second wind" of pain relief that the cocktail lacked; instead, both treatments eventually converged on the same level of comfort. The researchers also looked at the cost of the hospital stay. Because the custom cocktail uses common, inexpensive ingredients, the total cost for patients in that group was significantly lower than for those who received the expensive slow-release drug, even though their hospital stays were the same length.
The study concluded that the custom cocktail is a highly effective alternative for the critical first day of recovery. It offers a modest but meaningful reduction in movement-related pain and a lower need for rescue medication early on, all while costing less. While the slow-release drug remains a strong option, the custom mix proved that a combination of standard, affordable medicines can achieve similar long-term results without the high price tag. The researchers noted that while the cocktail worked well, the study was limited to a single hospital and a one-week follow-up, so further testing in different settings is needed to confirm these findings. For now, the evidence suggests that for patients facing hemorrhoid surgery, a carefully prepared mix of common drugs can provide excellent early relief and a faster start to recovery, making a difficult process just a little bit easier.
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