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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 18 | Nitroderm TTS ® Band Application for Pain After Hemorrhoidectomy [2001년 5월 DCR] | 2011-11-17 | 3599 |
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A. Coskun, M.D.,S. A. Duzgun, M.D.,A. Uzunkoy, M.D.,M. Bozer, M.D.,O. Aslan, M.D.,B. Canbeyli, M.D.
From Harran University School of Medicine, Departments of General Surger~ and Pharmacolog, Sanliurfa, Turkey PURPOSE: Anal sphincter spasm is believed to play an important role in pain after hemorrhoidectomy. We tested a different form of nitroglycerin: the Nitroderm TFS ® band. We investigated its efficacy on posthemorrhoidectomy pain and the relation between pahl and anal resting pressure measured preoperatively and postoperatively.
METHODS: Thirty-eight hemorrhoid patients were divided into two groups: those with high anal resting pressure were classified as group A (n = 24) and those with low anal resting pressure were classified as group B (n = 14). After hemorrhoidectomy, Nitroderm TFS ® bands were placed into the anal canal in half of the patients in groups A and B (groups A-1 and B-l) and not in the remaining half (groups A-2 and
B-2). Anal resting pressure measurement was repeated at the first day and third month postoperatively. Postoperative pain was assessed by linear analog scale, and analgesic consumption was recorded. RESULTS: Preoperative anal resting pressure was 112.0 (range, 95-140) cm HzO in group A-1 and 110.6 (range, 96-138) cm H20 in group A-2. The difference was insignificant. However, on the first postoperative day, anal resting pressures were 88.7 (range, 75-115) and 110.9 (range, 92-135) cm H20 (P = 0.0001), and at the third month, they were 76.5 (range, 70-100) and 78.0 (range, 70-105) cm H20, respectively (P = 0.690). Postoperative pain scores were significantly lower in group A-1 than group A-2 (P = 0.0001 ). In the low-pressure groups 03-1 and B-2), anal resting pressures before surgery, on the first postoperative day, and at the third month postoperatively were 70.4 (range, 56-76), 67.4 (range, 50-75), and 67.2 (range, 55-74) cm H20 in group B-1 and 69.8 (range, 58-76), 70.2 (range, 60-76), and 68.4 (range, 60-74) cm HzO in group B-2. The differences were insignificant (P --> 0.660). The differences between pain scores in these groups were also insign~cant (P -> 0.160). CONCLUSION: Nitroderm TrS ® bands effectively reduced anal resting pressure and relieved pain in patients with high preoperative anal resting pressure.
DISCUSSION
Hemorrhoidal disease is the most prevalent disorder of the anorectal region. Treatment depends on the degree of hemorrhoids and the symptoms. Surgical excision is used as the main method for the treatment of third- or fourth-degree symptomatic hemorrhoids. However, postoperative pain is still a
challenging problem that causes a number of patients with hemorrhoids to prefer the symptoms of the disease instead. Although nonsteroid anti-inflammatory drags and narcotic analgesics have frequently been used for pain relief, their analgesic effects are temporary, and side effects due to overdose are not uncommon. Therefore, new methods to reduce postoperative pain after hemorrhoidectomy need to be investigated. Manometric studies have demonstrated that patients with hemorrhoids have higher anal pressures
than the healthy population. Pain after hemorrhoidectomy has been attributed to increased anal resting pressure (RAP) and internal sphincter spasm.: Several methods to relieve internal sphincter spasm have been used, such as internal sphincterotomy, anal dilation, local trimebutine application, and nitroglycerin ointment. Some improvement in postoperative pain by these methods has been reported, however, the relation between RAP reduction and pain relief has not been demonstrated clearly. Moreover, to the best of our knowledge, preoperative and early postoperative RAP values and their impact on results have never been studied. In this study, we tested the efficacy of a different form of nitroglycerin, the Nitroderm TTS ® 5 band
(Ciba-Geigy, SA, Bale, Switzerland), on pain after hemorrhoidectomy and correlated the results with preoperative and early postoperative RAP. We also evaluated late postoperative RAP values. Nitric oxide plays an important role in relaxation of smooth muscle. Nitroglycerin, a potent nitric oxide
donor, has been used in an ointment form to relax the internal anal sphincter and to reduce anal pain. In practice, various concentrations of nitroglycerin are applied to the anal area and are absorbed rapidly by anal skin and mucosa. At least three or four applications per day are required. The most common side effects are headache, postural hypotension, and local itching. In the present study, we introduced a different form of nitroglycerin, Nitroderm TFS ® 5, for this purpose. It contains 25 mg of nitroglycerin, ahhough only 0.2 mg/hr is released continuously, yielding a total of 5 mg over a 24-hour period. When the Nitroderm TFS ® 5 is rolled with the nitroglycerin facing outside and then put into the anal canal, flatus may be passed without causing any disturbance to the patient. We observed very few side effects in our patients, and none of them required special measures or cessation of medicine. The Nitroderm "ITS ® band appears to be a safe and practical nitroglycerin form for local application to the anal canal. Treatment of hemorrhoidal disease addresses hemorrhoidal prolapse by fixing the mucosa on the internal anal sphincter by scarring. Less invasive methods, such as infrared coagulation or rubber band
ligation, are viable options. Hemorrhoidectomy, however, is often necessary for third- and fourth degree symptomatic hemorrhoids, which usually results in severe postoperative pain. Many methods, such as internal sphincterotomy, anal dilation, and local nitroglycerin, have been used to reduce RAP. These may relieve anal sphincter spasm, which is believed to be responsible for pain after hemorrhoidectomy. Nevertheless, the effect of these methods on postoperative pain has been controversial. Some studies have shown a benefit, others have reported no benefit over routine analgesics, with high complication rates. In fact, RAP shows individual variations, and this variability could explain such contradictory results. In the present study, we grouped patients according to their preoperative RAP and found that nitroglycerin provided better postoperative pain relief in those patients with high preoperative RAP, whereas patients with low preoperative RAP did not benefit from nitroglycerin. Moreover, when preoperative and postoperative RAP changes between these groups were compared, we observed that the low RAP group did not show significant RAP reduction postoperatively by nitroglycerin, as the high RAP group did. This result suggests that preoperative RAP should be used as a guide in determining which measures to take to reduce postoperative pain and RAP. The factors that increase RAP in hemorrhoid patients have been debated. The hemorrhoidal mass
itself is thought to be responsible because of elevated sphincteric spasm. It has been demonstrated that hemorrhoidectomy effectively reduces elevated RAP to normal ranges within 3 months of the procedure. We observed similar results. However, this effect requires several months, and in the early postoperative period, hemorrhoidectomy has no effect on high RAP and pain reduction. In addition, ligation of sensitive epithelium or denuded areas of the anal canal causes internal sphincteric spasm and increases pain immediately after hemorrhoidectomy, particularly in patients with high preoperative RAP. Therefore, other methods are usually necessary to reduce both RAP and pain during the early postoperative period. Lateral internal sphincterotomy has been found to effectively reduce RAP. On the other hand, internal
sphincterotomy has also been reported to carry the risk of incontinence if used routinely. Hiltunen and Matikainen have suggested that preoperative RAP should be 6 kPa (60 cmH20) or above to avoid postoperative anal incontinence due to internal sphincterotomy. This is consistent with our results. In the present study, we set the limit as 76 cm H20 , which was the average RAP value of our healthy volunteers. We did not gain meaningful reduction in pain score or RAP with Nitroderm TFS ® application after hemorrhoidectomy in patients whose preoperative RAP was below 76 cm H20. These findings support the idea that RAP-reducing measures should be used that are based on preoperative RAP. |
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