Nitroderm TTS ® Band Application for Pain After Hemorrhoidectomy A. Coskun, M.D.,* S. A. Duzgun, M.D.,* A. Uzunkoy, M.D.,* M. Bozer, M.D.,* O. Aslan, M.D.,t B. Canbeyli, M.D.* From Harran University School of Medicine, Departments of General Surger~ and Pharmacolog)/f, 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 classi- fied as group A (n = 24) and those with low anal resting pressure were classified as group B (n = 14). After hemor- rhoidectomy, 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 post- operative 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 postopera- tively 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 pres- sure and relieved pain in patients with high preoperative anal resting pressure. [Key words: Hemorrhoidectomy; Anal resting pressure; Pain; Nitroderm TTS®] Coskun A, Duzgun SA, Uzunkoy A, Bozer M, Asian O, Can- beyli B. Nitrodman TTS*? band application for pain after hemorrhoidectomy. Dis Colon Rectum 2001;44:680-685. H emorrhoidal disease is the most prevalent dis- order of the anorectal region. Treatment de- pends on the degree of hemorrhoids and the symp- toms. Surgical excision is used as the main method for the treatment of third- or fourth-degree symptomatic Address reprint requests to Dr. Coskun: Harran Universitesi Tip FaMiltesi, Uygulama ve Arastirma Hastanesi Genel Cerrahi Servisi, 63200 Sanliurfa, Turkey. hemorrhoids.: However, postoperative pain is still a challenging problem that causes a number of patients with hemorrhoids to prefer the symptoms of the dis- ease instead. Although nonsteroid anti-inflammatory drags and narcotic analgesics have frequently been used for pain relief, 2'3 their analgesic effects are tem- porary, and side effects due to overdose are not un- common. 4 Therefore, new methods to reduce post- operative pain after hemorrhoidectomy need to be investigated. Manometric studies have demonstrated that pa- tients with hemorrhoids have higher anal pressures than the healthy population. 5'6 Pain after hemorrhoid- ectomy 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 di- lation, local trimebutine application, and nitroglycerin ointment. 7-9 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 post- operative 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. METHODS Study Groups This study" included 38 patients (30 men, 8 women) with a mean age of 43.5 (range, 20-72) years. Routine clinical and sigmoidoscopic examinations were con- ducted to create the hemorrhoidal groups before op- eration. All patients had third- or fourth-degree symp- tomatic hemorrhoids. Patients who had previously 68O