title: [Effectiveness of contemporary injection of botulinum toxin and topical application of glyceryl trinitrate against postoperative pain after Milligan-Morgan haemorrhoidectomy].
abstract: OBJECTIVE
  After haemorrhoidectomy the maximum resting pressure (MRP) of the anal canal is significantly increased. This increase play an important role in the making of postoperative pain. Recently, both the topical application of glyceryl trinitrate (GT) and the intrasphincter injection of botulinum toxin (Tox), resulted effective, in reducing temporary the MRP although with different mechanism of action. In this study the effectiveness and safe of contemporary injection of Tox and topical application of 300 mg/die of GT after Milligan-Morgan haemorrhoidectomy, were evaluated.
  
  
  METHODS
  Ten patients, undergoing Milligan-Morgan haemorrhoidectomy for 3rd and 4th degree haemorrhoids are included in this study. In all subjects, preoperatively and after 5 and 40 day following surgery, an ano-rectal manometry was performed. At the end of surgery, in all patients, 0.4 ml of solution containing 20UI of Tox was injected and 100 mg of 0.2% of GT was applied in the anal canal and in the perianal wounds. Afterwards the patients has been instructed to apply 100 mg of GT three times daily, for seven days. Time of perianal wounds healing, of first defecation, to return to work, of duration of surgery, of hospital stay, the complications, postoperative pain either on resting or during defecation, the analgesic consumption and side effects were recordered.
  
  
  RESULTS
  On the 5th and 40th postoperative day, the MRP resulted significantly reduced as compared to preoperative values. Postoperative pain either on resting or during defecation was higher on the 1st assessment, afterwards it progressively decreased. Anal incontinence was observed only in two patients, whereas headache only in one case.
  
  
  CONCLUSIONS
  The contemporary intrasphincter injection of Tox and perianal application of 300 mg/die of GT is safe and effective, with an incidence of complications similar to those detected when this drugs are given alone.
authors.affiliation: Università degli Studi di Palermo, Dipartimento di Discipline Chirurgiche ed Oncologiche. Divisione di Chirurgia Generale.
authors.forename: Rosalia
authors.initials: R
authors.lastname: Patti
authors.forename: Mariangela
authors.initials: M
authors.lastname: Angileri
authors.forename: Giovanni
authors.initials: G
authors.lastname: Migliore
authors.forename: Sergio
authors.initials: S
authors.lastname: Sammartano
authors.forename: Stefania
authors.initials: S
authors.lastname: Termine
authors.forename: Floriana
authors.initials: F
authors.lastname: Crivello
authors.forename: Franco Paolo
authors.initials: FP
authors.lastname: Gioè
authors.forename: Gaetano
authors.initials: G
authors.lastname: Di Vita
mesh_terms: D000287:Administration, Topical; D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D003113:Colonoscopy / Q000379:methods*; D004359:Drug Therapy, Combination; D005260:Female; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D007267:Injections; D008297:Male; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D005996:Nitroglycerin / Q000627:therapeutic use*; D010149:Postoperative Pain / Q000188:drug therapy*; D014665:Vasodilator Agents / Q000627:therapeutic use*
chemical_list: D009465:Neuromuscular Agents; D014665:Vasodilator Agents; D019274:Botulinum Toxins, Type A; D005996:Nitroglycerin