Surgical versus chemical [Botulinum toxin] sphincterotomy for chronic anal fissure

This is a prospective randomized trial aiming to compare the effect of open lateral internal sphincterotomy versus Botulinum toxin injection in the treatment of chronic anal fissure. Thirty patients diagnosed as suffering from chronic anal fissure were randomly allocated into two groups. In the surgical sphincterotomy group [n =15] lateral internal sphincterotomy was done. In the Botulinum toxin group [n = 15] 20 U of type A botulinum toxin was injected into the internal anal sphincter. The injection was repeated two months later of complete healing was not accomplished. The patients were re-examined by inspection and re-evaluated for symptoms at 2, 6 and 12 months. Two months after treatment, the healing rate was 60% [9/15] in the BT group, and 93.5% [14/15] in the LIS group [p=0.031]. In the BT group 6 patients were offered a second injection at the second month. Six months after treatment one patient of the LIS group developed recurrences. Therefore, at six months the healing rate was 73.3% [11/15] in the BT group, compared to 86.7% [13/15] in the LIS group [p=0.36]. By 12 months post treatment, the healing rate remained stable in the LIS group 86.7% [13/15], while three patients in the BT group developed recurrence, resulting in an overall success rate of 53.3% [8/15] [P=0.046]. The return to daily activity was significantly longer in the LIS group [12.8 +/- 4.6 days] vs. [1 day] in the BT group [p<0.0001]. The incidence of complications in the sphincterotomy [4 cases of transient partial incontinence] group was significant as compared with none in the BT group [p=0.32]. In comparing the results of the two treatment modalities, BT injection was found to be inferior to LIS regarding the healing rates. On the other hand the BT therapy is easy to perform, can be done as an outpatient procedure, and associated with less complication. Considering these factors BT therapy might be valuable in selected patients with high surgical risks, or high incidence of future incontinence

Abdominal access injuries in laparoscopic surgery, a retrospective study

This study was performed to assess the incidence, diagnosis, management and morbidity and mortality of laparoscopic access injuries. Using available injury based reports,patients documents and some available video tape recording of some laparoscopic procedures, 54 patients were collected and reported of having laparoscopic access injuries out of total 608 laparoscopic surgical and gynecological procedures done in Kasr Elaini teaching hospital during the period from August 2001 to April 2003 representing 8.8% of the total cases in comparison to what was reported in the literature which showed low incidence of these access injuries ranging from 5/10000 to 1.3%. Most of the reported injuries were minor vascular injuries [2.6%] and extraperitoneal gas insufflation [3.7%]. These minor complications caused only some technical difficulties during the procedures but they had no impact upon morbidity and mortality of the patients and were managed conservatively. Major retroperitoneal vascular injuries and visceral injuries, although represented minor incidence in our study 0.5% and 1.3% respectively, yet they were the major source of morbidity and mortality to the patients. Not only so but they also necessitate termination of the primary procedure and conversion to open surgery for their management. It seems that there is no single method of laparoscopic access safer than the other since there was no significant difference between them in inducing injury. In although laparoscopic access injuries seem to be of low incidence, yet they should be minimized. Since access injuries may be the result of integration between patient related factors, surgeons factors and the technique of access, so adoption of good laparoscopic technique, improvement of learning curve of junior surgeons proper site selection and port placement and proper choice of equipment, all may reduce the risk of access complications

Haemorrhoidectomy; classical Milligan and Morgan versus diathermy technique with and without the use of lactulose and metronidazole; a prospective study

Haemorrhoidectomy is the treatment of choice in third and fourth degree haemorrhoids. Unfortunately, it may be accompanied by significant postoperative complications such as pain, bleeding and wound sepsis, which can result in a protracted period of patient recovery. By studying a group of patients with 3 rd and 4 th degrees haemorrhoids we found that those who underwent both diathermy haemorrhoidectomy and Milligan and Morgan haemorrhoidectomy with the combined post operative use of Metronidazole and Lactulose had the best clinical outcome as regard hospitalization time, pain, wound status and period of return to their work compared to those who did not receive this treatment. However, those who underwent diathermy haemorrhoidectomy proved a smoother post-operative course than those who underwent Milligan and Morgan haemorrhoidectomy

Trauma score systems: prediction of hospital outcome of critically ill trauma patients: a validation study

Most standard trauma score systems have been developed to predict the outcome and assess the severity of trauma patients. This study test the validity of seven current trauma scoring systems [Glasgow coma scale, APACHE II score, trauma score [TS], Revised Trauma Score [RTS], Injury Severity Score [ISS], TRISS TS, TRISS RTS in 612 patients. Between January 1, 2003 and December 31. 2003, all trauma patients who were admitted to the surgical ICU in Kasr Al Aini hospital with a trauma score [TS] below 16 were included in this study [n=625]. Complete evaluation was successfully done for 612 patients [97%]. Their hospital outcome regarding morbidity and mortality was correlated with their individual score result. All trauma score systems under study showed high accuracy rates. TR1SSRTS and TRJSSTS performed the best accuracy rates in assessing the hospital outcome of trauma patients

role of total mesorectal excision and short term preoperative radiotherapy in improving the outcome of rectal cancer surgery

Colorectal cancer is the most common gastrointestinal cancer. One of the main problems in the treatment of rectal cancer is the development of local recurrence. Recurrences of rectal cancer are often confined to the pelvis without distant metastases and considered as a loco-regional failure. Total mesorectal excision [TME] was described 25 years ago and is now being established as the therapeutic gold standard for rectal cancer surgery in a number of countries worldwide. The analysis of this study which included 54 patients who underwent potentially curative radical surgery for rectal cancer showed that the introduction of TME has led to substantial lower loco-regional recurrence rate within the first 2 years postoperatively from 66.6% in group A [20 patients] to 33.3% in group B [34 patients]. Further improvement was recognized in group B2 who underwent TME + short course of preoperative radiotherapy. However the risk of anastomotic leak was higher among the low anterior resection+ TME group [5 patients] 25%, specifically in those who received a short term preoperative radiotherapy, in comparison with patients among [group A] who underwent curative low anterior resection without TME. Despite the initial controversy. TME + preoperative short term adjuvant radiotherapy is now a feasible, reproducible, adjunctive therapy in the management of rectal cancer