Congenital Esophageal Stenosis: To dilate or To resect

Congenital esophageal stenosis [CES] is a rare condition in children. The definitive preoperative diagnosis often is difficult to make, and a standard therapeutic protocol remains controversial. This study was carried out to determine the proper management strategy in children suffering from CES. The medical records of 17 patients with CES treated during a period of10 years [from 1995 to 2005] were retrospectively reviewed. Each patient was evaluated as regard to the clinical presentation, pathology, management, and outcome. The ages of patients at time of diagnosis ranged from 3 months to 9 years. The sites of stenosis were located more frequently at the lower third of the esophagus [n=10] than the upper third [n-3] and middle third [n=4], The diagnosis was made by esophagogram, esophagoscopy and was confirmed by histopathologic examination. Fifteen patients were diagnosed primarily, while 2 patients were diagnosed after unsuccessful surgical treatment for an initial misdiagnosed achalasia of the cardia. Six patients had confirmed tracheobronchial remnants [TBR], five had fibromuscular stenosis [FMS] and 2 had membranous web stenosis [MS]. The histopathology was unknown in 4 patients due to inadequate biopsies taken during esophagoscopy. All patients were treated initially by repeated esophageal dilatations [2-8 times] over two to thirty month period. The dilatation alone was successful in 11 patients, but was complicated by esophageal perforation in one case. Six patients required surgery; five of them were treated by resection and anastomosis, and one required esophageal replacement The pathology of this later group was TBR in 5 patients and FMS in one. 1. this study emphasizes the diagnostic difficulties in some children with CES; 2. Esophageal dilatation may be tried initially 3. Resection should be reserved for cases not responding to repeated dilatation particularly those with proven TBR

Chronic anal fissure: a comparative study between surgical and chemical sphincterotomy

The standard treatment of chronic anal fissure is surgical in the form of lateral sphincterotomy. However, temporary incontinence for flatus or faeces occurs in up to 30% of patients. Recently, Glyceryl trinitrate has been used effectively to treat chronic anal fissure. This study compares the efficacy and complications of chemical and surgical sphincterotomy. This prospective randomized study included 30 patients with chronic anal fissure presenting to Kasr el Ainy hospital in the period from February to September 2002. The patients were divided randomly into two groups. Group A [15 patients] were treated surgically using the standard treatment of lateral sphincterotomy. Group B [15 patients] were treated using local nitrate donor "GTN". Patients using nitrates for coexisting pathology were not included in the study. Assessment of patients included detailed history and clinical examination. Anorectal manometry was performed before and after therapy to assess the efficacy of therapy. Follow up period ranged from 2-6 months. Results and complications: In Group A [surgical sphincterotomy], fourteen patients had complete healing of the fissure in 8 weeks. One patient had complete healing in 12 weeks. Complications included discharge [6 patients, 40%], Bleeding [6 patients, 40%], temporary incontinence for 3 weeks [1 patient], incontinence for flatus [1 patient]. There was no recurrence of symptoms in any of the patients for the whole period of follow up. In group B [chemical sphincterotomy], eleven patients had complete healing of the fissure as evidenced by clinical and manometric study in 8 weeks [73%]. One patient had complete healing in 12 weeks; one patient stopped the treatment because of severe headache, while two patients did not respond to chemical therapy. Complications included headache which was severe in one patient to stop therapy, recurrence in two patients. There was no incontinence in any of the patients. The results of the present study suggest that surgical sphincterotomy was more effective in the treatment of chronic anal fissure [not statistically significant]. However, it was associated with more morbidity and complications. The study suggests to use Glyreryl trinitrate as a first line of treatment of chronic anal fissure because it is cheap, safe and associated with less complications especially incontinence