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

Early surgical intervention in acute cholecystitis

The role of early surgical intervention in the management of acute cholecystitis is evaluated. Forty one patients were studied. Early cholecystectomy was planned to be carried out for all patients unless there was a contraindication or poor surgical risk. Real time ultrasonography proved to be very reliable in establishing the diagnosis. Three patients were managed conservatively. Thirty eight patients were explored. Cholecystectomy was successfully accomplished in 30 patients and 2 had cholecystostomy. Flexibility of the time limit for performing early operation allowed cholecystectomy to be performed up to 8 days from the onset of the acute attack. Routine operative cholangiography is recommended since it detected CBD stones in 19.4% of patients. The morbidity rate was 13.9% and there was no mortality. The mean hospital stay for the surgically treated group was 9.8 days. Early surgical intervention is a safe, effective and relatively less costly procedure in the management of acute cholecystitis

Pancreaticoduodenectomy for pancreatic and duodenal malignancy

Radical resection of malignant tumors of pancreatic head, distal common bile duct, periampullary region and duodenum was performed in 11 patients with a mean age 51.4 years. More than half of the patients had been jaundiced at the time of operation. Preoperative stenting of the CBD helped to improve the jaundice prior to resection. Formal Whipple pancreaticoduodenectomy was the standard procedure in 8 patients and pylorus-preserving pancreaticoduodenectomy was done in 3 patients. Five patients had carcinoma of the pancreatic head proper, 3 patients had periampullary carcinoma, 2 patients had carcinoma of the distal CBD, and one patient had lymphoblastic lymphoma of the second part of the duodenum. Pancreatic fistula occurred in 2 patients, one of whom died because of associated uncontrollable infection and nutritional depletion, and the other one closed spontaneously. Minor septic complications developed in 2 patients. Long-term follow up showed 5 patients who are alive and free of recurrence. Certain detailed meticulous steps in the technique of reconstruction and pancreaticojejunal anastomosis helped to improve the results. Pancreaticoduodenectomy is considered to have an acceptable morbidity and mortality and the long-term survival is possible even for patients with cancer head proper of pancreas

Phytomenadione [vitamin K1] infusion versus bolus injection on the clotting process in cirrhotic patients [Sup]

The effect of intravenous bolous injection of phytomenadione [vitamin K1] versus its infusion on the coagulation mechanisms, was prospectively studied in 40 cirrhotic patients randomized into two groups of 20 patients each: Bolous Group 1 Infusion Group 2.Blood samples were tested at 1/4,6, 12 and 24 hours following its administration. The prothrombin time was more accurate than the whole blood clotting time in the assessment of the results. The overall effect of the infusion, particularly shown by the prothrombin time, was significantly better than the bolous injection. The significantly superior effect of the infusion to the bolous injection was quite apparent during the 6th [p=<0.001] after injection. The 12th hour samples, still showed the same significant pattern apart from the improvement in the clotting time which was better in the bolous group. Although the bolous injection improved the clotting and prothrombin times significantly, yet the infusion gave a maintained and significantly less fluctuant improvement than the bolous injection. It is suggested that phytomenadione infusion could achieve a sustained uniform improvement in the haemostatic mechanisms of cirrhotic patients, which may be helpful in the treatment of critical patients with acute variceal bleeding