Tratamiento local de la fisura anal crónica con diltiazem vs. nitroglicerina. Estudio comparativo / Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study

Objetivo Investigar el valor de la utilización de fármacos relajantes de la musculatura lisa y analizar los resultados de la utilización tópica de diltiazem 2% como alternativa a la nitroglicerina 0,2% en el tratamiento de la fisura anal crónica (FAC).Métodos Revisión de las FAC contenidas en una base de datos de fisuras anales con recogida prospectiva, incluyendo 145 pacientes tratados con medidas estándar en 2 periodos de tiempo consecutivos. Durante el primer periodo, se asignaron alternativamente a no recibir más tratamiento (Grupo EST) o a tratarse con nitroglicerina local (Grupo NTG). En un segundo periodo, todos fueron tratados con diltiazem local (Grupo DTZ). Se analizan los resultados después de un mes de tratamiento y las recidivas. Resultados Inicialmente hubo diferencias significativas en las tasas de mejoría (45% EST, 62,5% NTG y 80% DTZ; p<0,01), pero no en la curación (27% EST, 40% NTG y 39% DTZ) y el tratamiento fue completado por 124 pacientes (85,5%). Ocurrieron más efectos adversos y más abandonos en el grupo NTG. En el seguimiento posterior, durante una mediana de 2 años, hubo un 25% de recidivas y casi todas respondieron al tratamiento médico reiterado. Conclusiones Aunque los fármacos relajantes de la musculatura lisa no consiguen más curaciones que las medidas tradicionales en las FAC, brindan más alivio sintomático, ofreciendo una oportunidad para evitar la cirugía. El diltiazem local carece de efectos secundarios y es mejor aceptado que la nitroglicerina. Las recidivas son frecuentes, pero responden bien al tratamiento médico repetido (AU)

Aim To assess the value of using smooth muscle relaxants drugs and assess the results of the topical use of 2% diltiazem as an alternative to 0.2% nitroglycerin in the treatment of chronic anal fissure (CAF).Methods Review of the CAF contained in a prospectively collected database of anal fissures including one hundred forty-five patients diagnosed with CAF and treated with standard measures (ST) in two consecutive periods. During the first period they were allocated alternatively to not receive further treatment (ST group) or to be treated with nitroglycerin ointment (NTG group). In the second period all were treated with local diltiazem (DTZ group). One hundred forty-five patients entered the study and 124 completed it. Results Initially there were significant differences in improvement rates (45% ST, 62.5% NTG and 80% DTZ, p<0.01), but not in the cure rates (27% ST, 40% NTG and 39% DTZ) and the treatment was completed by 124 patients (85.5%). There were more side effects and more dropouts in the NTG group. In the subsequent follow-up for a median period of 25 months there were 25% recurrences and almost all responded to repeated medical treatment. Conclusions Smooth muscle relaxant drugs do not achieve a higher cure rate than the traditional measures used in CAF, but offer more symptomatic relief, providing an opportunity to avoid surgery. Topical diltiazem does not have the side effects of the nitroglycerin and is better accepted by patients (AU)

Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto / Self-evaluation of a clinical pathway to improve the results of rectal cancer

Objetivo Analizar si la autoevaluación de una vía clínica mejora los resultados del tratamiento del cáncer de recto (CR).Pacientes y método Pacientes intervenidos de CR divididos en 3 grupos según modificaciones bianuales de una vía clínica analizando diversos indicadores. Resultados Ciento sesenta y seis pacientes: grupo A: 2002–2003, n=50; B: 2004–2005, n=53 y C: 2006–2007, n=63; sin diferencias en edad, sexo o comorbilidad. El estudio preoperatorio mejoró con la introducción de TC toracoabdominopélvico: un 76% en el grupo C frente a un 6% del A (p<0,001). Todos los tumores del grupo C fueron estadificados mediante RM, ECO rectal o ambas, frente a un 84% del A (p<0,001). La tasa de amputaciones de recto pasó del 42% en el grupo A, al 17% en el C (p=0,007). Un 48% de cirujanos del grupo A frente al 94% en el C (p<0,001) tenían dedicación específica a la coloproctología. La media de adenopatías analizadas fue: grupo A: 6,2±4,5 frente a 13±6,5 en el C (p<0,001) y se informó del margen circunferencial en un 24% del grupo A frente al 76% en el C (p<0,001). Parámetros como la transfusión perioperatoria de hemoderivados, ingreso en UCI, uso de sonda nasogástrica, tolerancia precoz o analgesia epidural también mejoraron progresivamente. La mortalidad operatoria descendió de forma no significativa hasta el 4,7% y las dehiscencias anastomóticas del 24% al 9,5%, reduciéndose la estancia postoperatoria de 15–11 días (p=0,029).Conclusiones Se han mejorado múltiples indicadores de forma significativa en un período relativamente corto al efectuar autoevaluaciones del proceso (AU)

Objectives To analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment. Patients and method Patients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators.Results166 patients: Group A: 2002–3 n=50, B: 2004–5 n=53 and C: 2006–7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2±4.5 vs. 13±6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029).Conclusions Several indicators have significantly improved in a relatively short period of time due to self-evaluations of the process (AU)

[Local treatment of a chronic anal fissure with diltiazem vs. nitroglycerin. A comparative study]. / Tratamiento local de la fisura anal crónica con diltiazem vs. nitroglicerina. Estudio comparativo.

AIM: To assess the value of using smooth muscle relaxants drugs and assess the results of the topical use of 2% diltiazem as an alternative to 0.2% nitroglycerin in the treatment of chronic anal fissure (CAF). METHODS: Review of the CAF contained in a prospectively collected database of anal fissures including one hundred forty-five patients diagnosed with CAF and treated with standard measures (ST) in two consecutive periods. During the first period they were allocated alternatively to not receive further treatment (ST group) or to be treated with nitroglycerin ointment (NTG group). In the second period all were treated with local diltiazem (DTZ group). One hundred forty-five patients entered the study and 124 completed it. RESULTS: Initially there were significant differences in improvement rates (45% ST, 62.5% NTG and 80% DTZ, p<0.01), but not in the cure rates (27% ST, 40% NTG and 39% DTZ) and the treatment was completed by 124 patients (85.5%). There were more side effects and more dropouts in the NTG group. In the subsequent follow-up for a median period of 25 months there were 25% recurrences and almost all responded to repeated medical treatment. CONCLUSIONS: Smooth muscle relaxant drugs do not achieve a higher cure rate than the traditional measures used in CAF, but offer more symptomatic relief, providing an opportunity to avoid surgery. Topical diltiazem does not have the side effects of the nitroglycerin and is better accepted by patients.

[Self-evaluation of a clinical pathway to improve the results of rectal cancer]. / Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto.

OBJECTIVES: To analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment. PATIENTS AND METHOD: Patients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators. RESULTS: 166 patients: Group A: 2002-3 n=50, B: 2004-5 n=53 and C: 2006-7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2+/-4.5 vs. 13+/-6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029). CONCLUSIONS: Several indicators have significantly improved in a relatively short period of time due to self-evaluations of the process.