Botulinum toxin reduces anal spasm but has no effect on pain after haemorrhoidectomy.

OBJECTIVE: Pain following haemorrhoidectomy is due to a combination of factors including spasm of the internal sphincter, an open wound and local infection. In this study, we investigated the effect of botulinum toxin on postoperative pain following Milligan-Morgan haemorrhoidectomy. METHOD: A prospective randomized controlled trial was conducted in 32 patients undergoing haemorrhoidectomy. Routine postoperative care included metronidazole and bupivacaine. Patients were also given an inter-sphincteric injection of either placebo or botulinum toxin (150 units). Maximal resting pressure (MRP) and maximal squeeze pressure (MSP) were measured postoperatively. A linear analogue score was used to assess postoperative pain. The sample size calculation was calculated to show one standard deviation difference between groups. The primary endpoint was reduction in postoperative pain. RESULTS: The MRP was significantly lower in the botulinum toxin group (mean 50.5 mmHg; 95% CI 39.77-61.23) compared with the placebo group (mean 64.94 mmHg; 95% CI 55.65-74.22) (P = 0.04) at week 6. At week 12 there was no significant difference in MRP between the two groups. In contrast MSP was significantly lower in the botulinum toxin group at weeks 6 and 12 (mean 87.1 mmHg; 95% CI 66.9-107.1) compared with the placebo group (mean 185.8 mmHg; 95% CI 134.2-237.4) at week 12 (P = 0.0014). There was no significant effect on overall or maximal pain scores. Median time for return to normal activities was not significantly different between groups. CONCLUSION: Botulinum toxin reduces anal spasm but has no significant effect on postoperative pain.

The case for standardisation of the management of gallstones spilled and not retrieved at laparoscopic cholecystectomy.

INTRODUCTION: This observational study was carried out to establish how surgeons performing laparoscopic cholecystectomy currently deal with the issue of spilled gallstones. MATERIALS AND METHODS: A questionnaire was circulated amongst laparoscopic surgeons attending the annual conference of the Association of Laparoscopic Surgery of Great Britain and Ireland in November 2006. RESULTS: Eighty-two surgeons completed the questionnaire. Only half of surgeons inform patients when gallstones are spilled. Less than 30% of surgeons inform general practitioners (GPs) of this complication, when it occurs. Less than a quarter of surgeons include this information in the consent literature provided to patients. CONCLUSIONS: We recommend that trusts review their policy towards spilled stones either by local audit or adopt the guidance given by the UK Healthcare Commission. While some surgeons feel informing patients and GPs may unnecessarily heighten anxiety from an uncommon complication, our review of the literature suggests this position is not tenable in the current medicolegal climate.

Outcome following bypass, and proximal and distal ligation of popliteal aneurysms.

BACKGROUND: The aim of this study was to describe early and late results of proximal and distal ligation for popliteal aneurysm (PA), combined with bypass, with particular reference to the fate of the excluded aneurysm. METHODS: Of a cohort of 116 patients with PAs, 66 were treated with bypass and ligation. Graft patency was determined by duplex surveillance. In addition, 17 patients with bypassed PAs underwent a total of 33 duplex scans to determine flow within the aneurysm and change in size. RESULTS: For initially patent PAs, 3-, 5- and 8-year primary bypass graft patency was 78, 78 and 51 per cent respectively. These rates were not statistically significantly different from those following bypass for thrombosed PA, 3- and 5-year primary patency being 72 and 65 per cent respectively. No PA produced further symptoms after bypass and ligation. No flow was seen in any aneurysm at follow-up. Only one showed an increase in size. CONCLUSION: Proximal and distal ligation with bypass produced satisfactory long-term patency with good exclusion of the PA.

Long-term follow-up of strictureplasty for Crohn's disease.

BACKGROUND: Strictureplasty is an effective means of alleviating obstructive Crohn's disease while conserving bowel length. The aim of this study was to establish long-term outcomes of strictureplasty. METHODS: Between 1978 and 2003, 479 strictureplasties were performed in 100 patients during 159 operations. Information on Crohn's disease, medical therapy, laboratory indices, surgical details, complication rates and outcomes was recorded. The primary endpoint was abdominal reoperation. RESULTS: Mean follow-up was 85.1 (range 0.2-240.9) months. The overall morbidity rate was 22.6 per cent, with septic complications in 11.3 per cent, obstruction in 4.4 per cent and gastrointestinal haemorrhage in 3.8 per cent. The 30-day mortality rate was 0.6 per cent and the procedure-related series mortality rate 3.0 per cent. Perioperative parenteral nutrition was the only marker for morbidity (P < 0.001). Reoperation rates were 52 per cent at a mean of 40.2 (range 0.2-205.8) months after a first, 56 per cent at 26.1 (range 3.5-63.5) months after a second, 86 per cent at 27.4 (range 1.4-74.5) months after a third, and 62.5 per cent at 25.9 (range 7.3-70.5) months following a fourth strictureplasty procedure. The major risk factor for reoperation was young age (P < 0.001). CONCLUSION: Long-term follow-up has confirmed the safety of strictureplasty in Crohn's disease. Morbidity is appreciable, although the surgical mortality rate is low. Reoperation rates are comparable following first and repeat strictureplasty procedures.

Nutrition and hypertension.

There has been a good deal of interest in the relation of nutrition to cardiovascular diseases and this is likely to continue. We consider recent research developments concerned with the well known examples of the association of high salt intake with hypertension and of saturated fats with atherosclerosis. Some of the difficulties encountered in the investigation of dietary factors in hypertension are similar to those encountered in the investigation of dietary factors in atherosclerosis and coronary heart disease. Much additional research, which takes into account the multifactorial nature of cardiovascular disease, is needed to determine the effects of diet on the development and treatment of these diseases.

Physiological effects of varying dietary linoleic acid in spontaneously hypertensive rats.

The effect of dietary variations in linoleic acid (LA) on the development of hypertension was studied in young male spontaneously hypertensive rats (SHR). All groups developed elevated systolic blood pressures, but after 7 weeks on the experimental diets the blood pressures of the rats fed the diet with a low LA content (0.17% as supplied by 8% coconut oil) were significantly lower than the group fed a high level of LA (9.5% as supplied by 17% corn oil) in the diet. Rats fed the high LA diet had increased urine output and developed a mild but persistent polydipsia. After 4 months on the experimental diets, potassium excretion was decreased in proportion to the amount of LA in the diet but sodium excretion was not altered. Serum potassium was significantly elevated in the group fed high LA after 5 months. The effects of LA on hypertension of SHR appear to be opposite to those observed during salt-induced hypertension. Since LA is the dietary precursor of the prostaglandins, the effects observed may be due to the availability of precursor for renal prostaglandin synthesis which has been reported to be altered in SHR.