Comparative study of glyceryl trinitrate ointment versus surgical management of chronic anal fissure.

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.

Clinical profile and surgical outcome of Meckel's diverticulum.

The aim of the study was to estimate the incidence and analyse the clinical profile and surgical outcome of the Meckel's diverticulum. This prospective study included 632 patients who were operated upon for acute abdomen during August 1999 to July 2004 in a single surgical unit. Pre-operative abdominal ultrasonography and plain x-ray abdomen erect were done depending on the necessity. These patients were subjected to laparotomy/appendicectomy depending on the case. A search for Meckel's diverticulum was done and if found, surgical resection and analysis by histopathological confirmation of the Meckel's diverticulum was performed. This study detected 9 patients (1.42%) with Meckel's diverticulum during the operation. In none of these cases pre-operative diagnosis of Meckel's diverticulitis was made. Out of 9 patients, 6 (66.6%) were males, 3 (33.4%) females. Four cases (44.4%) were symptomatic due to Meckel's diverticulum and 5 (55.6%) were asymptomatic. One patient presented with haematochezia, one with intestinal obstruction due to gangrene of the Meckel's diverticulum and one case of duplication of (double) Meckel's diverticulum. Histopathological examination of these specimens confirmed 2 cases with inflammation, one with gangrene and one ulcerated gastric mucosa in the Meckel's diverticulum. In 2 cases (22.2%) there was heterotopic epithelium (gastric-1, colonic-1). It is recommended that a search for Meckel's diverticulum in every case of appendicectomy, laparotomies for acute abdomen should be conducted and if found, Meckel's diverticulectomy/resection should be performed to avoid secondary complications arising from it.

Double Meckel's diverticulum.

Meckel's diverticulum is present in 2% of the population. Duplications of the alimentary tract are rare congenital malformations. The small bowel is the commonest site of alimentary tract duplication. They mimic other surgical diseases and may result in significant morbidity if left untreated. Pre-operative diagnosis of Meckel's diverticulum is difficult. A case of duplication of Meckel's diverticulum is reported here.

Practical advice on clinical decision making during neoadjuvant chemotherapy for primary breast cancer.

Neoadjuvant chemotherapy (NACT) is a useful approach in the treatment of many breast cancers. One of the main advantages of NACT is the possibility of breast conservation surgery in patients who would otherwise require a mastectomy. Most literature on NACT focuses on the effectiveness of different chemotherapy regimen and subsequent mastectomy rates. There is little guidance in the literature on aspects of individual patient management and decision making during NACT. This paper considers practical management advice where NACT is considered and adopted.

Postoperative wound complications and systemic recurrence in breast cancer.

Many factors involved in wound healing can stimulate tumour growth in the experimental setting. This study examined the relationship between wound complications and the development of systemic recurrence after treatment of primary breast cancer. One thousand and sixty-five patients diagnosed with operable primary invasive breast cancer between 1994 and 2001 were assessed for development of systemic recurrence according to whether or not a wound complication occurred after surgery, with a median follow-up of 54 months (range 15-119). There were 93 wound complications (9%). There was a statistically significant greater risk of developing systemic recurrence in patients with wound problems than those without (hazard ratio (HR) 2.87; 95% CI: 1.97, 4.18; P<0.0001). This remained in a multivariate analysis after adjustment for case mix variables, including Nottingham Prognostic Index (NPI) and oestrogen-progesterone receptor status (HR: 2.52; 95% CI: 1.69, 3.77; P<0.0001). In the good prognostic NPI group, 4 out of 27 patients (15%) with wound problems vs 11 out of 334 (3%) without wound problems developed systemic recurrence. The corresponding figures were 10 out of 35 (29%) vs 48 out of 412 (12 %) in the moderate prognostic group and 18 out of 29 (62%) vs 75 out of 199 (38%) in the poor prognostic group. In 29 patients NPI could not be calculated. Smokers at the time of diagnosis were more likely to develop metastatic disease than the non-smokers (HR: 1.50; 95% CI: 1.04, 2.15; P=0.03) after adjustment for other factors. The results suggest that patients with wound complications at primary surgery have increased rates of systemic recurrence of breast cancer.

Properties and characteristics of the dyes injected to assist axillary sentinel node localization in breast surgery.

AIMS: A review of the safety profile of dyes injected to assist in sentinel lymph node biopsy (SLNB) in breast cancer. METHODS: A literature search was performed of the medline database 1966-2005 using the Ovid web Gateway detailing the words sentinel node, breast cancer, allergic reactions, blue dye, isosulfan blue, patent blue and methylene blue. RESULTS: There are reported side-effects from the parenteral administration of dyes, which range from minor to life threatening in severity. There are differences between the dyes as regards their effects. These aspects are discussed. CONCLUSION: Many dyes have been used for SLNB with acceptable identification rates. There are variable side-effects for each of those dyes. Further research is needed to clarify the safety profile of these dyes.