Azab El-Shabrawi

Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?

PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P=0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents

SummaryIntroductionMalignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and re-establish and preserve the passage in the GI-tract.Patients and methodsBetween October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer.ResultsIn all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation.ConclusionStent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.ZusammenfassungEinleitungMaligne Magenausgangsstenosen sind durch Tumorobstruktion bedingt und beeinträchtigen die orale Nahrungsaufnahme des Patienten und damit auch dessen Lebensqualität. Durch die endoskopische Implantation von selbstexpandierbaren Metallstents (SEMS) ist es möglich, Stenosen im Gastrointestinaltrakt zu beseitigen, die Passage wieder herzustellen und aufrecht zu erhalten.Patienten und MethodikSieben Patienten (Alter 50–90 Jahre) sind zwischen Oktober 2001 und April 2003 wegen einer malignen Magenausgangsstenose oder malignen Stenose im Bereich des proximalen Jejunums durch die Implantation von SEMS behandelt worden. Vier Patienten hatten eine maligne Magenausgangsstenose im Bereich des proximalen Duodenums oder Antrum ventriculi, zwei Patienten hatten eine Tumorstenose im Bereich der abführenden Jejunumschlinge nach subtotaler Billroth II Operation wegen eines Magenkarzinoms und ein Patient hatte eine Tumorbstruktion des Jejunums durch ein Tumorrezidiv nach Gastrektomie 20 cm distal der Ösophagojejunostomie.ErgebnisseBei allen sieben Patienten konnte die Obstruktionsymptomatik mittels endoskopischer Platzierung von SEMS beseitigt werden, sodass alle Patienten ab dem zweiten Tag oral ernährt werden konnten. Es kam bei der Stentimplantation zu keinen schwerwiegenden Komplikationen und die Mortalitätsrate des Eingriffes lag bei null Prozent.SchlussfolgerungDie Stentimplantation zur Therapie von malignen Magenausgangsstenosen ist ein risikoarmes, Ressourcen schonendes und für den Patienten wenig belastendes Verfahren, das sich hervorragend zur Palliation bei Patienten mit malignen Magenausgangsstenosen eignet.INTRODUCTION Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract. PATIENTS AND METHODS Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer. RESULTS In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation. CONCLUSION Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

Liver ischemia, catecholamines and preoperative condition influencing postoperative tachycardia in liver surgery

The aim of our study was to assess the influence of intraoperative hypoxic stress -unavoidably brought about by so called Pringle maneuver - on free and conjugated catecholamines during major hepatic resection. Judging from earlier results of fatigue-experiments in rats we also wanted to check the relationship between of poor general preoperative condition and conspicuously low triglyceride serum concentrations. The study included 26 patients with primary and secondary liver tumors. The mean age was 54 years (range 27-79). Twenty-one patients had segmental liver resections, 3 had hemihepatectomies and 2 hydatid cysts were treated by cystectomy. Blood samples were taken 2 days before and throughout surgery. Catecholamine plasma values were determined by high performance liquid chromatography. Statistical comparisons were made by t-test, ANOVA and chi square test. Free plasma catecholamines increased significantly during prolonged intraoperative ischemia (Pringle time 50-125 minutes). Patients with elevated intraoperative catecholamines had a significant correlation to postoperative episodes of tachycardia, and prolonged hospital stay. On the other hand, we could also see postoperative tachycardias in patients with short Pringle times (18-49 minutes) but with decreased preoperative serum triglycerides as an indicator of chronic stress and reduced general condition. Intraoperative hypoxic stress is associated with increased catecholamine values. Elevated catecholamines may well cause postoperative sinus-tachycardias (mean 20 hours) and are strongly related to postoperative liver failure and prolonged hospital stay.

Lokale Anwendung von Nitroglycerin-Salbe zur Behandlung von Analfissuren. Eine Alternative zur chirurgischen Therapie?

Zusammenfassung:Analfissuren werden häufig chirurgisch mit einer lateralen Sphinkterotomie behandelt, wobei jedoch die Gefahr einer postoperativen Inkontinenz besteht. Dies ist besonders ein Problem bei jüngeren Frauen, die noch mehrere Geburten vor sich haben, die eine weitere Belastung für die Sphinktermuskulatur darstellen. Stickstoffmonoxid-(NO-)Freisetzer wie Glyceryltrinitrate (GTN) konnten in kleineren Studien wirksam zur reversiblen chemischen Sphinkterotomie eingesetzt werden. NO ist ein wichtiger Neurotransmitter, der die Relaxation des inneren Schließmuskels bewirkt. Die klinische Wirksamkeit der lokalen NO-Therapie wurde in unserer prospektiv randomisierten Studie untersucht.Abstract:Patients suffering from anal fissures are commonly treated by lateral sphincterotomy. This surgical treatment includes the risk of postoperative incontinence, especially in young women with a possible vaginal delivery in their future. Glyceryl trinitrate, a nitric oxide donor, was shown to be effective to induce reversible chemical sphincterotomy. Nitric oxide is an important neurotransmitter mediating relaxation of the internal anal sphincter. The clinical evidence for therapeutic adequacy was examined in a prospective randomized study.