RESUMEN
PURPOSE: This was a multicenter, randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. METHODS: Patients with symptomatic chronic anal fissures were randomly assigned to 0.25 percent nitroglycerin tid or internal sphincterotomy. Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months. RESULTS: Ninety patients were accrued, but 8 were excluded from the analysis because they refused internal sphincterotomy after randomization (6), the fissure healed before surgery (1), or a fissure was not observed at surgery (1). There were 38 patients in the internal sphincterotomy group (22 males; mean age, 40.3 years) and 44 patients in the nitroglycerin group (15 males; mean age, 38.7 years). At six weeks 34 patients (89.5 percent) in the internal sphincterotomy group compared with 13 patients (29.5 percent) in the nitroglycerin group had complete healing of the fissure (P = 5x10(-8)). Five of the 13 patients in the nitroglycerin group relapsed, whereas none in the internal sphincterotomy group did. At six months fissures in 35 (92.1 percent) patients in the internal sphincterotomy group compared with 12 (27.2 percent) patients in the nitroglycerin group had healed (P = 3x10(-9)). One (2.6 percent) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 (45.4 percent) patients in the nitroglycerin group who required an internal sphincterotomy (P = 9x10(-6)). Eleven (28.9 percent) patients in the internal sphincterotomy group developed side effects compared with 37 (84 percent) patients in the nitroglycerin group (P<0.0001). Nine (20.5 percent) patients discontinued the nitroglycerin because of headaches (8) or a severe syncopal attack (1). CONCLUSIONS: Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence. Thus, internal sphincterotomy remains the treatment of choice for chronic anal fissure.
Asunto(s)
Canal Anal/cirugía , Fisura Anal/tratamiento farmacológico , Fisura Anal/cirugía , Nitroglicerina/uso terapéutico , Vasodilatadores/uso terapéutico , Administración Tópica , Adulto , Anciano , Femenino , Fisura Anal/patología , Humanos , Masculino , Persona de Mediana Edad , Nitroglicerina/administración & dosificación , Resultado del Tratamiento , Vasodilatadores/administración & dosificaciónRESUMEN
This report documents 2 cases of obstructive mucocele of the appendix secondary to endometriosis of the appendix. In 1 case, the tip of the mucocele was ruptured and associated with localized pseudomyxoma peritonei. Mucoceles of the appendix usually are associated with hyperplastic or neoplastic mucosal proliferation; obstruction, particularly that due to endometriosis, is an infrequent cause. Occurrence of localized pseudomyxoma peritonei associated with appendiceal endometriosis and mucocele has not been reported previously.
Asunto(s)
Apendicitis/etiología , Endometriosis/complicaciones , Perforación Intestinal/etiología , Mucocele/etiología , Neoplasias Peritoneales/etiología , Seudomixoma Peritoneal/etiología , Adulto , Apendicitis/patología , Femenino , Humanos , Perforación Intestinal/patología , Mucocele/patología , Neoplasias Peritoneales/patología , Seudomixoma Peritoneal/patología , Rotura EspontáneaRESUMEN
PURPOSE: The aim of this study was to determine if local injection of bupivacaine after hemorrhoidal banding causes a decrease in pain and in the incidence of associated symptoms. METHODS: After hemorrhoidal banding, patients were randomly assigned to receive a local injection of bupivacaine with 1:200,000 epinephrine, an injection of normal saline, or no injection, just superior to each band. Pain was graded by the patient and by the study nurse within 30 minutes, and any associated symptoms were recorded. At intervals 6, 24, and 48 hours postbanding, the patient recorded pain, limitation of activities, and analgesic requirements. Associated symptoms while at home were recorded. RESULTS: Of 115 patients studied, 42 received bupivacaine injection, 42 received normal saline injection, and 31 received no injection. In patients receiving bupivacaine compared with no injection, within 30 minutes postbanding there was a significant reduction in pain graded by the patient (P = 0.000002) and by the nurse (P = 0.000005) and a significant reduction in incidence of nausea (P = 0.01) and shaking (P = 0.008). However, in the bupivacaine group compared with the other two groups, at the intervals of 6, 24, and 48 hours postbanding there was no sustained reduction in the severity of pain and no reduction in analgesic requirements or limitation of normal activities. In the week after banding, there was no difference between groups in symptoms of nausea, shaking, lightheadedness, urinary retention, or bleeding. CONCLUSIONS: Bupivacaine injection may be useful for reducing pain and associated symptoms long enough to tolerate a trip home from the outpatient department but does not show a sustained effect.
Asunto(s)
Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Hemorroides/cirugía , Epinefrina/administración & dosificación , Femenino , Humanos , Inyecciones , Ligadura/métodos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , GomaRESUMEN
BACKGROUND AND PURPOSE: To determine the percentage of complete responders and the resectability rate for patients with locally advanced carcinoma of the rectum treated by 5-fluorouracil (5-FU) infusional chemotherapy and pelvic radiation. MATERIALS AND METHODS: Between October 1992 and June 1996, 29 patients with a diagnosis of locally advanced unresectable rectal cancer received preoperative 5 FU by continuous intravenous infusion at a dose of 225 mg/m2/day concurrent with pelvic radiation (median 54 Gy/28 fractions). All patients were clinical stage T4 on the bases of organ invasion or tumor fixation. Median time for surgical resection was 6 weeks. RESULTS: Median follow-up for the group was 28 months (range 5-57 months). Six patients were felt to be persistently unresectable or developed distant metastases and did not undergo surgical resection. Of the 29 patients, 23 proceeded to surgery, 18 were resectable for cure, 13 by abdominoperineal resection, 3 by anterior resection and 2 by local excision. Of the 29 patients, 4 (13%) had a complete response, and 90% were clinically downstaged. Of the 18 resected patients, 1 has died of his disease, 17 are alive, and 15 disease-free. The regimen was well tolerated; there was only one treatment-related complication, a wound dehiscence. CONCLUSION: The combination of 5 FU infusion and pelvic radiation in the management of locally advanced rectal cancer is well tolerated and provides a baseline for comparison purposes with future combinations of newer systemic agents and radiation.