Effect of isosorbide dinitrate ointment on anal fissure

Effect of isosorbide dinitrate ointment on anal fissure. Songun I, Boutkan H, Delemarre JB, Breslau PJ. Department of Surgery, Rode Kruis Ziekenhuis, The Hague, The Netherlands. BACKGROUND/AIMS: Until recently, the treatment of choice for anal fissure was surgery, consisting of a partial lateral internal sphincterotomy. This treatment has a high complication rate: impaired continence is reported in 8-30% of the patients in the literature. Therefore, recently nonsurgical treatment modalities have been developed, such as local application of isosorbide dinitrate (ISDN) ointment. This treatment has comparable effectiveness with lower complication rates. To study the effect of ISDN on the healing of anal fissures in a general surgical practice, a prospective study was performed in our hospital. METHODS: In the period between June 1997 and January 2000, 100 consecutive patients with anal fissure were treated with ISDN. RESULTS: Of these 100 patients, 93 were healed within 8 weeks and 7 patients had no response and were operated. Of the 93 patients with primary healing fissures, 13 patients had recurrence during the 1-year follow-up. Seven of them were cured with ISDN, and the remaining 6 patients needed surgery. The only complication observed in this study was temporary headache which was observed in 7 patients. CONCLUSIONS: The primary healing rate of anal fissures was 93% with ISDN. In case of recurrence, 54% (7/13) could again be treated successfully with ISDN. Therefore, we recommend ISDN as first choice treatment for primary and recurrent anal fissures. Copyright 2003 S. Karger AG, Base

Bannayan-Riley-Ruvalcaba syndrome: further delineation of the phenotype and management of PTEN mutation-positive cases.

Item does not contain fulltextBannayan-Riley-Ruvalcaba syndrome (BRRS) is characterised by macrocephaly, intestinal hamartomatous polyps, lipomas, pigmented maculae of the glans penis, developmental delay and mental retardation. The syndrome follows an autosomal dominant pattern of inheritance. In 1997 reports on two BRRS patients with a deletion at 10q23.2-q24.1 were published. In the same year, the first two families with BRRS and a mutation of the PTEN gene were reported. Mutations in the PTEN gene have also been demonstrated in patients with Cowden syndrome (CS), which shows partial clinical overlap with BRRS, and in families with cases both of BRRS and CS. PTEN mutation positive BRRS and CS are likely to be different phenotypic presentations of the same syndrome. If BRRS and CS are one single condition, the question arises whether patients with BRRS should be screened for malignant tumours, since patients with Cowden syndrome have an increased risk of breast, endometrial, thyroid and renal cancer. We present two isolated cases and one family and confirm that BRRS and CS are allelic. Furthermore, we review the PTEN mutation positive BRRS cases, to further delineate the phenotype and to compare the cases with a genomic deletion with the cases with a point mutation. We recommend offering BRRS cases with a mutation in PTEN the same surveillance protocol for (malignant) tumours as is currently recommended for CS. In addition, we propose a yearly haemoglobin test from early infancy for the early detection of intestinal hamartomas, which are likely to give severe complications, especially in BRRS cases

Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer.

Item does not contain fulltextBACKGROUND AND STUDY AIMS: The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction. PATIENTS AND METHODS: Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1). RESULTS: A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy. CONCLUSIONS: The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention