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

Saphenous Vein Versus PTFE for Above-Knee Femoropopliteal Bypass. A Review of the Literature

AbstractThe autogenous saphenous vein is considered the best bypass graft material for arterial bypasses below the inguinal ligament. However, a synthetic graft or prosthesis is considered an acceptable alternative, especially when the distal anastomosis is situated above the knee. Some studies even suggest that patency rates for vein and synthetic grafts are comparable, whereas others indicate that a vein graft is superior to a prosthetic graft, even above the knee.To test the hypothesis that both vein grafts and synthetic prostheses are equally beneficial in the above-knee position, we performed a systematic review of available studies comparing the patency of saphenous vein and polytetrafluoroethylene (PTFE) as bypass material. English and German medical literature from 1966 to 2002 was searched using Medline, and 25 articles meeting our inclusion and exclusion criteria were selected.The patency of venous bypasses was superior to that of PTFE bypasses at all time intervals studied. After 2 years, the primary patency rate of venous bypasses was 81% as compared to 67% for PTFE bypasses, and after 5 years it was 69 and 49%, respectively. After 5 years, the secondary patency of PTFE bypasses reached 60%. When only randomized trials were considered, venous bypasses were again superior to PTFE bypasses at all intervals studied. After 2 years, the primary patency rate of venous and PTFE bypasses was 80 and 69%, respectively, and after 5 years it was 74 and 39%, respectively.Since both randomized and retrospective studies comparing venous with PTFE bypasses showed that vein grafts were ‘better’ than PTFE prostheses, the null hypothesis that there is no difference between the two types of graft material was rejected (p=0.008).We conclude from this systematic review that if a saphenous vein is available, a venous bypass should be chosen at all times, even if patients have an anticipated short life expectancy (<2 years). If the saphenous vein is absent or not suitable for bypass grafting, PTFE is a good alternative as bypass material

Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making

Objective To evaluate the diagnostic accuracy of clinical evaluation and cross-sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision-making. Method A prospective analysis was conducted of 802 consecutive patients that presented with abdominal pain at the emergency department. Initial clinical diagnoses and management proposals were compared to the final diagnoses and therapeutic strategies for all patients. Results Fifty-seven patients were identified with colonic diverticulitis as the final diagnosis. The positive and negative predictive values for the clinical diagnosis of colonic diverticulitis were 0.65 and 0.98 respectively. Additional cross-sectional imaging had a positive and negative predictive value of respectively 0.95 and 0.99 or higher. These additional examinations led to a correct change of the initial clinical diagnosis in 37% of the patients, and a change in management in only 7%. Conclusion The accuracy of the clinical diagnosis for colonic diverticulitis is low. Ultrasound and computed tomography have superior diagnostic accuracy but these examinations rarely change the initial management proposal

Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making

Objective To evaluate the diagnostic accuracy of clinical evaluation and cross-sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision-making. Method A prospective analysis was conducted of 802 consecutive patients that presented with abdominal pain at the emergency department. Initial clinical diagnoses and management proposals were compared to the final diagnoses and therapeutic strategies for all patients. Results Fifty-seven patients were identified with colonic diverticulitis as the final diagnosis. The positive and negative predictive values for the clinical diagnosis of colonic diverticulitis were 0.65 and 0.98 respectively. Additional cross-sectional imaging had a positive and negative predictive value of respectively 0.95 and 0.99 or higher. These additional examinations led to a correct change of the initial clinical diagnosis in 37% of the patients, and a change in management in only 7%. Conclusion The accuracy of the clinical diagnosis for colonic diverticulitis is low. Ultrasound and computed tomography have superior diagnostic accuracy but these examinations rarely change the initial management proposal.Vascular Surger

More than 25 years of surgical treatment of hydatid cysts in a nonendemic area using the "frozen seal" method

BACKGROUND: Hydatid disease of the liver remains endemic in the world and is an imported disease in The Netherlands. The aim of this study was to evaluate the treatment and outcome of surgically treated patients for hydatid disease in a single center in The Netherlands. METHODS: This retrospective study included 112 consecutive patients surgically treated for hydatid disease between 1981 and 2007. The primary outcome was relapse of the disease. Secondary outcomes were infections, complications, reoperations, length of hospital stay, and mortality. RESULTS: In all cases, echinococcosis was diagnosed by computed tomography or ultrasonography (US). Serology (enzyme-linked immunosorbent assay, immunofluorescence) confirmed the diagnosis in 92.9%. Most of the cysts were seen only in the liver (73.5%). All cysts were operated on with the frozen seal technique. Relapse of disease was seen in 9 (8.0%) cases. Five (4.5%) required surgical treatment at a later stage. Twenty (17.9%) complications were recorded. Four (3.6%) needed radiological drainage and three (2.7%) a reoperation. Follow-up was performed with US and/or serology at a mean of 24 months (range 0.5–300 months). All but one complication were seen in the liver-operated group, this proved not to be of statistical significance (P = 0.477). Patients with complications stayed significantly longer in hospital than did the patients without complications (P < 0.001). No mortality was observed in this study. CONCLUSIONS: The present study suggests that the frozen seal method of surgery for hydatid disease is safe and effective. Future studies are needed to prove its position in the treatment of hydatid disease as new developments show promising results

Standard Outpatient Re-Evaluation for Patients Not Admitted to the Hospital After Emergency Department Evaluation for Acute Abdominal Pain

The aim of the present study was to investigate the efficacy and safety of standard outpatient re-evaluation for patients who are not admitted to the hospital after emergency department surgical consultation for acute abdominal pain. All patients seen at the emergency department between June 2005 and July 2006 for acute abdominal pain were included in a prospective study using a structured diagnosis and management flowchart. Patients not admitted to the hospital were given appointments for re-evaluation at the outpatient clinic within 24 h. All clinical parameters, radiological results, diagnostic considerations, and management proposals were scored prospectively. Five-hundred patients were included in this analysis. For 148 patients (30%), the final diagnosis was different from the diagnosis after initial evaluation. Eighty-five patients (17%) had a change in management after re-evaluation, and 20 of them (4%) were admitted to the hospital for an operation. Only 6 patients (1.2%) had a delay in diagnosis and treatment, which did not cause extra morbidity. Standard outpatient re-evaluation is a safe and effective means of improving diagnostic accuracy and helps to adapt management for patients that are not admitted to the hospital after surgical consultation for acute abdominal pain at the emergency department

Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis

Vascular Surger

Standard Outpatient Re-Evaluation for Patients Not Admitted to the Hospital After Emergency Department Evaluation for Acute Abdominal Pain

The aim of the present study was to investigate the efficacy and safety of standard outpatient re-evaluation for patients who are not admitted to the hospital after emergency department surgical consultation for acute abdominal pain. All patients seen at the emergency department between June 2005 and July 2006 for acute abdominal pain were included in a prospective study using a structured diagnosis and management flowchart. Patients not admitted to the hospital were given appointments for re-evaluation at the outpatient clinic within 24 h. All clinical parameters, radiological results, diagnostic considerations, and management proposals were scored prospectively. Five-hundred patients were included in this analysis. For 148 patients (30%), the final diagnosis was different from the diagnosis after initial evaluation. Eighty-five patients (17%) had a change in management after re-evaluation, and 20 of them (4%) were admitted to the hospital for an operation. Only 6 patients (1.2%) had a delay in diagnosis and treatment, which did not cause extra morbidity. Standard outpatient re-evaluation is a safe and effective means of improving diagnostic accuracy and helps to adapt management for patients that are not admitted to the hospital after surgical consultation for acute abdominal pain at the emergency department.Vascular Surger