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Biomedical subjects

Chris Cunningham

Publications and source records attributed to Chris Cunningham.

12 recordsLinked to original sources
PubMed2005

Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable.

PURPOSE: Chronic anal fissure is said to be associated with internal sphincter hypertonia. However, an unknown proportion of fissures may be associated with normal or even low resting pressures and may subsequently be resistant to pharmacological treatments or at risk from surgical treatments, both of which aim to reduce sphincter hypertonia. This study investigated the ability of surgeons to detect low or normal pressure fissures by digital rectal examination. METHODS: Patients with chronic anal fissure were assessed prospectively. The results of anal manometry performed on these patients were compared with digital rectal assessment of sphincter tone undertaken by a surgeon blinded to the manometry results. RESULTS: Forty consecutive patients (21 male) with chronic anal fissure were studied. Twenty-two (55 percent) had normal maximum resting pressure and a further 3 (8 percent) had low pressures on anal manometry. On clinical assessment, only five (13 percent) patients were evaluated as having no anal hypertonia. Clinical assessment of anal tone correctly identified 14 of 15 patients with high manometric maximum resting pressure (sensitivity, 93 percent), yet detected only 4 of 25 patients with normal or low pressures (specificity, 16 percent). The positive predictive value of clinical assessment of anal tone was 40 percent and the negative predictive value, 80 percent. CONCLUSIONS: The incidence of patients with chronic anal fissure without high manometric maximum resting pressure is higher than previously reported. The ability of surgeons to identify this group clinically was poor. It is reasonable to treat all patients primarily medically, and then selectively investigate by manometry those patients who fail medical therapy before considering lateral sphincterotomy.

Anal Canal↗
PubMed2005

Neoadjuvant therapy for rectal cancer: improved tumor response, local recurrence, and overall survival in nonanemic patients.

INTRODUCTION: Preoperative, long-course chemoradiotherapy is recommended for rectal cancers involving or threatening the mesorectal resection margin, but tumor response is variable. Some highly radiosensitive cancers completely regress, leading to reduced local recurrence and improved survival. This study was designed to evaluate the influence of anemia during chemoradiotherapy on tumor response, local and distant recurrence, and overall survival. METHODS: Mean hemoglobins during chemoradiotherapy of consecutive patients with rectal cancer undergoing chemoradiotherapy and surgery were calculated and ranked. Anemia was defined as lowest quartile for males and females. Tumor response was histologically quantified using rectal cancer regression grade. RESULTS: Of 100 patients, 5 females and 20 males were anemic. Nonanemic patients achieved better tumor response (54 percent regression Grade 1) than anemic patients (28 percent, P = 0.028). There were more locally advanced cancers in anemic (48 percent T4) compared with nonanemic patients (21 percent T4), but radiologic T stage did not influence tumor response (50 percent T3 vs. 43 percent T4 regression Grade 1, P = 0.53) or overall survival. Mesorectal margin positivity was less in nonanemic (15 percent) compared with anemic patients (36 percent, P = 0.021). At median follow-up of 39 months, nonanemic patients (7 percent) suffered less local recurrence than anemic patients did (38 percent, P = 0.003). Overall survival at two years was improved in nonanemic (91 percent) compared with anemic patients (64 percent, P = 0.021), but was similar for T3 and T4 patients. CONCLUSIONS: Patients with normal hemoglobin during chemoradiotherapy achieved better tumor response, less local recurrence, and improved overall survival compared with anemic patients, independent of radiologic T stage. Correcting anemia before chemoradiotherapy might improve tumor response and oncologic outcomes.

Adenocarcinoma↗
PubMed2004

Patterns of fecal incontinence after anal surgery.

PURPOSE: Conservative anal surgery, with maximum preservation of the anal sphincters and continence, is becoming increasingly possible with the emergence of new sphincter-sparing treatments. Many surgeons remain skeptical, however, of the nature and impact of incontinence after anal surgery. We aimed to characterize the patterns of anal sphincter injury in patients with fecal incontinence after anal surgery. METHODS: We reviewed our fecal incontinence database and studied a subset developing incontinence after anal surgery. Maximum resting and squeeze pressures and the distal high-pressure zone to mid-anal canal resting pressure gradient were evaluated. Anal ultrasounds were evaluated and specific postoperative lesions were characterized. RESULTS: Patterns of sphincter injury in 93 patients with fecal incontinence after manual dilation, internal sphincterotomy, fistulotomy, and hemorrhoidectomy were studied. The internal sphincter was almost universally injured, in a pattern specific to the underlying procedure. One-third of patients had a related surgical external sphincter injury. Two-thirds of women had an unrelated obstetric external sphincter injury. The distal resting pressure was typically reduced, with reversal of the normal resting pressure gradient of the anal canal in 89 percent of patients. Maximum squeeze pressure was normal in 52 percent. CONCLUSION: Incontinence after anal surgery is characterized by the virtually universal presence of an internal sphincter injury, which is distal in the high-pressure zone, resulting in a reversal of the normal resting pressure gradient in the anal canal. These data support concerns that non-sphincter-sparing anal surgery leads to fecal incontinence and is increasingly difficult to justify given the availability of modern sphincter-sparing approaches.

Adult↗
PubMed2004

Fissurectomy-botulinum toxin: a novel sphincter-sparing procedure for medically resistant chronic anal fissure.

BACKGROUND: Botulinum toxin heals only approximately one-half of glyceryl trinitrate-resistant chronic anal fissures, perhaps because chemical sphincterotomy alone treats internal sphincter spasm but not chronic fissure fibrosis. We aimed to assess whether a novel procedure, fissurectomy-botulinum toxin, improves the healing rate of medically resistant fissures over that achieved with botulinum toxin alone. METHODS: A prospective pilot study of chronic fissure patients failing medical therapy was undertaken. Fissurectomy was performed, with excision of the fibrotic fissure edges, curetting of the fissure base, and excision of the sentinel pile if present. Twenty-five units of botulinum toxin (Botox) were injected into the internal sphincter. The primary end point was fissure healing, and secondary end points were improvement in symptoms, need for lateral internal sphincterotomy, and side effects. RESULTS: Thirty patients underwent fissurectomy-botulinum toxin (57 percent female; median age, 39 years). Nineteen patients had failed glyceryl trinitrate, whereas 11 had failure of both glyceryl trinitrate and botulinum toxin. At a median of 16.4 weeks follow-up, 28 fissures (93 percent) were healed. Two fissures (7 percent) remained unhealed but were symptomatically better and avoided lateral internal sphincterotomy. Two patients (7 percent) experienced transitory flatus incontinence. CONCLUSION: Fissurectomy-botulinum toxin heals over 90 percent of fissures resistant to medical therapy. Fissurectomy-botulinum toxin allows patients with medically resistant fissures to achieve a high rate of healing while avoiding the risk of incontinence associated with lateral internal sphincterotomy.

Adult↗
PubMed2004

Indigenous participation in the 'new' New Zealand health structure.

OBJECTIVES: This paper presents preliminary evaluative findings from research on key areas of concern to Māori and forms part of a wider project on the 2001 health system reforms in New Zealand. The paper reports on the development and implementation of the Māori Health Strategy, representation in decision making at governance level in District Health Boards, the inclusion of the Treaty of Waitangi in legislation and workforce issues. METHODS: Key informant interviews with 35 Māori and non-Māori respondents, in addition to data from five case study districts, were thematically analysed to gain an understanding of views on the health system reforms to date. RESULTS: The development of a Māori Health Strategy and the mandatory inclusion of Māori in governance and consultation processes have had a positive effect on Māori participation in the public health sector. Whereas previously Māori participation was concentrated in health service provision, the inclusion of specific provisions in the New Zealand Public Health and Disability Act 2000 has resulted in greater Māori inclusion in governance, planning and decision-making roles. However, there are concerns over strategy implementation, sustainability and workforce development. CONCLUSIONS: Overall, the findings at this stage indicate that there is support for the post-2000 model. Māori and non-Māori alike have identified positive features of the model that could go some way towards contributing to improved Māori health. However challenges still remain.

Community Participation↗
PubMed2003

Nocturnal penile tumescence is diminished but not ablated in postproctectomy impotence.

PURPOSE: We aimed to assess objectively the integrity of the parasympathetic neural pathway that controls the inflow choke vessels to the corpora cavernosa in a group of male patients with postproctectomy erectile dysfunction. METHODS: The study group was male patients with erectile dysfunction after proctectomy for rectal cancer and inflammatory bowel disease identified by sexual function questionnaire. The group underwent two consecutive nights of home nocturnal penile tumescence monitoring with the Nocturnal Electrobioimpedance Volumetric Assessment device. The control group was also monitored. It comprised preoperative potent patients with rectal cancer and inflammatory bowel disease who had not yet undergone a variety of surgical procedures. Demographics and nocturnal penile tumescence parameters were recorded, including number, duration, and percentage increase in penile volume of tumescent events. RESULTS: Thirty-four impotent study group and 28 potent control group patients underwent nocturnal penile tumescence monitoring. The groups were well matched for mean age (difference, 1.4 years; 95 percent confidence interval, -5.8 to 8.6 years) and proportion with rectal cancer (difference, 6 percent; 95 percent confidence interval, -1 to 13 percent). The number of nocturnal penile tumescent events was greater for the potent group than for the control group (mean rank, 40.4 vs. 24.2; P = 0.0004). There was no significant difference between the mean duration (difference, 2.6 minutes; mean rank, 27.9 vs. 34.4; P = 0.16) or the mean penile volume increase (difference, 5.4 percent increase; mean rank, 30.6 vs. 32.6; P = 0.66) for tumescent events between the study and control groups. Mean age was significantly higher in complete than in partial impotence (60.9 vs. 53.1 years; difference, 7.8 years; 95 percent confidence interval, 0.1 to 15.5 years). There was a nonsignificant trend to a lower mean number of tumescence events among sildenafil responders than among nonresponders (3.5 vs. 4.8 events; mean rank, 11.2 vs. 17.3; P = 0.14). CONCLUSION: Nocturnal penile tumescence activity is diminished but not ablated by the trauma of surgical dissection. This suggests that some of the cavernous nerves that govern inflow to the corpora cavernosa are intact after surgery and that the nerve lesion responsible for erectile dysfunction is partial, and it explains why the response to sildenafil in such patients is surprisingly high.

Adult↗
PubMed2003

Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate.

PURPOSE: Glyceryl trinitrate paste is used by many as first-line therapy for chronic anal fissure but heals only approximately 50 to 60 percent of fissures. We use botulinum toxin as second-line therapy after failed glyceryl trinitrate and aimed to evaluate efficacy, side effects, and patient preference. METHODS: A prospective, nonrandomized, open-label study of patients with chronic anal fissure failing a course of glyceryl trinitrate treated with 20 units of botulinum toxin A injected into the internal sphincter was conducted. Symptomatic relief, visual healing of fissures, side effects, and patient preference were assessed at 8-week follow-up. RESULTS: Forty patients underwent botulinum toxin treatment. Twenty-nine patients (73 percent) overall were improved symptomatically and avoided surgery. Seventeen fissures (43 percent) were healed, whereas 23 fissures (57 percent) remained unhealed. Of the unhealed fissures, 5 (12 percent) were asymptomatic, 7 (18 percent) were symptomatically much improved, and 11 (27 percent) were no better symptomatically and came to surgery. Discomfort associated with injection was minimal. Of 34 patients undergoing botulinum toxin injection in the clinic, 24 (71 percent) preferred botulinum toxin, 7 glyceryl trinitrate (20 percent; difference = 51 percent; 95 percent confidence interval = 31-71 percent), and 9 percent were undecided. Transient minor incontinence symptoms were noted in 7 patients (18 percent). CONCLUSIONS: Second-line botulinum toxin injection improves symptoms in approximately three-quarters of patients after failed primary glyceryl trinitrate therapy and at least in the short term avoids surgical sphincterotomy. Botulinum toxin heals approximately one-half of these fissures. Discomfort and side effects were minimal. A policy of first-line glyceryl trinitrate/second-line botulinum toxin will avoid sphincterotomy in 85 to 90 percent. Higher rates of healing may be achieved by giving botulinum toxin as first-line therapy, or addressing the chronic fibrotic nature of the fissure.

Adult↗
PubMed2002

A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula.

PURPOSE: Fibrin glue is a novel treatment for anal fistulas and possesses many advantages in the treatment of difficult high fistulas. Fibrin glue treatment is simple and repeatable; failure does not compromise further treatment options; and sphincter function is preserved. We aimed to compare the outcomes of patients with low and high anal fistulas randomly assigned to either fibrin glue or conventional treatment. METHODS: Patients with simple fistulas (low fistulas) and complex fistulas (high, Crohn's, and low fistulas with compromised sphincters) were randomly assigned to either fibrin glue or conventional treatment (fistulotomy or loose seton insertion with or without subsequent advancement flap). Patients with rectovaginal fistulas and anal fistulas associated with chronic cavities, acute sepsis, and side branches were excluded. The primary end point was fistula healing. Secondary end points were complications, changes in preoperative continence score, changes in maximum resting and squeeze pressure, satisfaction scores, and pain scores and time off work (simple fistulas only). RESULTS: Patients in the fibrin glue and conventional treatment arms were well matched for gender, median age, duration of fistula symptoms, and follow-up. Fibrin glue healed three (50 percent) of six and fistulotomy seven (100 percent) of seven simple fistulas (difference, 50 percent; confidence interval, 10 to 90 percent; P= 0.06, Fisher's exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures between the study arms. Return to work was quicker in the glue arm, but pain scores were similar and satisfaction scores higher in the fistulotomy group. Fibrin glue healed 9 (69 percent) of 13 and conventional treatment 2 (13 percent) of 16 complex fistulas (difference, 56 percent; 95 percent confidence interval, 25.9 to 86.1 percent; P= 0.003, Fisher's exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures in either study arm. Satisfaction scores were higher in the fibrin glue group. CONCLUSIONS: No advantage was found for fibrin glue over fistulotomy for simple fistulas, but fibrin glue healed more complex fistulas than conventional treatment and with higher patient satisfaction.

Adult↗