Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy (Br J Surg 2001; 88: 669-74).
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Diathermy↗
Biomedical subjects
E A Carapeti
Publications and source records attributed to E A Carapeti.
Randomized, controlled trial of topical phenylephrine for fecal incontinence in patients after ileoanal pouch construction.
INTRODUCTION: Fecal incontinence is experienced by some patients with an ileoanal reservoir pouch. The alpha1-adrenergic agonist phenylephrine raises resting anal sphincter pressure in healthy volunteers and may be of value in these patients. METHODS: Twelve patients (7 female), median age 44 (range, 29-67) years were studied. All had fecal incontinence despite a noninflamed pouch of normal size and ultrasonographically structurally normal anal sphincter muscles. Patients were treated with topical 10 percent phenylephrine and placebo gels, allocated in random order in a double-blind, crossover study for two four-week periods. Before and during treatment, maximum resting anal sphincter pressure and anodermal blood flow were measured, a symptom questionnaire was completed, and incontinence score was determined using a validated scale. RESULTS: Six of 12 (50 percent) patients improved subjectively after phenylephrine compared with one on placebo (P = 0.07). Four patients had complete cessation of incontinence with active treatment. Phenylephrine significantly reduced the incontinence score (P = 0.015). It also resulted in a significant rise in mean maximum resting anal sphincter pressure when compared with placebo (P = 0.012). For all 12 patients, mean percent subjective improvement was higher after phenylephrine compared with placebo (P = 0.04). There were no side effects. CONCLUSIONS: Topical phenylephrine significantly improves fecal continence in patients with an ileoanal pouch. In some patients it totally eliminates nocturnal episodes. The mechanism of benefit is likely to be one of altered neural sphincter control. This is the first study of the use of a topical pharmacologic agent to treat fecal incontinence and may have a wider application.
Administration, Topical↗
Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects.
PURPOSE: Topical glyceryl trinitrate heals anal fissures, but a majority of patients experience headache. Topical gels of the calcium channel blocker diltiazem and the cholinomimetic bethanechol significantly lower anal sphincter pressure in volunteers. This study investigated the use of these two new pharmacologic agents in the treatment of patients with chronic anal fissure. METHODS: Two studies were conducted, each involving 15 patients with chronic anal fissure. In each study patients underwent anal manometry and laser doppler flowmetry before treatment. They were treated with either 2 percent diltiazem gel or 0.1 percent bethanechol gel three times daily for eight weeks. Assessment every two weeks was by clinical examination, repeat anal manometry, and laser doppler flowmetry. Daily pain was assessed by linear analog charts. RESULTS: Fissures healed in 10 of 15 (67 percent) patients treated with 2 percent diltiazem gel and in 9 (60 percent) patients treated with 0.1 percent bethanechol gel. There was no significant difference in the pretreatment maximum resting sphincter pressure (MRP) between responders and nonresponders in either group. There was significant reduction in the pain score after treatment with diltiazem (P = 0.002) and bethanechol (P = 0.005) compared with that before treatment. MRP was significantly lower after diltiazem (P = 0.0001) and bethanechol (P = 0.02) compared with pretreatment MRP. No headaches or side effects were reported. CONCLUSIONS: Both topical diltiazem and bethanechol substantially reduce anal sphincter pressure and achieve fissure healing to a similar degree reported with topical nitrates, but without side effects.
Administration, Topical↗
Randomized controlled trial of topical phenylephrine in the treatment of faecal incontinence.
BACKGROUND: Anal incontinence due to internal sphincter dysfunction is not amenable to simple surgical repair. The alpha-adrenergic agonist phenylephrine produces contraction of the internal sphincter and raises resting pressure when applied topically in healthy volunteers. The effect of topical phenylephrine in the treatment of faecal incontinence due to internal sphincter dysfunction was investigated. METHODS: Thirty-six patients (22 women) aged 28-81 (mean 58) years with faecal incontinence and ultrasonographically structurally normal anal sphincter muscles were treated with topical 10 per cent phenylephrine and placebo gels, allocated in random order in a double-blind crossover study. Maximum resting anal sphincter pressure and anodermal blood flow were measured. A symptom questionnaire was completed and incontinence score determined using a validated scale. RESULTS: There were no significant differences in incontinence score, resting anal pressure and anodermal blood flow between the active and placebo treatments. Six patients on active treatment and two on placebo experienced more than 75 per cent subjective improvement. Three patients developed allergic dermatitis to phenylephrine. CONCLUSION: This is the first study of the use of a topical pharmacological agent to treat faecal incontinence. This concentration of topical phenylephrine did not produce a significant improvement in symptoms or function. A subgroup of patients may respond. Further studies are required with increased concentrations.
Administration, Topical↗
Topical phenylephrine increases anal sphincter resting pressure.
BACKGROUND: Phenylephrine is an alpha1-adrenergic agonist which causes contraction of human internal anal sphincter muscle in vitro. Its intra-arterial administration in animals has been shown to increase resting sphincter pressure in vivo. In this study the effect of topical application of phenylephrine on resting anal pressure in healthy human volunteers was investigated. METHODS: Twelve healthy volunteers had measurements of maximum resting sphincter pressure (MRP) and anodermal blood flow taken before and after topical application of increasing concentrations of phenylephrine gel to the anus. To determine the duration of effect of the agent, readings were taken throughout the day after a single application. RESULTS: There was a dose-dependent rise in the resting anal sphincter pressure, with a small 8 per cent rise after 5 per cent phenylephrine (P = 0.012) and a larger 33 per cent rise with 10 per cent phenylephrine (mean(s.d.) MRP 85(12) cmH2O before versus 127(12) cmH2O after treatment, P < 0.0001). Thereafter no additional response was noted with higher concentrations of phenylephrine. The median duration of action of a single application of 10 per cent phenylephrine was 7 (range from 6 to more than 8) h. CONCLUSION: Topical application of 10 per cent phenylephrine gel to the anus produces a significant rise in the resting anal sphincter pressure in healthy human volunteers. This represents a potential novel therapeutic approach to the treatment of passive faecal incontinence associated with a low resting anal sphincter pressure.
Administration, Topical↗
Randomized trial of open versus closed day-case haemorrhoidectomy.
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Adult↗
Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate.
BACKGROUND: Topical application of glyceryl trinitrate (GTN) ointment heals chronic anal fissures, providing an alternative to the traditional first line treatment of surgical sphincterotomy. AIMS: To determine the most effective dose of topical GTN for treatment of chronic anal fissures and to assess long term results. METHODS: Seventy consecutive patients with chronic anal fissure, were randomly allocated to eight weeks treatment with placebo, 0.2% GTN three times daily, or GTN starting at 0.2% with weekly 0.1% increments to a maximum of 0.6%, in a double blind study. RESULTS: After eight weeks fissure had healed in 67% of patients treated with GTN compared with 32% with placebo (p=0.008). No significant difference was seen between the two active treatments. Headaches were reported by 72% of patients on GTN compared with 27% on placebo (p<0.001). Maximum anal sphincter pressure reduced significantly from baseline by GTN treatment (p=0.02), but not placebo (p=0.8). Mean pain scores were lower after treatment with GTN compared with placebo (NS). Of fissures healed with placebo 43% recurred, compared with 33% of those healed with 0.2% GTN and 25% healed with escalating dose GTN (p=0.7). CONCLUSIONS: GTN is a good first line treatment for two thirds of patients with anal fissure. An escalating dose of GTN does not result in earlier healing. Significant recurrence of symptomatic fissures and a high incidence of headaches are limitations of the treatment.
Adult↗
Topical diltiazem and bethanechol decrease anal sphincter pressure without side effects.
BACKGROUND: Topical nitrates lower anal sphincter pressure and heal anal fissures, but a majority of patients experience headache. The internal anal sphincter has a calcium dependent mechanism to maintain tone, and also receives an inhibitory extrinsic cholinergic innervation. It may therefore be possible to lower anal sphincter pressure using calcium channel blockers and cholinergic agonists without side effects. AIMS: To investigate the effect of oral and topical calcium channel blockade and a topical cholinomimetic on anal sphincter pressure. METHODS: Three studies were conducted, each involving 10 healthy volunteers. In the first study subjects were given oral 60 mg diltiazem or placebo on separate occasions. They were then given diltiazem once or twice daily for four days. In the second and third studies diltiazem and bethanechol gels of increasing concentration were applied topically to lower anal pressure. RESULTS: A single dose of 60 mg diltiazem lowered the maximum resting anal sphincter pressure (MRP) by a mean of 21%. Once daily diltiazem produced a clinically insignificant effect but a twice daily regimen reduced anal pressure by a mean of 17%. Diltiazem and bethanechol gel produced a dose dependent reduction of the anal pressure; 2% diltiazem produced a maximal 28% reduction, and 0.1% bethanechol a maximal 24% reduction, the effect lasting three to five hours. CONCLUSIONS: Topical diltiazem and bethanechol substantially reduce anal sphincter pressure for a prolonged period, and represent potential low side effect alternatives to topical nitrates for the treatment of anal fissures.
Administration, Oral↗
Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy.
BACKGROUND: Haemorrhoidectomy is commonly an inpatient procedure because patients and doctors worry about postoperative pain. Day-case haemorrhoidectomy (DCH) is possible if patient anxiety is addressed and postoperative pain and bowel function are managed. Pain sometimes increases a few days after haemorrhoidectomy, possibly because of secondary infection. We studied the effect of metronidazole on pain after DCH. METHODS: We randomly assigned 40 consecutive patients admitted for DCH metronidazole 400 mg (n = 20) or placebo (n = 20) three times daily, both for 7 days. All patients received lactulose from 2 days before surgery for 2 weeks. Diathermy DCH was performed without pedicle ligature or anal-canal dressing, and a diclofenac suppository was administered at the end of the procedure. Patients were discharged on the same day with diclofenac, 0.2% glyceryl-trinitrate ointment, lactulose, a telephone number to call for queries in emergencies, and an outpatient appointment. Patients took paracetamol or Co-dydramol (dihydrocodeine and paracetamol) as required; they completed linear analogue charts every day and completed questionnaires on satisfaction at 1 and 6 weeks. FINDINGS: 34 patients had all three major piles excised, of whom seven had additional division and reconstruction of the posterior skin bridge. Overall, both groups of patients experienced less pain than expected, except on days 3 and 4. Patients in the metronidazole group had significantly less pain than those in the placebo group on days 5, 6, and 7 (p = 0.004, p = 0.02, and p = 0.006). Median time to return to work or normal activity was 15 days (range 12-28) in the metronidazole group and 18 days (7-34) in the placebo group (p = 0.009). The patient satisfaction score was higher in the metronidazole group than in the placebo group at 1 week (p = 0.005). INTERPRETATION: Prophylactic metronidazole in diathermy DCH suppressed secondary pain around days 5-7 and increased patient satisfaction and earlier return to work.
Ambulatory Surgical Procedures↗
Randomised study of sterile versus non-sterile urethral catheterisation.
Indwelling urethral catheters are the most common cause of urinary tract infections (UTI), yet there is no direct evidence that technique of catheter insertion affects this. In a prospective study, 156 patients underwent preoperative urethral catheterisation, randomly allocated to 'sterile' or 'clean/non-sterile' technique groups. There was no statistical difference between the two groups with respect to the incidence of UTI. There was a considerable cost difference between the two groups, the 'sterile' method being over twice as expensive as the 'clean' method. Strict sterility is not necessary in preoperative short-term urethral catheterisation and is more expensive and time consuming.
Adult↗
Goblet cell mucin in human foetal colon, its composition and susceptibility to enzyme degradation: a histochemical study.
This work is part of an investigation into G. I. mucin susceptibility to enzyme degradation in normal and disease states. Formalin-fixed/paraffin embedded foetal (14-23 weeks) and neonatal colonic tissue was stained for mucins (neutral, N- and O-acylated sialomucins and sulphomucins) and PNA, UEA1, and Limax flavus. Enzymes tested: neuraminidases, alpha- and beta-galactosidase (E. coli and B. testis), beta-N-acetyl-glucosaminidase, alpha-fucosidase, single or in sequence, with and without prior neuraminidase treatment and followed by the stains. Acid mucins predominate throughout foetal life, sulphation occurs at 14 weeks and O-acylated sialomucins at 23 weeks. PNA and UEA1 are seen in traces or not detected. The mucin profile at birth is similar to the adult. Colonic mucins are susceptible to neuraminidase which abolishes Limax staining. The glycosidases effect on PNA is seen only with prior neuraminidase treatment and is particularly marked with beta-Gal(BT) in Neu----beta-Gal----beta-N-AcetylGlc than with beta-Gal (EC). Fucosidase with prior neuraminidase treatment has effect on UEA1 (decreases) and PNA (increases) affinities. Neuraminidase is essential as a first step in the process and by using beta-galactosidases EC and BT it was possible to show different PNA binding affinities. Preliminary data demonstrate the feasibility of this histochemical approach to the study of colonic mucins and forms the basis for further studies in the adult.
Colon↗