The British journal of surgery
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Anal fissure is often treated surgically by sphincterotomy. There is growing concern over the effects of this procedure on continence. Nitric oxide donors such as glyceryl trinitrate are thought to cause a reversible 'chemical sphincterotomy', capable of healing the fissure. ⋯ The fissure recurred in four patients after cessation of treatment; three were successfully treated by further glyceryl trinitrate. Mild headache occurred in four patients. Anal fissure can be successfully treated with 0.2 per cent glyceryl trinitrate ointment applied topically.
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POSSUM (Physiological and Operative Severity Score for the enUmeration of Morbidity and mortality) has been studied as a possible surgical audit system for a 9-month interval using a sample of 28 per cent of the general surgical workload. Mortality or survival was analysed as an endpoint. In this sample the published POSSUM predictor equation for mortality overpredicted deaths by a factor of more than two. ⋯ Logistic regression was done on a set of 1485 surgical episodes to generate a local predictor equation for mortality. This process gave a predictor equation that fitted well with the observed mortality rate and gave a minimum predicted risk of mortality of 0.20 per cent. The previously published POSSUM predictor equation for mortality performed badly when tested using a standard test of goodness of fit for logistic regression and must be modified.
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This prospective study investigated the value of segmental colonic transit time studies in the surgical treatment of slow transit constipation. Overall, 346 patients with chronic constipation were analysed; slow transit constipation was diagnosed in 86 (25 per cent). Based on the results of segmental colonic transit time studies, 18 patients underwent partial left-sided colectomy and 24 subtotal colectomy. ⋯ Severe abdominal discomfort was noted in six of 18 and 15 of 24 respectively. Disabling diarrhoea and faecal incontinence developed in two of 14 and five of 20 patients with an anastomosis respectively. Although these results indicate that segmental colonic transit time studies are useful in selecting patients with slow transit constipation for partial left-sided or subtotal colectomy, both procedures should be performed with prudence.
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Fifty patients with aortic prosthetic infection were managed in a period of 10 years from 1983 to 1993. Twenty-five patients had recurrent sepsis after local surgery (group 1) and 22 of these eventually required radical surgery. Twenty-five patients had radical graft excision as the first procedure (group 2). ⋯ The number of amputations was also similar (five in group 1 versus four in group 2). The triad of occlusive disease, aortobifemoral bypass and groin symptoms was associated with eight of nine amputations. While the authors would consider using local techniques if the anastomosis was intact, the graft remained patent and infection appeared to be confined to the groin, this combination is uncommon and radical graft excision remains the preferred treatment.