Clinical Outcome of 0.2% Glyceryl Trinitrate Topical Ointment Compared to Lateral Internal Sphincterotomy in the Treatment of Patient with Chronic Anal Fissure: A Randomized Control Trial.

The objective of study was to evaluate the clinical outcome of topical 0.2% Glyceryl trinitrate topical (GTN) ointment in the treatment of chronic anal fissure. This randomized control trial was carried out in the Colorectal Surgery Unit, Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from May 2015 to April 2016. Total 94 patients were included in this trial, where 47(50.0%) patients were treated by 0.2% GTN ointment as Trial group 12 hourly for 8 weeks and 47(50.0%) patients by lateral internal sphincterotomy (LIS) as Control group in this study. Patients were randomized in two groups by lottery following purposive sampling. Post-procedural outcome variables with 6 months follow up were evaluated. Majority of the patients were found in between 20 to 40 years of age in both groups. The mean age was 34.6±10.4 years and 33.2±8.6 years in GTN and LIS respectively. Overall male female ratio was 0.88:1. All (100.0%) patients presented with pain in anus and 86.15% patients presented with per rectal bleeding. Pain relief in GTN arm versus LIS arm in 2nd and 6th week was 55.31% vs. 76.6%, 74.5% vs. 87.23% with no significant difference between two groups. But at 6 month it was 57.44% vs. 93.6% respectively. The fall in pain relief at 6th month in GTN arm was due to recurrence of fissure. At the end of 2nd, 6th week and 6month, cessation of bleeding improved gradually in both groups after treatment but the improvement was significantly better in LIS group than in GTN group indicating sphincterotomy stops bleeding better. Healing after 2nd week in both groups was minimum but equal 2(4.26%) patients. After 6 weeks LIS group had significant better healing than GTN 40(85.1%) versus 26(55.3%) with p value <0.001. In 6 month time GTN group had increased healing but LIS group had significant better healing than GTN group 42(89.36) vs. 32(68.08) with p value 0.004. Transient flatus and liquid incontinence were 8.51% and 6.4% respectively in LIS group with 0.0% in GTN group. Headache and recurrence were significantly higher in GTN group 61.7% and 34.04% with p<0.001. Lateral internal anal sphincterotomy is superior to the topical application of 0.2% nitroglycerin ointment in the treatment of chronic anal fissure with the advantages of good symptomatic relief, high rate of healing and a very low rate of transient continence disturbances.

Evaluation of Short Term Outcome of Stapled Transanal Rectal Resection (STARR) for ODS (Obstructed Defecation Syndrome) by Comparing Pre and Post-operative ODS Score.

Obstructed defecation syndrome (ODS) is a common anorectal problem and it can be corrected by various surgical approaches but most of these have high recurrence and complication rates. Antonio Longo introduced Stapled transanal rectal resection (STARR) in 2003 as a minimally invasive transanal operation for correction ODS associated with rectocele and or rectal intussusception. This study was designed to assess the short term outcome of Stapled Transanal Rectal Resection (STARR) as a surgical treatment of Obstructed Defecation Syndrome (ODS). This is a quasi experimental study which was carried out in the department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from May 2016 to June 2017. Seventeen (17) patients were included in the study. Patients with obstructed defecation syndrome and rectocele and or rectal intussusception admitted in the department of Colorectal Surgery were enrolled in the study as per inclusion and exclusion criteria. History, clinical examination, Proctoscopy, Colonoscopy and MR Defecography was done for evaluation of the patients. During evaluation preoperative Longo's ODS score of every patient also determined and compared with postoperative ODS score. The patient was followed up regularly at one, three and six months after each operation. The ODS score in 82.35% patients improved significantly. The postoperative score was high (13-15) only in 02(11.8%) patients probably due to presence of physiological factors. Post-operative defecatory urgency was developed in only 02(11.76%) patients. Major postoperative complication like hemorrhage or rectovaginal fistula did not develop in any patient. STARR is an effective, less invasive and simple procedure for the treatment of ODS with rectocele and/or rectal intussusception without major morbidity but other physiological causes of ODS should exclude preoperatively because its presence makes the surgical intervention fruitless.

The Role of Histological Assessment of Distal Doughnut in Low Anterior Resection for Low Rectal Cancer.

Anterior resection (AR), especially low anterior resection (LAR), for low rectal cancer and colorectal anastomosis is a technical challenge to surgeons. But by using circular stapling devices now it is possible make more LARs technically feasible. A stapled end-to-end colorectal anastomosis is increasingly adopted following a low anterior resection for low rectal cancer. This descriptive cross-sectional study was carried out in the department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from December 2015 to December 2016. The ensuing doughnuts created from the stapling device are routinely sent for histological analysis. However, its efficacy remains debatable. This study aims to determine the role of sending distal doughnut for histological examination following a stapled end-to-end colorectal anastomosis done in low anterior resection for low rectal cancers.

Correlation of the Serum Level of Carcinoembryonic Antigen and Prolactin with Different Stages of Colorectal Carcinoma According to Dukes' Staging.

Carcinoembryonic antigen (CEA) is well established tumor marker for colorectal cancers worldwide. Recent studies show that serum prolactin level is also raised in colorectal cancers. The purpose of the study is to evaluate the correlation of serum CEA and Prolactin with Dukes' staging of colorectal carcinomas. Between January 2013 and June 2013, Serum CEA and Serum Prolactin were measured by radioimmunoassay from 103 patients who were histopathologically diagnosed as colorectal carcinomas. Evaluation of the stages of the colorectal cancers was done on the basis of preoperative investigations and postoperative histopathology and correlated with Preoperative Serum CEA and Serum Prolactin. Results were presented as median value, range and percentage. Male to female ratio was 1.4:1 with median age of 42.26 years (range 17-78 years). Most of the patients in this series presented with carcinoma rectum (42%). Most of the patients (52%) were found in Dukes' stage C and 27% and 15% cases were found as Dukes' stage B and Dukes' stage D respectively. Stage of the disease is directly proportionate to percentage of the patient with high serum prolactin except early stage (Dukes' A-50%, Dukes' B-28.6%, Dukes' C-33.3% & Dukes' D-46.7%). Similarly serum CEA level is directly proportionate to tumor stage (Dukes' A-0%, Dukes' B-32%, Dukes' C-40.7% & Dukes' D-74.7%). A preoperative high serum CEA value suggests advanced disease either locally or with distant metastasis. In contrast preoperative high serum prolactin (hyperprolactinaemia) did not suggest advanced disease as it can be elevated even in early stage of disease. Serum CEA and Serum Prolactin both are valuable tumor markers but serum CEA could not be replaced by serum Prolactin. Serum Prolactin may be a helpful marker in earlier stages of the colorectal cancer.

Total proctocolectomy with ileal pouch-anal anastomosis by stapling technique.

An ileal pouch-anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis coli. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch. The aim of this study was to assess the outcome of ileal pouch-anal anastomosis by stapling technique after total proctocolectomy. This prospective observational study of six patients who underwent proctocolectomy followed by an ileal pouch-anal anastomosis by stapling technique. Whole colon and rectum was mobilized and resected; J pouch created by GIA device and pouch-anal anastomosis done by staplers. All patients were continent. Patients with familial adenomatous polyposis (FAP) and ulcerative colitis showed excellent outcome regarding their disease after proctocolectomy. The ileal pouch-anal anastomosis has become a feasible alternative to the conventional permanent ileostomy after total proctocolectomy. Satisfactory results have been reported, although the procedure is associated with considerable morbidity. Excision of all the affected mucosa is an essential part of the procedure. Our experience with the ileal pouch-anal anastomosis using stapling devices without mucosectomy.

Results of emergency appendectomy for appendicular mass.

Emergency appendectomy was done on 1142 patients during the period of July 1990 to January 2003 to evaluate the results. Of which 656(57.44%) were male and 496(42.56%) were female. The mean age was 22.21+/-3.93 years (04-85 years). The duration of pain before admission was 3.05+/-0.94 days (01-17 days) and 708(62%) patients presented with palpable mass; ultrasonogram revealed additional lump in 114(9.98%) patients, rest of the lump (28.02%) was detected during operation. 342(30%) patients had appendix abscess and 228(19.96%) had loculated collection. Eight patients had tuberculosis and four had carcinoma in addition. All had appendicitis except two of which one patient had carcinoid tumor and one had enteric fever perforation. Operative time ranged from 15-85 minutes (29.38+/-3.19 minutes). The average hospital stay was 4.22+/-0.82 days (03-17 days). There was no failure, faecal fistula or death. The overall wound related complication was 22.86% of which 14.62% was very minor and overall intra abdominal complication was 4.12%. Persistent wound pain was in 43(3.87%) and hypertrophied scar was found in 05 (0.45%) patients. 05(0.45%) patients needed exploration for persistent sinus one of which was tuberculosis and remaining was due to suture material. Remote complications like RTI, UTI, and DVT was found in 04(0.35%) patients. There was no death, no faecal fistula and no failure. It seems that emergency appendectomy could safely be done in appendix mass without any increased risk of mortality and morbidity.

Continuous-flow fluoro-immunosensor for paclitaxel measurement.

A fluorescence-based continuous-flow immunosensor for sensitive, precise, accurate and fast determination of paclitaxel was developed. The sensor utilizes anti-paclitaxel antibody immobilized through its Fc region and crosslinked by dimethylpimelimidate to protein A attached covalently onto the silanized inner walls of a glass capillary column followed by saturation of the paclitaxel-binding sites with rhodamine-labeled paclitaxel. The assay is based on the displacement and detection downstream of the rhodamine-labeled paclitaxel, by a flow-through spectrofluorometer, as a result of the competition with paclitaxel introduced as a pulse into the stream of carrier buffer flowing through the system. The peak height of the fluorescence intensity profile of the displaced rhodamine-labeled paclitaxel was directly proportional to the concentration of paclitaxel applied and was a function of the carrier buffer flow rate. The sensitivity of the immunosensor response ranged from 0.31 relative fluorescence units (RFU)/ng/ml at a flow rate 0.1 ml/min to 0.52 RFU/ng/ml at 1 ml/min, while the lower detection limit ranged from 1 ng/ml at 0.1 ml/min to 4 ng/ml at 1 ml/min. The immunosensor response was very reproducible (RSD=4.8%; n=10) and linear up to 100 ng/ml. The assay time ranged from 2 min at 1 ml/min to 8 min at 0.1 ml/min. A technique developed to resaturate the antigen binding sites of the immobilized antibody with rhodamine-labeled paclitaxel was successful in regenerating the capillary column without affecting its performance, thus enhancing the economic viability of the immunosensor. The immunosensor was successfully applied for the determination of paclitaxel in human plasma.