Sphincter‐sparing anal‐fissure surgery: a 1‐year prospective,observational, multicentre study of fissurectomy with anoplasty

Aim Internal sphincterotomy is the standard surgical treatment for chronic anal fissure, but is frequently complicated by anal incontinence. Fissurectomy is proposed as an alternative technique to avoid sphincter injury. We describe 1‐year outcomes of fissurectomy. Method This was a prospective, multicentre, observational study. All patients with planned surgery for chronic anal fissure were included and had fissurectomy. Data were collected before surgery, at healing, and 1 year after fissurectomy. Patient self‐assessed anal symptoms and quality of life (using the 36‐item short‐form health survey [SF‐36] questionnaire). Presurgical and postsurgical variables were compared using the Wilcoxon signed‐rank test for paired samples. Results Two‐hundred and sixty‐four patients were included (median age, 45 years; 52% women). Anoplasty was associated with fissurectomy in 83% of the 257 documented cases. The main complications were urinary retention (n = 3), local infection (n = 4) and faecal impaction (n = 1). Healing was achieved in all patients at a median of 7.5 weeks after surgery. No recurrence occurred. At 1 year, 210 (79%) questionnaires were returned. Median anal pain had dropped from 7.3/10 to 0.1/10 (P < 0.001), anal discomfort had decreased from 5.0/10 to 0.1/10 (P < 0.001) and the Knowles–Eckersley–Scott Symptom constipation score had decreased from 9/45 to 5/45 (P < 0.001). There was a nonsignificant increase in the Wexner anal incontinence score, from 1/20 to 2/20. De‐novo clinically significant anal incontinence (Wexner score > 5) affected 7% of patients at 1 year, but presurgical incontinence had disappeared in 15% of patients. All SF‐36 domains significantly improved. Anoplasty did not impact any result. Conclusion Given its high rate of healing and low rate of de‐novo anal incontinence, fissurectomy with anoplasty is a valuable sphincter‐sparing surgical treatment for chronic anal fissure.     

Anal stenosis: use of an algorithm to provide a tension‐free anoplasty

Background: Anal stenosis is a debilitating condition that often is iatrogenic in cause. Various surgical procedures to manage this problem have been described. The present study evaluates the use of different anoplasty techniques in a series of 11 patients with anal stenosis. To the best of the authors' knowledge, this is the first study to provide a stepwise algorithm for the anoplasty techniques used. Methods: A series of 11 patients were evaluated for presenting symptoms, cause of anal stenosis, type of anoplasty used, complications and post‐operative success in relieving symptoms. All operations were performed by one surgeon in three hospitals, and were followed up by the same surgeon and by a surgical registrar. Results: The most common presenting symptoms were constipation and decreasing calibre of stool. The main causes of anal stenosis were previous surgery, neoplasia and fissure. Transverse closure, Y‐V and diamond advancement flaps were used in an escalating manner to deal with increasing severity of stenosis. All 11 patients had some level of improvement in symptoms post‐operatively. There were no long‐term complications. Conclusion: Anoplasty is a safe and successful option in the treatment of anal stenosis, and this stepwise algorithm takes the guesswork out of choosing the most appropriate procedure for each patient.     

Nerve‐stimulator‐guided pudendal nerve block by pararectal approach

Aim Various techniques have been described for performing a pudendal nerve block (PNB) and have associated problems such as multiple needle injections, the need for special equipment and consumption of time. This study aimed to describe a nerve‐stimulator‐guided PNB using a pararectal approach and to evaluate the safety and the efficacy of that procedure. Method We conducted a prospective study of 53 patients who underwent a PNB from December 2009 to July 2010. With the index finger of the left hand inserted into anus, we guided the nerve stimulator needle along the second finger tip on the ischial spine to the site where the maximal contraction of the external anal sphincter could be felt. Once the position of the needle tip had been confirmed, the desired drug was injected. Of the 53 patients, a cohort of eight underwent manometry before and after the pudendal block. Results A total of 53 patients underwent the nerve‐stimulator‐guided procedure: 13 patients for pudendal neuralgia and the other 40 patients for anorectal disease. The mean maximal resting and squeezing pressures before the block were 55 and 161 mmHg, respectively, compared with 35 and 67 mmHg after the block. The PNB took just minutes to perform, was well tolerated by the patients, and resulted in neither severe complications nor repeated attempts. Conclusion Nerve‐stimulator‐guided PNB using a pararectal approach proved to be easy and safe, with acceptable patient tolerance. In addition, it can be used for a variety of anorectal procedures where relaxation of anal tone is required.     

A contraction response of the internal anal sphincter to Botulinum toxin: does low‐pressure chronic anal fissure have a different pathophysiology?

Aim A subset of low‐pressure fissures is not associated with typical internal anal sphincter hypertonia and may involve a different pathophysiological mechanism. We aimed to assess the manometric response of the internal anal sphincter to botulinum toxin in low‐pressure fissures compared to high‐pressure fissures. Method Twenty five units of botulinum toxin (Botox^TM) were injected directly into the internal anal sphincter. Maximum resting pressure (MRP) and maximum squeeze increment (MSI) were documented at baseline and four weeks after injection. Results Nine (31%) of 29 patients had a low‐pressure fissure. Those with an anterior fissure had a significantly lower median baseline MRP than those with a posterior fissure (66 vs 83 mmHg, P = 0.009). Significantly more patients with low‐pressure fissures developed a contraction or no response (78%vs 30%, difference 48%, 95% CI 14–82%, P = 0.006). Those developing a contraction response had a lower mean baseline MRP than those developing a relaxation response (56 vs 86 mmHg, difference 30 mmHg, 95% CI 17–43%, P < 0.001). Conclusion Botulinum toxin appears to have an atypical contraction effect on the internal anal sphincter in low‐pressure (usually anterior) fissures. This may be accounted for by blockade of acetylcholine released at parasympathetic nerve terminals and the sympathetic ganglion (relaxation). Low pressure fissures may be physiologically different from high‐pressure fissures.     

The efficacy of anal fistula plug in fistula‐in‐ano: a systematic review

Aims To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula‐in‐ano especially the complex fistulas. Method The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995–2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula‐in‐ano. Results A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow‐up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula‐in‐ano in prospective studies (8/12 studies), the success rate was 35–87%. The success rate in patients with Crohn’s disease was 29–86%. The success rate in the patients with single tracts was 44–93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4–29% (11/108) and the plug extrusion rate was 4–41% (42/232–19%). Conclusion Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula‐in‐ano, there was a moderate success rate of 35–87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.     

Long‐term outcome of the use of botulinum toxin injection for functional anal pain

Aim Anal pain may occur in the absence of demonstrable anal pathology. Spasm of the sphincter muscles has been suggested as a cause in some patients. We aimed to assess the effectiveness of injection of botulinum toxin in treating this condition. Method Patients who had injection of botulinum toxin over a 3‐year period were identified retrospectively. Patients were excluded if anal fissure or other organic pathology was found to account for their symptoms on examination under anaesthetic. Long‐term outcome was assessed at a minimum 3‐year post‐procedure telephone follow up. Results Fourteen (eight male) patients were identified, of median age 50 years. Botulinum toxin (20–200 u) was injected into the internal sphincter. Seven of the 14 patients reported significant improvement in symptoms at 3 months. Seven were available for a structured telephone review at a median of 59 (42–68) months. The four patients who had benefited from the injection had remained asymptomatic. Conclusion Injection of botulinum toxin into the internal anal sphincter has a role in alleviating symptoms in a small proportion of patients with functional anal pain.     

Three‐dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

Aim Anal sphincter anatomy on two‐dimensional endoanal ‐ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three‐dimensional (3D) measurements yield a better correlation. Method The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2‐year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF‐FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. Results Sixty‐one patients of median age 53 years (range 15–82) were evaluated. Thirty‐two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF‐FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact‐sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF‐FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. Conclusion Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.     

Mucosectomy and stapled pouch‐anal anastomosis in familial adenomatous polyposis

Aim In familial adenomatous polyposis, a restorative proctocolectomy with an ileo‐anal pouch may be performed either with a mucosectomy and a hand‐sewn anastomosis or as a stapled anastomosis without a mucosectomy. The disadvantage of the former is suboptimal bowel function and the disadvantage of the latter is a high risk of recurrent adenomas in the rectal mucosal remnant. Method A procedure is presented that combines the advantages of mucosectomy and stapled ileo‐anal anastomosis. Results No severe complications were seen in 14 patients. After a median follow up of 29 (range 7–144) months, 13 (93%) patients were fully continent day and night with a median frequency of defecation of 5 (range 2–8)/24 h. No adenomas were found at the annual endoscopic follow up. Conclusion Mucosectomy with a stapled ileo‐anal pouch has few complications. Short‐term results show good function and a very low risk of recurrent adenoma development.     

Is routine pouchogram prior to ileostomy closure in colonic J‐pouch really necessary?

Introduction Colonic J‐pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch‐anal anastomosis. Methods All patients who underwent a colonic J pouch‐anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. Results Eighty‐four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch‐vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch‐vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch‐vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch‐vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. Conclusion Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J‐pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.     

Double stapled ileal pouch anal anastomosis (DS‐IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow‐up biopsy?

Purpose This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double‐stapled ileal pouch‐anal anastomosis (DS‐IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. Methods The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow‐up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. Results Median age at surgery was 43 (range 15–71) years and duration of MUC was 9.6 (range 0.3–42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0–2.5) cm cephalad to the dentate line and biopsy follow‐up was undertaken at median 34 (range 2–110) months after DS‐IPAA. The distal donuts were analysed in all cases, as were 305 follow‐up biopsies (median 3.4; range 1–7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow‐up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow‐up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS‐IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. Conclusion The correlation between CE in the circular stapler donut and at follow‐up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS‐IPAA, periodic follow‐up biopsy should be obtained.     

Gender of the patient may influence perioperative and long‐term complications after restorative proctocolectomy

Aim Gender‐related differences in preoperative characteristics and early and long‐term outcome for patients undergoing ileal pouch anal anastomosis (IPAA) have not previously been well studied. Method All male and female patients undergoing IPAA at a single centre between 1983 and 2008 were compared for perioperative variables and long‐term outcome. Statistical tests were used as appropriate. A multivariate analysis was performed to evaluate the effects of gender on pouch failure. Results Female patients (n = 1495) were younger than male patients (n = 1912) (P < 0.001). Surgery type and pouch configuration were similar, although male gender was associated with a higher use of ileostomy (P < 0.001) and a higher incidence of 30‐day anastomotic separation (P = 0.001). During a median follow up of 9.9 (female) and 9.3 (male) years, female patients were more likely to develop bowel obstruction (20.8 vs 16.7%, P = 0.02) and pouch‐related fistula (10.9 vs 7.6%, P = 0.001). Women had a higher number of daily bowel movements than men (P = 0.001), and more frequently had urgency (P = 0.001), daily seepage (P = 0.01) and pad use (P < 0.001). A higher percentage of female patients reported dietary (P < 0.001) and work (P = 0.022) restrictions and lower mental component of the Short‐Form 36 quality of life score (P = 0.018). On multivariate analysis of perioperative variables, female gender was associated with pouch failure (P = 0.05). Conclusion The gender of the patient seems to be associated with specific differences in preoperative variables and postoperative outcomes for patients undergoing IPAA.     

The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra‐anal rectal intussusception

Aim Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra‐anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients. Method Forty consecutive patients with incontinence and intra‐anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded. Results The mean CCI scores were 13.2 (=/?4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as ‘cured’ in 26 (65%), ‘improved’ in 13 (32.5%) and ‘unchanged’ in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow‐up of 38 months. Conclusion Intra‐anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.     

Seton or glue for trans‐sphincteric anal fistulae: a prospective randomized crossover clinical trial

Objective Fibrin glue treatment of anal fistulae has been proposed to minimize the risk of faecal incontinence but its acceptance by coloproctologists is still poor because the published data is controversial. Therefore, we carried out a prospective randomized crossover trial comparing treatment with a commercial fibrin glue to classical seton treatment, with healing rate, hospital stay, healing time, faecal incontinence and postoperative pain as study outcomes. Method Sixty‐four homogeneous patients with trans‐sphincteric anal fistulae referred to seven colorectal units were randomized to undergo fibrin glue (39 patients) or seton (25 patients) treatment. Patients failing to heal after treatment with fibrin glue were re‐randomized to undergo a second injection with glue or seton treatment. Results Sixty‐two of the 64 patients completed the minimum 1‐year follow‐up period. Twenty‐one of 24 patients healed in the seton group compared with 15/38 in the fibrin glue group (P = 0.0007). The 23 failures after glue treatment were re‐randomized to have a second glue injection (eight patients) or a seton treatment (15 patients). Four of the eight (50%) patients treated with a second injection of glue, and nine out of the 15 (60%) patients in the seton group, healed. Patients treated with fibrin glue reported less postoperative pain and had a shorter hospital stay than patients treated with a seton; furthermore, faecal continence and anal manometry significantly worsened after seton treatment. Conclusion Seton treatment has a significantly higher probability of success compared with fibrin glue treatment but poses a higher risk of faecal incontinence. Fibrin glue could be considered as a first line of treatment for patients at risk of faecal incontinence or other comorbidities.     

Long‐term anal continence and quality of life following postpartum anal sphincter injury

Objective Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long‐term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3). Method In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound. Results Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3. Conclusion Our study indicates that long‐term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).     

Does the incidence of unexpected malignancy in ‘benign’ rectal neoplasms undergoing trans‐anal endoscopic microsurgery vary according to lesion morphology?

Aim Mucosectomy by trans‐anal endoscopic microsurgery (TEMS) allows safe and effective excision of benign rectal lesions. Preoperative endoscopic, clinical and ultrasonographic assessment aims to select benign lesions whilst avoiding inappropriate mucosectomy in lesions with malignancy. This study examines the relationship between lesion morphology and accurate benign preoperative classification of rectal lesions undergoing TEMS. Method Primary lesions preoperatively assessed as benign were identified from a prospective TEMS database. Operative specimen morphology was independently classified by two blinded investigators, using photographs, into flat‐sessile, exophytic or mixed morphology. The accuracy of the preoperative assessment by rectal ultrasonography was compared with the results of histological examination of the excised specimen (χ² and Fisher’s exact tests). Results Of 167 lesions with adequate data, the morphological classification showed 60 flat‐sessile, 56 mixed morphology and 51 exophytic tumours, of which 5, 7 and 9, respectively, contained unexpected malignancy (P = 0.48). Accurate preoperative assessment of a lesion as benign occurred in 89% of flat‐sessile and mixed morphology (n = 55 and 49, respectively) and in 70% of exophytic lesions (n = 36) (P = 0.01). Only the exophytic group contained patients in whom preoperative endoscopic and ultrasonographic staging could not be confidently made (uTx). Histology demonstrated six of the seven uTx cases to be benign. Conclusion In this study exophytic polyps were less likely to be accurately classified as benign using preoperative ultrasonography/endoscopy when compared with flat‐sessile or mixed morphology polyps.     

Laparoscopic restorative proctocolectomy: a 10‐year experience of an evolving technique

Aim Restorative proctocolectomy is the definitive procedure for ulcerative colitis. The potential benefits of a minimal invasive approach make it appropriate to consider this approach provided that there are no adverse effects. The aim of the present study was to report our experience of laparoscopic assisted and ‘total’ laparoscopic restorative proctocolectomy (LRPC) and to highlight the difficulties encountered and the functional results obtained. Method Electronic data were prospectively collected from all patients who underwent laparoscopic restorative proctocolectomy (LRPC) from October 1999 to April 2010. Results Seventy‐two (40 male) patients [median body mass index 24 (19–48) kg/m²] underwent LRPC over 10 years. Three had cancer. Forty‐two had undergone a previous colectomy (laparoscopic in 38). There were 40 W‐ and 32 J‐pouch reconstructions; seven were single‐port procedures. The median operation time was 210 (75–330) min. There were five (7%) conversions, one of which resulted in immediate pouch failure. The median time to full diet was 36 (4–168) h, with a median hospital stay of 7 (2–64) days. There were seven (10%) readmissions. Complications were immediate (3%), early (22%) and long term (11%). The incidence of failure (excision or indefinite diversion) was 2.7%. The stoma has been closed in 67 patients. Median frequency of defaecation was 4/24 h, with normal continence in 90% and the ability to defer during the day in 98%. There was no new case of impotence or dyspareunia. Conclusion Laparoscopic restorative proctocolectomy is safe and gives good results when performed by an experienced laparoscopic surgeon.     

Botulinum toxin vs glyceryltrinitrate for the medical management of chronic anal fissure: a meta‐analysis

Objective The objective of this review was to analyse systematically the prospective randomized controlled trials on the effectiveness of botulinum toxin (BTX) and glyceryltrinitrate (GTN) for the pharmacological management of chronic anal fissure (CAF). Method A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of BTX and GTN for the management of CAF were selected according to specific criteria and analysed to generate summative data. Results Six studies encompassing 355 patients with CAF were retrieved from electronic databases. Only three randomized controlled trials on 180 patients qualified for the meta‐analysis according to inclusion criteria. There were 90 patients in BTX and 90 in the GTN group. BTX and GTN were equally effective in healing/improving the CAF. There was no statistically significant difference between the two pharmacotherapies [RR 1.29 (0.98–1.70) 95% CI, z = ?1.83, P = 1.93, Fig. 1 ]. However, there was statistically significant heterogeneity among the trials (Q = 4.03, df = 1, P = 0.042). On fixed effect model, GTN was associated with higher incidence of total side effects [fixed effect model RR 0.14 (0.05–0.40) 95% CI, z = ?3.71, P = 0.0002] and headache [RR 0.07 (0.02–0.20) 95% CI, z = ?5.05, P = 0.0007] among patients of CAF.

Figure 1 Open in figure viewer PowerPoint Healing.     

Colorectal complications of end‐stage renal failure and renal transplantation: a review

Aim End‐stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications. Method A review of the literature was performed to assess the prevalence and outcome in both benign and malignant colorectal disease. Results No prospective randomized studies assessing colorectal complications in ESRF or renal transplant were identified. Case series and case reports have described the incidence and management of benign colorectal complications. Complications included diverticulitis, infective colitis, colonic bleeding and colonic perforation. There was insufficient evidence to associate diverticular disease with adult polycystic kidney disease. Three population‐based studies have shown up to a twofold increased incidence of colonic cancer but not rectal cancer for renal transplant recipients. Bowel cancer screening (as per the general population) by faecal occult blood testing appears justified for renal transplant patients; however, evidence suggests that consideration of starting screening at a younger age may be worthwhile because of an increased risk of developing colonic cancer. Two population‐based studies have shown a threefold and 10‐fold increased incidence of anal cancer for renal transplant recipients. A single case–control study demonstrated significant increased prevalence of anal human papillomavirus (HPV) and intraepithelial neoplasia (AIN) in patients with established renal transplants. Conclusions Despite the lack of high‐level evidence, ESRF and renal transplantation were associated with colorectal complications that could result in major morbidity and mortality. Bowel cancer screening in this patient group appears justified. The effectiveness of screening for HPV, AIN and anal cancer in renal transplant recipients remains unclear.