Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure. A randomized, prospective trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure. Patients diagnosed as having chronic anal fissure were randomly assigned to one of the two treatment arms. In the botulinum toxin group (n = 61), 20 to 30 U (approximately 0.3 U/kg) of type A botulinum toxin (Botox) was injected into the internal anal sphincter. The injection was repeated two months later if complete healing was not accomplished. Patients in the sphincterotomy group (n = 50) underwent lateral internal anal sphincterotomy. The same investigators evaluated the patients on postoperative/postinjection days 7 and 28, and then in a blinded manner at 2, 6, and 12 months. In the botulinum group, single injection resulted in complete healing in 45 of the 61 patients (73.8 percent) at the second month. Of the 16 failures, 6 patients refused further treatment, and 10 were treated with a second injection, which resulted in an overall healing rate of 86.9 percent (53/61) at 6 months. In the sphincterotomy group, the success rate was 82 percent (41/50) at day 28 and 98 percent (49/50) at the second month (P = 0.023 and P < 0.0001, respectively, compared with the botulinum group-single injection). At 6 months, 2 patients in the LIS group developed recurrences, and the healing rate was similar to that of the botulinum group (86.9 96.4 percent; P = 0.212). At 12 months, the success rate of the Botox group fell to 75.4 percent (46/61) with 7 recurrences, whereas it remained stable in the sphincterotomy group (94 percent, P = 0.008). Sphincterotomy was associated with a significantly higher complication rate (8 cases of anal incontinence none in the botulinum toxin group; P < 0.001). Full return to daily activities took significantly less time in the botulinum group (1 14.8 +/- 5.7 days; P < 0.0001). Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy, it occasionally requires a repeat injection, and the healing is slower. The early (two months) and late (one year) healing rates are significantly higher in the sphincterotomy group, the two groups reaching similar healing rates only at six months.

Adhesion formation after peritoneal surgery is a major cause of postoperative bowel obstruction, infertility, and chronic pelvic pain. In this study, we compared the possible individual effects of phosphatidylcholine (PC), Seprafilm II, and tissue plasminogen activator (t-PA) and the combined effects of phosphatidylcholine and t-PA on postoperative adhesion formation in a rat surgical model. A total of 50 Wistar male rats underwent median laparotomy and standardized abrasion of the visceral and parietal peritoneum. phosphatidylcholine, Seprafilm II, and t-PA alone and phosphatidylcholine and t-PA in combination were applied intraperitoneally at the end of the surgical procedure. Seven days after surgery, a relaparotomy was performed for adhesion grading and histopathological examination. A comparison of adhesion stages demonstrated a significant difference between the control group and the study groups (p<0.001). The adhesion grade of the combined treatment group was statistically different from that of the other groups (p<0.05). In the t-PA group and the combined group, six and two rats, respectively, developed hematomas locally on the cecum. PC, t-PA, and Seprafilm II used individually reduced the adhesion grade. The t-PA and phosphatidylcholine combination was most effective in reducing adhesion formation. On the other hand, usage of t-PA alone or in combination may increase risk of bleeding. More detailed studies are needed, and future studies on the efficacy of a material for decreasing adhesion formation should include a comparison of several control materials in the same model.

Laparoscopic cholecystctomy has become the treatment of choice for symptomatic gallstones. The potential risks have dissuaded some surgeons from using the laparoscopic procedure in patients with previous abdominal surgery. Therefore, we aimed to investigate the effect of previous abdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. This study included 600 well-documented patients with gallstones who underwent laparoscopic cholecystctomy at our surgical department between May 2000 and January 2004. The patients were classified into 3 groups: group 1, patients without a history of previous abdominal surgery (n=408); group 2, patients with a history of upper abdominal surgery (n=92); group 3, patients with a history of lower abdominal surgery (n=100). The data were collected and analyzed for open conversion rates, operative times, perioperative and postoperative complications, and hospital stay. Of the 600 study patients, 192 had undergone previous abdominal surgery (92 upper, 100 lower). Conversion rate, hospital stay, and complication rates were similar in each group. Mean operating time was the longest (57±9.8 min) in patients with previous upper abdominal surgery (P0.05). Previous abdominal surgery is not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a prolonged operation time.

Sildenafil may lead an improvement in anastomotic healing of ischemic left colon anastomosis. Thirty-six male Wistar albino rats were randomized into four experimental groups (n=9 in each group). In group 1, a well-perfused left colonic segment was transected, and free ends were anatomosed. In groups 2, 3 and 4 animals underwent a standardized surgical procedure to induce ischemic left colon anastomosis. Group 2 animals received only tap water. In groups 3 and 4 animals received 10mg/kg/body-weight and 20mg/kg/body-weight sildenafil, single dose a day during 4 days, respectively. Rats were sacrificed on day 4 following operation. Anastomotic integrity, intra-peritoneal adhesion scores, anastomotic bursting pressures and tissue hydroxyproline levels were recorded. Histopathological examination of the anastomosis was also performed. There was no statistically significant difference among groups with respect to anastomotic integrity (p=0.142) but ischemia decreased the anastomotic bursting pressure. The mean bursting pressure values were 78.8+/-24.1, 43.3+/-26, 55.1+/-32.4, and 43.3+/-20.4 in groups 1, 2, 3, and 4, respectively. Group 1 had the highest values whereas; there was no statistically significant difference between groups 1 and 3. There was no statistically significant difference among groups 2, 3, and 4 with respect to tissue hydroxyproline levels, adhesion scores and the Chiu scores. The highest inflammatory cell presence in the granulation tissue was detected in group 2, whereas the lowest was detected in group 4 (p=0.0001). The highest fibroblast infiltration in the granulation tissue was detected in group 1 (p=0.045). Our results showed that 10mg/kg sildenafil decreased the adverse effects of ischemia on the healing of ischemic left colon anastomosis. Additional investigations are needed to confirm the effects of phosphodiesterase-5 inhibitors in ischemic colon anastomosis models.

Introduction: 2-octyl-cyanoacrylate may be a good alternative in ischemic colon anastomosis without impairment of tissue perfusion. Methods: Forty male Wistar albino rats were randomized into four experimental groups (n = 10 in each group). In group 1 (control), a well-perfused left colonic segment was transected, and free ends were anastomosed by propylene sutures. In groups 2, 3, and 4, the animals underwent a standardized surgical procedure to induce ischemic left colon anastomosis. In group 2, an end-to-end anastomosis was created using six interrupted 6-0 polypropylene sutures between ischemic edges. In group 3, after approximating the mesenteric and antimesenteric edges of the anastomosis with two 6-0 polypropylene sutures, 2-octyl-cyanoacrylate was applied between the edges. In group 4, anastomosis was created by the same technique as described in group 2, and additionally 2-octyl-cyanoacrylate was applied on suture line. Rats were killed on day 4 following operation. Anastomotic integrity, intraperitoneal adhesion scores, anastomotic bursting pressures, and tissue hydroxyproline levels were recorded. Histopathological examination of the anastomosis was also performed. Results: There were no statistically significant differences among groups with respect to anastomotic integrity (p =.142). The mean bursting pressure values were 81.1 ± 23.83, 43.3 ± 26.06, 15.8 ± 11.3, and 17.6 ± 18.02 in groups 1, 2, 3, and 4, respectively. There were no statistically significant differences among groups 2, 3, and 4 with respect to tissue hydroxyproline levels and bursting pressure levels. The highest adhesion scores were observed in groups 3 and 4. Discussion: 2-octyl cyanoacrylate does not have additional advantages in the healing of experimental ischemic colon anastomosis.