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Perioperative Topical Nitrate and Sphincter Function in Patients Undergoing Transanal Stapled Anastomosis: A Randomized, Placebo-Controlled, Double-Blinded Trial

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Diseases of the Colon & Rectum

PURPOSE

The use of transanal stapling devices may impair continence because of digital dilatation and/or instrumentation. This study assessed the effect of pharmacological dilatation of the sphincter prior to stapler insertion.

METHODS

A randomized, placebo-controlled, double-blinded study of 60 patients undergoing transanal stapled anastomosis was undertaken. Consenting patients were randomly assigned to receive a single intraoperative dose of topical 0.2 percent nitroglycerin (glyceryl trinitrate) ointment or nitroglycerin-free placebo. All patients were assessed preoperatively and postoperatively by clinical methods (Wexner incontinence scores and examination), anorectal manometry by a station pull-through technique, and endoanal ultrasonography.

RESULTS

Intraoperative mean (±SEM) resting pressures (mmHg) were significantly reduced by nitroglycerin compared with prenitroglycerin levels (9.9 ± 0.9 vs. 50.5 ± 2.7; P = 0.002) or controls (56.0 ± 3.2; P = 0.001). Twenty-one of the 28 controls (75 percent) but only 4 of the 32 patients in the nitroglycerin group (12.5 percent) required digital dilatation to insert the stapling instrument (P = 0.003). Squeeze pressures were unaltered by the intervention but mean resting pressures were higher in the nitroglycerin group postoperatively (52.9 ± 3.2 − 31.6 ± 1.3 = 21.3 mmHg; 95 percent confidence interval, 14–27). Incontinence scores were lower in the nitroglycerin group at the 3-month (1.1 ± 0.2 vs. 4.6 ± 0.3; P = 0.003) and 12-month (0.9 ± 0.1 vs. 4.4 ± 0.3; P = 0.002) clinic visits.

CONCLUSION

Preoperative nitroglycerin dilatation protects sphincter function in patients undergoing transanal stapled anastomoses.

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REFERENCES

  1. WO Kirwan (1981) ArticleTitleIntegrity of low colorectal EEA stapled anastomosis Br J Surg 68 539–40

    Google Scholar 

  2. WO Kirwan MG O’Riordain R Waldron (1989) ArticleTitleDeclining indications for abdominoperineal resection Br J Surg 76 1061–3

    Google Scholar 

  3. HM MacRae RS McLeod (1998) ArticleTitleHandsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis Dis Colon Rectum 41 180–9

    Google Scholar 

  4. NS Williams R Price D Johnston (1980) ArticleTitleThe long-term effect of sphincter preserving operations for rectal carcinoma on function of the anal sphincter in man Br J Surg 67 203–8

    Google Scholar 

  5. PG Horgan PR O’Connell CA Shinkwin WO Kirwan (1989) ArticleTitleEffect of anterior resection on anal sphincter function Br J Surg 76 783–6

    Google Scholar 

  6. G Batignani I Monaci F Ficari F Tonelli (1991) ArticleTitleWhat affects continence after anterior resection of the rectum? Dis Colon Rectum 34 329–35

    Google Scholar 

  7. RG Molloy KT Moran J Coulter R Waldron WO Kirwan (1992) ArticleTitleMechanism of sphincter impairment following low anterior resection Dis Colon Rectum 35 462–4

    Google Scholar 

  8. MG O’Riordain RG Molloy P Gillen A Horgan WO Kirwan (1992) ArticleTitleRectoanal inhibitory reflex following low stapled anterior resection of the rectum Dis Colon Rectum 35 874–8

    Google Scholar 

  9. T Hallgren S Fasth D Delbro S Nordgren T Öresland L Hultén (1993) ArticleTitlePossible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy Br J Surg 80 631–5

    Google Scholar 

  10. WG Lewis IG Martin ME Williamson et al. (1995) ArticleTitleWhy do some patients experience poor functional results after anterior resection of the rectum for carcinoma? Dis Colon Rectum 38 259–63

    Google Scholar 

  11. S Snooks MM Henry M Swash (1984) ArticleTitleFaecal incontinence after anal dilatation Br J Surg 71 617–8

    Google Scholar 

  12. CT Speakman SJ Burnett MA Kamm CI Bartram (1991) ArticleTitleSphincter injury after anal dilatation demonstrated by anal endosonography Br J Surg 78 1429–30

    Google Scholar 

  13. MB Nielsen OØ Rasmussen JF Pedersen J Christiansen (1993) ArticleTitleRisk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic study Dis Colon Rectum 36 677–80

    Google Scholar 

  14. JM Gattuso MA Kamm SM Halligan CI Bartram (1996) ArticleTitleThe anal sphincter in idiopathic megarectum: effects of manual disimpaction under general anesthetic Dis Colon Rectum 39 435–9

    Google Scholar 

  15. PR O’Connell SJ Stryker AM Metcalf JH Pemberton KA Kelly (1988) ArticleTitleAnal canal pressure and motility after ileoanal anastomosis Surg Gynaecol Obstet 166 47–54

    Google Scholar 

  16. JH Pemberton KA Kelly RW Beart RR Dozois BG Wolff DM Ilstrup (1987) ArticleTitleIleal pouch-anal anastomosis for chronic ulcerative colitis: long-term results Ann Surg 206 504–13

    Google Scholar 

  17. YH Ho M Ang D Nyam M Tan F Seow-Choen (1998) ArticleTitleTransanal approach to rectocoele repair may compromise anal sphincter pressures Dis Colon Rectum 41 354–8

    Google Scholar 

  18. WO Kirwan RB Turnbull VW Fazio FL Weakley (1978) ArticleTitlePull-through operation with delayed anastomosis for rectal cancer Br J Surg 65 695–9

    Google Scholar 

  19. F Cavaliere JH Pemberton M Cosimelli VW Fazio RW Beart SuffixJr (1995) ArticleTitleColoanal anastomosis for rectal cancer: long-term results at the Mayo and Cleveland Clinics Dis Colon Rectum 38 807–12

    Google Scholar 

  20. R Farouk GS Duthie PW Lee JR Monson (1998) ArticleTitleEndosonographic evidence of injury to the internal anal sphincter after low anterior resection: long-term follow-up Dis Colon Rectum 41 888–91

    Google Scholar 

  21. YH Ho M Tan A Leong KW Eu D Nyam F Seow-Choen (1999) ArticleTitleAnal pressures impaired by stapler insertion during colorectal anastomosis: a randomized, controlled trial Dis Colon Rectum 42 89–95

    Google Scholar 

  22. YH Ho C Tsang CL Tang D Nyam KW Eu F Seow-Choen (2000) ArticleTitleAnal sphincter injuries from stapling instruments introduced transanally: randomized, controlled study with endoanal ultrasound and anorectal manometry Dis Colon Rectum 43 169–73

    Google Scholar 

  23. BJ Nothmann MM Schuster (1974) ArticleTitleInternal anal sphincter derangements with anal fissures Gastroenterology 67 216–20

    Google Scholar 

  24. MJ McNamara JP Percy IR Fielding (1990) ArticleTitleA manometric study of anal fissure treated by subcutaneous lateral internal sphincterotomy Ann Surg 211 235–8

    Google Scholar 

  25. WR Schouten TJ Van vroonhoven (1986) ArticleTitleLateral internal sphincterotomy in the treatment of hemorrhoids: a clinical and manometric study Dis Colon Rectum 29 869–72

    Google Scholar 

  26. Rosen, L, Abel, ME; The Standards Task Force, The American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissure. Dis Colon Rectum 1992;35:206–8.

  27. JN Lund JH Schofield (1996) ArticleTitleAetiology and treatment of anal fissure Br J Surg 83 1335–44

    Google Scholar 

  28. JN Lund JH Schofield (1997) ArticleTitleA randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure Lancet 349 11–4

    Google Scholar 

  29. RD Madoff (1998) ArticleTitlePharmacologic therapy for anal fissure N Engl J Med 338 257–9

    Google Scholar 

  30. EA Carapeti MA Kamm PJ McDonald SJ Chadwick D Melville RK Phillips (1999) ArticleTitleRandomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Gut 44 727–30

    Google Scholar 

  31. CS Richard R Gregoire EA Plewes et al. (2000) ArticleTitleInternal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group Dis Colon Rectum 43 1048–58

    Google Scholar 

  32. DF Altomare M Rinaldi G Milito et al. (2000) ArticleTitleGlyceryl trinitrate for chronic anal fissure—healing or headache? Results of a multicenter, randomized, placebo-controlled, double-blind trial Dis Colon Rectum 43 174–81

    Google Scholar 

  33. J Evans A Luck P Hewett (2001) ArticleTitleGlyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial Dis Colon Rectum 44 93–7

    Google Scholar 

  34. T O’Kelly A Brading N Mortensen (1993) ArticleTitleNerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide Gut 34 689–93

    Google Scholar 

  35. WR Schouten JW Briel MO Boerma JJA Auwerda EB Wilms BH Graatsma (1996) ArticleTitlePathophysiological aspects and clinical outcome of intra-anal application of isosorbide dinitrate in patients with chronic anal fissure Gut 39 465–9

    Google Scholar 

  36. SM Sentovich GJ Blatchford LJ Rivela K Lin AG Thorson MA Christensen (1997) ArticleTitleDiagnosing anal sphincter injury with transanal ultrasound and manometry Dis Colon Rectum 40 1430–4

    Google Scholar 

  37. SJ Lee YS Park (1998) ArticleTitleSerial evaluation of anorectal function following low anterior resection of the rectum Int J Colorectal Dis 13 241–6

    Google Scholar 

  38. M Jonas KR Neal JF Abercrombie JH Scholefield (2001) ArticleTitleA randomized trial of oral vs. topical diltiazem for chronic anal fissures Dis Colon Rectum 44 1074–8

    Google Scholar 

  39. Y Dun YB Hao YX Wu Y Zhang RR Zhao (2001) ArticleTitleProtective effects of nitroglycerin-induced preconditioning mediated by calcitonin gene-related peptide in rat small intestine Eur J Pharmacol 430 317–24

    Google Scholar 

  40. BI Jugdutt MI Khan (1994) ArticleTitleEffect of prolonged nitrate therapy on left ventricular remodeling after canine acute myocardial infarction Circulation 89 2297–307

    Google Scholar 

  41. T Brzozowski SJ Konturek D Drozdowicz A Dembinski J Stachura (1995) ArticleTitleHealing of chronic gastric ulcerations by L-arginine. Role of nitric oxide, prostaglandins, gastrin and polyamines Digestion 56 463–71

    Google Scholar 

  42. SN Elliott W McKnight G Cirino JL Wallace (1995) ArticleTitleA nitric oxide-releasing nonsteroidal anti-inflammatory drug accelerates gastric ulcer healing in rats Gastroenterology 109 524–30

    Google Scholar 

  43. T Brzozowski PC Konturek Z Sliwowski D Drozdowicz EG Hahn SJ Konturek (1997) ArticleTitleImportance of nitric oxide and capsaicin-sensitive afferent nerves in healing of stress lesions induced by epidermal growth factor J Clin Gastroenterol 25 S28–38

    Google Scholar 

  44. RA Lehman RB Page GC Saggers EK Manders (1985) ArticleTitleTechnical note: the use of nitroglycerin ointment after precarious neurosurgical wound closure Neurosurgery 16 701–2

    Google Scholar 

  45. M Romanelli MH Katz AF Alvarez WH Eaglstein V Falanga (1991) ArticleTitleThe effect of topical nitroglycerin on transcutaneous oxygen Br J Dermatol 124 354–7

    Google Scholar 

  46. SA Ray TM Buckenham AM Belli RS Taylor JA Dormandy (1997) ArticleTitleThe nature and importance of changes in toe-brachial pressure indices following percutaneous transluminal angioplasty for leg ischaemia Eur J Vasc Endovasc Surg 14 125–33

    Google Scholar 

  47. JP Heggers H Elzaim R Garfield et al. (1997) ArticleTitleEffect of the combination of Aloe vera, nitroglycerin, and L-NAME on wound healing in the rat excisional model J Altern Complement Med 3 149–53

    Google Scholar 

  48. DA Khoury FG Opelka (1995) ArticleTitleAnoscopic-assisted insertion of end-to-end anastomosing staplers Dis Colon Rectum 38 553–4

    Google Scholar 

  49. Y-H Ho F Seow-Choen C Tsang K-W Eu (2001) ArticleTitleRandomised trial assessing anal sphincter injuries after stapled haemorrhoidectomy Br J Surg 88 1449–55

    Google Scholar 

  50. DF Altomare M Rinaldi PL Sallustio P Martino M Fazio ParticleDe V Memeo (2001) ArticleTitleLong-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity Br J Surg 88 1487–91

    Google Scholar 

  51. AJ Pilarsky JJ Singh SD Wexner (2000) ArticleTitleIntroducing the circular stapling device atraumatically with the use of a second anvil Colorectal Dis 2 176–7

    Google Scholar 

  52. DC Hoffmann JF Young JL Sweeney RA Hunter JW Moore (1996) ArticleTitleA modification of single stapled colorectal anastomosis using the transanal insertion device ANZ J Surg 66 768–9

    Google Scholar 

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Authors and Affiliations

  1. Academic Department of Surgery, National University of Ireland (Cork), Cork University Hospital, Wilton, Ireland

    D. C. Winter M.D., A. Murphy R.G.N., M. R. Kell M.D., C. J. Shields M.D., H. P. Redmond M.Ch. & W. O. Kirwan M.Ch.

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  1. D. C. Winter M.D.
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  2. A. Murphy R.G.N.
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Correspondence to D. C. Winter M.D..

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Winter, D., Murphy, A., Kell, M. et al. Perioperative Topical Nitrate and Sphincter Function in Patients Undergoing Transanal Stapled Anastomosis: A Randomized, Placebo-Controlled, Double-Blinded Trial. Dis Colon Rectum 47, 697–703 (2004). https://doi.org/10.1007/s10350-003-0120-8

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  • DOI: https://doi.org/10.1007/s10350-003-0120-8

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