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The Cochrane Database of Systematic... Feb 2012Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing.
OBJECTIVES
To assess the efficacy and morbidity of various medical therapies for anal fissure.
SEARCH METHODS
Search terms include "anal fissure randomized". Timing from 1966 to August 2010. Further details of the search below.
SELECTION CRITERIA
Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded.
DATA COLLECTION AND ANALYSIS
Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.
MAIN RESULTS
In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, "healer cream" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence.
AUTHORS' CONCLUSIONS
Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a "healer cream") but lack comparison to more established medications.
Topics: Adult; Anal Canal; Child; Dilatation; Fissure in Ano; Humans; Hydrotherapy; Randomized Controlled Trials as Topic
PubMed: 22336789
DOI: 10.1002/14651858.CD003431.pub3 -
Acta Bio-medica : Atenei Parmensis Jan 2019The nose exerts many functions, mainly for the respiration and the olfaction and represents the first doorway for the oxygen, but also for pathogens. The present... (Review)
Review
The nose exerts many functions, mainly for the respiration and the olfaction and represents the first doorway for the oxygen, but also for pathogens. The present Supplement reports some clinical experiences concerning the use of a new internal nasal dilator in different settings, including nasal obstructive disorders, obstructive sleep apnea syndrome, continuous positive active pressure (CPAP), and sport activity. The outcomes support the concept that a healthy nose should be maintained ever patent and free from secretions, as impaired nasal function can significantly affect quality of life. Therefore, an "open and clean nose" contributes in a relevant way to the subjective wellness.
Topics: Continuous Positive Airway Pressure; Dilatation; Female; Humans; Male; Nasal Cavity; Nasal Lavage; Nasal Lavage Fluid; Nasal Obstruction; Reference Values; Respiration; Risk Factors; Sleep Apnea, Obstructive
PubMed: 30715029
DOI: 10.23750/abm.v90i2-S.8104 -
Current Opinion in Gastroenterology Jul 2020The EsoFLIP integrates impedance planimetry technology into a dilator balloon capable of dilating from diameters between 10 and 30 mm via controlled volumetric... (Review)
Review
PURPOSE OF REVIEW
The EsoFLIP integrates impedance planimetry technology into a dilator balloon capable of dilating from diameters between 10 and 30 mm via controlled volumetric distension while providing real-time visualization and objective measurement during the dilation procedure, potentially negating the need for fluoroscopy. This review aims to describe the use and application of EsoFLIP and the potential advantages this novel technology may afford.
RECENT FINDINGS
Small pilot and retrospective studies demonstrate EsoFLIP feasibility and safety, but larger studies are needed to understand its impact on clinical outcomes.
SUMMARY
EsoFLIP is an appealing new technology that offers advantages in therapeutic dilation of the lower esophageal sphincter in achalasia or of esophageal strictures because of previous surgery, gastroesophageal reflux disease, or radiation.
Topics: Dilatation; Esophageal Achalasia; Esophageal Stenosis; Humans; Retrospective Studies; Treatment Outcome
PubMed: 32398561
DOI: 10.1097/MOG.0000000000000639 -
JAMA Jul 2019Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial.
IMPORTANCE
Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the standard treatment for patients with achalasia, are lacking.
OBJECTIVE
To compare the effects of POEM vs pneumatic dilation as initial treatment of treatment-naive patients with achalasia.
DESIGN, SETTING, AND PARTICIPANTS
This randomized multicenter clinical trial was conducted at 6 hospitals in the Netherlands, Germany, Italy, Hong Kong, and the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The study was conducted between September 2012 and July 2015, the duration of follow-up was 2 years after the initial treatment, and the final date of follow-up was November 22, 2017.
INTERVENTIONS
Randomization to receive POEM (n = 67) or pneumatic dilation with a 30-mm and a 35-mm balloon (n = 66), with stratification according to hospital.
MAIN OUTCOMES AND MEASURES
The primary outcome was treatment success (defined as an Eckardt score ≤3 and the absence of severe complications or re-treatment) at the 2-year follow-up. A total of 14 secondary end points were examined among patients without treatment failure, including integrated relaxation pressure of the lower esophageal sphincter via high-resolution manometry, barium column height on timed barium esophagogram, and presence of reflux esophagitis.
RESULTS
Of the 133 randomized patients, 130 (mean age, 48.6 years; 73 [56%] men) underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%]; P < .001). Of the 14 prespecified secondary end points, no significant difference between groups was demonstrated in 10 end points. There was no significant between-group difference in median integrated relaxation pressure (9.9 mm Hg in the POEM group vs 12.6 mm Hg in the pneumatic dilation group; difference, 2.7 mm Hg [95% CI, -2.1 to 7.5]; P = .07) or median barium column height (2.3 cm in the POEM group vs 0 cm in the pneumatic dilation group; difference, 2.3 cm [95% CI, 1.0-3.6]; P = .05). Reflux esophagitis occurred more often in the POEM group than in the pneumatic dilation group (22 of 54 [41%] vs 2 of 29 [7%]; difference, 34% [95% CI, 12%-49%]; P = .002). Two serious adverse events, including 1 perforation, occurred after pneumatic dilation, while no serious adverse events occurred after POEM.
CONCLUSIONS AND RELEVANCE
Among treatment-naive patients with achalasia, treatment with POEM compared with pneumatic dilation resulted in a significantly higher treatment success rate at 2 years. These findings support consideration of POEM as an initial treatment option for patients with achalasia.
TRIAL REGISTRATION
Netherlands Trial Register number: NTR3593.
Topics: Adult; Dilatation; Esophageal Achalasia; Esophageal Sphincter, Lower; Female; Follow-Up Studies; Gastroesophageal Reflux; Humans; Male; Manometry; Middle Aged; Natural Orifice Endoscopic Surgery; Quality of Life; Severity of Illness Index; Sphincterotomy; Treatment Outcome
PubMed: 31287522
DOI: 10.1001/jama.2019.8859 -
World Journal of Gastroenterology May 2018Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease (CD) within 10 years of disease onset. Strictures can be inflammatory,... (Review)
Review
Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.
Topics: Catheterization; Colon; Colonoscopy; Constriction, Pathologic; Crohn Disease; Dilatation; Gastrointestinal Agents; Humans; Injections, Intralesional; Intestinal Obstruction; Postoperative Complications; Quality of Life; Stents; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 29740201
DOI: 10.3748/wjg.v24.i17.1859 -
The Pan African Medical Journal 2017
Topics: Aged; Deglutition Disorders; Dilatation; Humans; Male; Pharyngeal Muscles; Spasm
PubMed: 29187957
DOI: 10.11604/pamj.2017.27.288.13296 -
Practical Radiation Oncology Nov 2019Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS);... (Review)
Review
PURPOSE
Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.
METHODS AND MATERIALS
A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.
RESULTS
VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.
CONCLUSIONS
This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
Topics: Constriction, Pathologic; Dilatation; Female; Humans; Radiation Oncology; Vagina
PubMed: 31302301
DOI: 10.1016/j.prro.2019.07.001 -
Chirurgia (Bucharest, Romania : 1990) Feb 2022Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of...
Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of type of treatment being a widely debated topic nowadays. We selected patients with the diagnosis of achalasia, calculating the Eckardt score on admission and they were treated by pneumatic dilation, respectively by myotomy associated with fundoplication. Therapeutic success at the end of treatment was analyzed, as well as that in subsequent follow-ups. At the same time, other important aspects of the study were quality of life and complications. Forty-eight patients were included, 20 in the group of those treated by pneumatic dilation, and 28 treated by surgery. The results of the therapeutic success were to the advantage of the surgery, both after the completion of the treatment, and in the follow-ups from one year to 2 years (96.4% vs 90%, respectively 92.9% vs. 85%). The quality of life was better in patients with pneumatic dilation throughout the period. Surgical treatment of achalasia has a higher success rate than pneumatic dilation, but the latter is associated with a better quality of life.
Topics: Dilatation; Esophageal Achalasia; Fundoplication; Humans; Quality of Life; Treatment Outcome
PubMed: 35272750
DOI: 10.21614/chirurgia.2683 -
Acta Bio-medica : Atenei Parmensis Jan 2019The nasal valve deserves relevant in patients presenting with nasal obstruction. In particular, the nasal valve plays an important role in nasal airflow control, it is... (Comparative Study)
Comparative Study Review
The nasal valve deserves relevant in patients presenting with nasal obstruction. In particular, the nasal valve plays an important role in nasal airflow control, it is relevant for the otolaryngologist to not only consider but also fully evaluate the nasal valve when seeing a patient with nasal obstruction. These data reported in this Supplement confirms the clinical relevance of the nasal valve in different groups of patients and normal subjects. In fact, an integrity of nasal valve is fundamental to ensure a physiological nasal breathing that in turn guarantees a correct pulmonary function. The possibility to use the non-surgical and well-accepted option constituted by the nasal internal dilator represent an interesting opportunity for both the physician and the patient.
Topics: Cross-Sectional Studies; Dilatation; Female; Humans; Male; Nasal Cavity; Nasal Obstruction; Nasal Septum; Quality of Life; Reference Values; Respiration
PubMed: 30715036
DOI: 10.23750/abm.v90i2-S.8105 -
Journal of Crohn's & Colitis Feb 2018Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and... (Review)
Review
BACKGROUND
Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis.
AIM
To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes.
METHODS
A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded.
RESULTS
Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach.
CONCLUSION
The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.
Topics: Colonic Pouches; Constriction, Pathologic; Digestive System Surgical Procedures; Dilatation; Endoscopy, Gastrointestinal; Humans; Ileum
PubMed: 29155985
DOI: 10.1093/ecco-jcc/jjx151