Role of topical nitrates in prevention of anal sphincter injury during transanal stapled anastomosis: A Randomized Controlled trial

Geet Midha, (2019) Role of topical nitrates in prevention of anal sphincter injury during transanal stapled anastomosis: A Randomized Controlled trial. Masters thesis, Christian Medical College, Vellore.


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INTRODUCTION: With significant improvement in surgical outcomes following treatment for rectal cancer, a lot of effort is being made into improving the quality of life. Bowel function is one of the main determinants of quality of life and it is influenced by the integrity and function of the anal sphincter complex. Operations like low anterior resections and Hartmann’s reversal have been associated with a significant drop in anal sphincter pressures. One of the factors contributing to this is the injury to the sphincter during insertion of the transanal stapler. It is hypothesized that use of a smooth muscle relaxant like 0.2% glyceryl trinitrate(GTN), prior to insertion of stapler would reduce this injury by relaxing the sphincters and facilitating smooth insertion of the stapler. The aim of this study was to examine the role of local application of 0.2% glyceryl trinitrate in the prevention of anal sphincter injury during transanal stapled anastomosis. OBJECTIVES: 1. To assess if transanal stapler is associated with injury to the anal sphincters. 2. Effect of glyceryl trinitrate during transanal stapled anastomosis on the anal sphincter pressure. METHODS: This was a randomized controlled trial conducted in the colorectal unit of a tertiary care teaching hospital. Patients undergoing a transanal stapled anastomosis were randomized to 0.2% GTN use and no GTN use before staple insertion. Computer generated block randomization was used, and allocation was concealed using serially numbered opaque envelopes. All patients underwent preoperative anal manometry 1-3 days before surgery and postoperative manometry 15-90 days after surgery. Data was collected on a predetermined proforma and analyzed using IBM SPSS Statistics version 21. An intention to treat analysis was performed and p values of < 0.05 were taken as significant. RESULTS: 43 patients were included in the study, 20 in the intervention arm and 23 in the control arm. Baseline demographic features were similar in both the groups. There was a significant decrease in the resting pressure in both intervention and the control arm. The comparison of change in the mean resting pressure between intervention and control arm showed no statistical significance with a p value 0.202. Similarly, the comparison of change in pressure increase, squeeze sustained duration and fatigue rate between intervention and control arm did not show statistical significance with a p value of 0.662, 0.486 and 0.637 respectively. CONCLUSION: The use of 0.2% GTN before insertion of transanal stapler does not prevent the anal sphincter injury due to insertion of transanal stapler.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Anal sphincter, anorectal manometry, transanal stapler, anal sphincter injury, GTN, carcinoma rectum, resting pressure.
Subjects: MEDICAL > General Surgery
Depositing User: Subramani R
Date Deposited: 02 Sep 2019 06:39
Last Modified: 02 Sep 2019 06:39

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