Abstract
Amaç: Hirschsprung hastalığında (HH) cerrahi sonrası genellikle iyi sonuçlar alınırken bazı olgularda barsak disfonksiyonu devam eder. Düzeltici ameliyat sonrası obstrüktif semptomların bir kısmına refleks olarak gevşemeyen internal anal sfinkter yol açar. Nitrik Oksit internal anal sfinkterin gevşemesinde rol oynayan mediatördür. Organik nitratlar hücresel metabolizma ile degrade olarak Nitrik Oksite (NO) dönüşerek ekzojen olarak uygulandıklarında internal anal sfinkterde gevşemeye neden olurlar. Çalışmamızda düzeltici ameliyat sonrası obstrüktif semptomları devam eden Hirschsprung hastalıklı olgularda topikal NO kullanımının değerlendirilmesi amaçlandı.Materyal ve Metod: Hirschsprung hastalığında nedeni ile opere olan 13 semptomatik olguda topikal NO kullanımı değerlendirildi. Olgularımızda anorektal manometri sonuçları ile, fonksiyonel ve klinik iyileşme değerlendirmeye alındı. Sekiz olguda enterokolit, beş olguda dirençli kabızlık mevcuttu. NO pomad günde iki kez, altı hafta süre ile uygulandı ve manometrik ölçümler tedavi sonrası tekrarlandı. Bulgular: Anorektal manometre değerlendirilmesinde 13 olguda refleks olarak gevşemeyen internal anal sfinkter izlendi. 6 haftalık NO pomad uygulaması sonrası belirgin semptomatik düzelme saptanırken, Maksimum anal istirahat basıncının (MAİB) % 34 oranında düştüğü belirlendi. Tedavinin kesilmesinden sonra MAİB değerleri tedavi öncesi değerlere geri döndü. Sonuç: Refleks olarak gevşemeyen internal anal sfinkter tek başına obstrüktif semptomlara neden olmasa da basıncın düşürülmesi klinik düzelmeye yol açmaktadır. İnternal anal sfinkterin basıncı NO pomad uygulaması ile yetersiz kolonik peristaltizmin aşabileceği düzeye indirildi. Topikal NO kullanımı reversible kimyasal sfinkterotomi sağlayarak başarılı bir şekilde obstrüktif bulguları olan Hirschsprung hastalıklı olgularda kullanılabilir.
Keywords
References
- Marty TL, Seo T, Matlak ME, Sullivan JJ, Black RE, Johnson DG.
- Gastrointestinal function after surgical correction of Hirschsprung's
- disease: Long term follow-up in 135 patients. J Pediatr Surg 1995;30: 655-658.
- Pediatr Surg 1995;30: 430-432.
- tudy of 880 Swenson procedures. J Pediatr Surg 1989; 24:833- 838. 6. Moore SW, Millar AJ, Cywes S. Long term clinical, manometric and
- histological evaluation of obstructive symptoms in the postoperative
- Hirschsprung's patient. J Pediatr Surg 1994: 29; 106-111. 7. Tiryaki T, Şenel E, Akbıyık F, Mambet E, Livanelioğlu Z, Atayurt H.
- Hirschsprung hastalıklı olgularda düzeltici ameliyat sonrası klinik seyrin anorektal manometre tetkiki ile değerlendirilmesi. Türkiye Çocuk
- Hastalıkları Dergisi 2007;1:29-33. 8. Tariq GM, Brereton RJ, Wright VM. Complications of endorectal
- pull-through for Hirschsprung's disease. J Pediatr Surg 1991;26: 1202-1206. 19. Loening-Baucke V. Constipation in early childhood: patients characteris- tics, treatment, and long term follow up. Gut 1993;34:1400-1404. 21.Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl tri- nitrate in the treatment of chronic anal fissure. Br J Surg 1996; 24.Langer Cj, Bimbaum E. Preliminary experience with intrasphincteric botulinum toxin for persistent constipation after pull-through for
- Hirschsprung's disease. J Pediatr Surg 1997: 32;1059-1062. 25.Miele E, Tozzi A, Staiano A, Toraldo C, Esposito C, Clause RE. Per- sistence of abnormal gastrointestinal motility a after operation for
- Hirschsprung's disease. Am J Gastroenterol 2000;95:1226-1230. 28.Carapeti EA , Kamm MA, Mc Donald PJ, Chadwick SJ, Melville D, Phillips RK. Randomised controlled trial shows that glyceryl tri
- nitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut 1999;44:727-730.
Abstract
Aim: Surgery for Hirschsprung's disease generally results in a satisfactory outcome, but some patients continue to have persistent bowel dysfunction. The symptoms of obstruction after surgery for Hirschsprung's disease may result from non-relaxing internal anal sphincter. Nitric oxide (NO) has been identified as the chemical messenger mediating relaxation of the internal anal sphincter. Organic nitrates are degraded by cellular metabolism, liberating NO and exagenous application results in a relaxation response. The purpose of this study is to investigate the topical Nitric oxide application for obstructive symptoms after surgery for Hirschsprung's disease.Material and Method: We reviewed application of topical NO on thirteen symptomatic children who were operated for Hirschsprung's disease. Thirteen patients were evaluated for anorectal manometric, functional and clinical outcomes. The symptoms included enterocolitis in eight and constipation in five patients. NO ointment was applied twice daily for six weeks in symptomatic patients and manometry was repeated. Results: Anorectal manometric evaluation of thirteen patients has shown a non-relaxing internal anal sphinctere without reflex relaxation on applying distending pressure to the rectum. Marked improvement of symptoms were noted after 6 week application of topical NO and also maximum anal resting pressure (MARP) decreased significantly (34 % reduction). After ceasing the application of topical ointment, MARP increased again.Conclusion: We conclude that impaired colonic peristaltism could pass the decreased internal anal sphinctere pressure after NO ointment application. Although non-relaxing anal sphinctere is not thought to be the causative reason for obstructive symptoms alone, relaxation of anal sphinctere may improve the symptoms causing a reversible chemical sphincterotomy. The symptomatic patients with Hirschprung's disease showing the signs of obstruction should be managed applying topical NO ointment
Keywords
References
- Marty TL, Seo T, Matlak ME, Sullivan JJ, Black RE, Johnson DG.
- Gastrointestinal function after surgical correction of Hirschsprung's
- disease: Long term follow-up in 135 patients. J Pediatr Surg 1995;30: 655-658.
- Pediatr Surg 1995;30: 430-432.
- tudy of 880 Swenson procedures. J Pediatr Surg 1989; 24:833- 838. 6. Moore SW, Millar AJ, Cywes S. Long term clinical, manometric and
- histological evaluation of obstructive symptoms in the postoperative
- Hirschsprung's patient. J Pediatr Surg 1994: 29; 106-111. 7. Tiryaki T, Şenel E, Akbıyık F, Mambet E, Livanelioğlu Z, Atayurt H.
- Hirschsprung hastalıklı olgularda düzeltici ameliyat sonrası klinik seyrin anorektal manometre tetkiki ile değerlendirilmesi. Türkiye Çocuk
- Hastalıkları Dergisi 2007;1:29-33. 8. Tariq GM, Brereton RJ, Wright VM. Complications of endorectal
- pull-through for Hirschsprung's disease. J Pediatr Surg 1991;26: 1202-1206. 19. Loening-Baucke V. Constipation in early childhood: patients characteris- tics, treatment, and long term follow up. Gut 1993;34:1400-1404. 21.Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl tri- nitrate in the treatment of chronic anal fissure. Br J Surg 1996; 24.Langer Cj, Bimbaum E. Preliminary experience with intrasphincteric botulinum toxin for persistent constipation after pull-through for
- Hirschsprung's disease. J Pediatr Surg 1997: 32;1059-1062. 25.Miele E, Tozzi A, Staiano A, Toraldo C, Esposito C, Clause RE. Per- sistence of abnormal gastrointestinal motility a after operation for
- Hirschsprung's disease. Am J Gastroenterol 2000;95:1226-1230. 28.Carapeti EA , Kamm MA, Mc Donald PJ, Chadwick SJ, Melville D, Phillips RK. Randomised controlled trial shows that glyceryl tri
- nitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut 1999;44:727-730.
Details
| Other ID | JA28VK38AK |
|---|---|
| Journal Section | Research Article |
| Authors | |
| Publication Date | June 1, 2008 |
| Submission Date | June 1, 2008 |
| Published in Issue | Year 2008 Volume: 2 Issue: 2 |
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