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Sacks RS, Anconina R, Farkas E, Zolotnik-Krupenich D, Kravarusic D, Tsodikov V, Shelef I, Taragin B. Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience. J Pediatr Surg 2020; 55:2009-2014. [PMID: 32713713 DOI: 10.1016/j.jpedsurg.2020.05.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception. MATERIALS AND METHODS This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed. RESULTS 414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction. CONCLUSION The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema. LEVEL OF EVIDENCE Treatment study level III.
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Affiliation(s)
- Robert S Sacks
- Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel.
| | - Reut Anconina
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Evelyn Farkas
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Diana Zolotnik-Krupenich
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Dragan Kravarusic
- Department of Pediatric Surgery, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Vadim Tsodikov
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Ilan Shelef
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Benjamin Taragin
- Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
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Hernanz-Schulman M. Commentary regarding sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception; 20 year experience. J Pediatr Surg 2020; 55:2015-6. [PMID: 32732161 DOI: 10.1016/j.jpedsurg.2020.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
This is a commentary on the manuscript by Sacks R, Anconina R, Farkas E, et al, titled "Sedated Ultrasound Guided Saline Reduction (SUR) of Ileocolic Intussusception: 20 Year Experience".
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Shen G, Zhang C, Li J, Zhang J, Liu Y, Guan Z, Hu Q. Risk factors for short-term recurrent intussusception and reduction failure after ultrasound-guided saline enema. Pediatr Surg Int 2018; 34:1225-1231. [PMID: 30151752 DOI: 10.1007/s00383-018-4340-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the safety and effectiveness of ultrasound-guided saline enema to treat intussusception and to analyze the risk factors affecting short-term recurrence and reduction failure. MATERIALS AND METHODS We selected patients who had undergone intussusception reduction via ultrasound-guided saline enema from January 2010 to December 2017. The overall success rate, overall pathologic intussusception rate, and pathologic intussusception rate were calculated in each group. All the patients were divided into two groups: the successfully reduced group and the failed reduction group. Then, the successfully reduced patients were divided into two groups: the short-term recurrence group and the short-term non-recurrence group. The differences between each of the two sets of groups were analyzed, and the risk factors affecting short-term recurrence and failure of intussusception were analyzed. RESULTS During the 8-year study period, a total of 1793 patients with intussusception were treated with ultrasound-guided saline enema reduction in our hospital. Among these patients, 1743 (97.2%) experienced successful reduction, 29 (1.6%) had pathologic intussusception, and 1 experienced perforation. After applying the univariate analysis and logistic regressive multivariate analysis, we found that age above 2 years and the absence of fever were risk factors for the early recurrence of intussusception. Pathologic intussusception was a risk factor for reduction failure. CONCLUSION The overall success rate of ultrasound-guided saline enemas was 97.2%, and the pathologic intussusception rate was 1.6%. Age above 2 years and the absence of fever were risk factors for short-term recurrence, and pathologic intussusception was a risk factor for the failure of reduction.
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Affiliation(s)
- Gang Shen
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Chuanguang Zhang
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Junfeng Li
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Jing Zhang
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Yongdong Liu
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Zheming Guan
- Weifang Medical University, Weifang, Shandong, China
| | - Qiang Hu
- Department of Pediatric Surgery, Weifang People's Hospital, Weifang, 261041, Shandong, China.
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Nada AM, Mohsen RA, Hassan YM, Sabry A, Soliman NS. Does saline enema during the first stage of labour reduce the incidence of Clostridium difficile colonization in neonates? A randomized controlled trial. J Hosp Infect 2018; 99:356-359. [PMID: 29452244 DOI: 10.1016/j.jhin.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Maternal rectal enemas may reduce neonatal bacterial exposure during labour, which may reduce the risk of neonatal colonization with Clostridium difficile. The aim of this study was to determine the effectiveness of a saline enema during the first stage of labour in reducing neonatal colonization with C. difficile. METHODS This study was conducted at Cairo University Hospital, Egypt from January 2016 to July 2016. Asymptomatic mothers with uncomplicated vaginal delivery and their neonates without diarrhoea were included. The study group underwent saline enema, and the control group had no intervention. Stool samples were collected from neonates one week after delivery. The primary outcome was the detection of C. difficile in stool culture and direct detection of C. difficile Toxin A and Toxin B by enzyme-linked immunosorbent assay. FINDINGS The two groups were comparable (P>0.05) in terms of age, gravidity, parity, body mass index and gestational age. C. difficile was detected in 13.54% and 37.63% of stool cultures from the enema group and the control group, respectively (P<0.001). Direct detection of Toxins A and B was positive in 22.92% of cases in the enema group and 53.76% of cases in the control group (P<0.001). CONCLUSION This study suggests that a saline enema for the mother during the first stage of labour may be useful in reducing the risk of neonatal gut colonization by C. difficile.
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Affiliation(s)
- A M Nada
- Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt.
| | - R A Mohsen
- Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt
| | - Y M Hassan
- Department of Clinical Pathology, Cairo University, Cairo, Egypt
| | - A Sabry
- Department of Paediatrics, Cairo University, Cairo, Egypt
| | - N S Soliman
- Department of Clinical Pathology, Cairo University, Cairo, Egypt
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Ibrahim T, Li Wei C, Bautista D, Sriram B, Xiangzhen Fay L, Rajadurai VS. Saline Enemas versus Glycerin Suppositories to Promote Enteral Feeding in Premature Infants: A Pilot Randomized Controlled Trial. Neonatology 2017; 112:347-353. [PMID: 28768263 DOI: 10.1159/000477999] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Meconium retention is associated with feeding intolerance. Trials using glycerol and Gastrografin to expedite the evacuation of meconium have failed to generate clinically valid results for efficacy and safety. OBJECTIVE We assessed the feasibility of aggressive meconium evacuation with saline rectal washout (RW) in very-low-birth-weight infants to reduce the time it took them to reach full enteral feeds. METHODS We conducted an open-label, pilot, randomized controlled trial (RCT) (birth weight stratified, i.e., to 750-999 g and 1,000-1,500 g) of early aggressive meconium evacuation with twice-daily normal saline RW compared to conventional management with glycerin suppositories (GS), until full enteral feeds (110 mL/kg/day) were reached. Primary outcome was time to reach full enteral feeds. Safety, process, and secondary efficacy outcomes were also evaluated. RESULTS Sixty-one infants were randomized, 28 to RW and 33 to GS. The process and feasibility outcomes were met. RW was found to be safe; none of the RW-randomized infants developed necrotizing enterocolitis (≥ stage II) or complications secondary to RW. Evidence of efficacy was supported: in the 750-999 g stratum (n = 15), the median time to full enteral feeds was shorter with RW (11.0 days, 95% CI: 10.4-11.6) than with GS (15.6 days, 95% CI: 13.0-18.2) by a reduction of 4.6 days (p = 0.027). In the 1,000-1,500 g stratum (n = 46), there was no evidence of benefit: RW 10.2 days (95% CI 8.3-12.1) and GS 10.1 days (95% CI 9.3-10.9, p = 0.304). CONCLUSION Our protocol was feasible and an adequately powered RCT is required to confirm the findings of this trial.
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Affiliation(s)
- Thowfique Ibrahim
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
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Parolini F, Armellini A, Boroni G, Bagolan P, Alberti D. The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem. J Pediatr Surg 2016; 51:304-9. [PMID: 26592954 DOI: 10.1016/j.jpedsurg.2015.10.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 08/01/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
AIM OF THE STUDY The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. MATERIALS AND METHODS The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. RESULTS Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). CONCLUSIONS Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required.
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Affiliation(s)
- Filippo Parolini
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy.
| | - Andrea Armellini
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy
| | - Giovanni Boroni
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesu' Research Children's Hospital, Rome, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Flaum V, Schneider A, Gomes Ferreira C, Philippe P, Sebastia Sancho C, Lacreuse I, Moog R, Kauffmann I, Koob M, Christmann D, Douzal V, Lefebvre F, Becmeur F. Twenty years' experience for reduction of ileocolic intussusceptions by saline enema under sonography control. J Pediatr Surg 2016; 51:179-82. [PMID: 26592955 DOI: 10.1016/j.jpedsurg.2015.09.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ultrasonography is a well-established efficient diagnostic tool for ileocolic intussusceptions in children. It can also be used to control hydrostatic reduction by saline enemas. This reduction method presents the advantage of avoiding radiations. Parents can even stay with their children during the procedure, which is comforting for both. The purpose of this study was to present our 20 years' experience in intussusception reductions using saline enema under ultrasound control and to assess its efficiency and safety. MATERIAL AND METHODS This retrospective single center study included patients with ileocolic intussusceptions diagnosed by ultrasound between June 1993 and July 2013. We excluded the data of patients with spontaneous reduction or who underwent primary surgery because of contraindications to hydrostatic reduction (peritonitis, medium or huge abdominal effusion, ischemia on Doppler, bowel perforation). A saline enema was infused into the colon until the reduction was sonographically confirmed. The procedure was repeated if not efficient. Light sedation was practiced in some children. RESULTS Eighty-tree percent of the reductions were successful with a median of 1 attempt. Reduction success decreased with the number of attempts but was still by 16% after 4 attempts. The early recurrence rates were 14.5%, and 61.2% of those had a successful second complete reduction. Forty-six patients needed surgery (11 of them had a secondary intussusception). Sedation multiplies success by 10. In this period, only one complication is described. CONCLUSION Ultrasound guided intussusception reduction by saline enema is an efficient and safe procedure. It prevents exposure of a young child to a significant amount of radiation, with similar success rate. We had very low complication rate (1/270 cases or 3‰). The success rate could be increased by standardized procedures including: systematic sedation, trained radiologists, accurate pressure measurement, and number and duration of attempts.
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Affiliation(s)
- Valérie Flaum
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France; Departement of Pediatric Surgery, Pediatric Clinic, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg.
| | - Anne Schneider
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
| | - Cindy Gomes Ferreira
- Departement of Pediatric Surgery, Pediatric Clinic, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Paul Philippe
- Departement of Pediatric Surgery, Pediatric Clinic, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | | | - Isabelle Lacreuse
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
| | - Raphael Moog
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
| | - Isabelle Kauffmann
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
| | - Meriam Koob
- Department of Pediatric Radiology, University Hospital Hautepierre, Strasbourg, France
| | - Dominique Christmann
- Department of Pediatric Radiology, University Hospital Hautepierre, Strasbourg, France
| | - Valérie Douzal
- Department of Pediatric Radiology, University Hospital Hautepierre, Strasbourg, France
| | - François Lefebvre
- Statistics and Public Health Department, Medicine Faculty, Strasbourg, France
| | - François Becmeur
- Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
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Karadağ ÇA, Abbasoğlu L, Sever N, Kalyoncu MK, Yıldız A, Akın M, Candan M, Dokucu Aİ. Ultrasound-guided hydrostatic reduction of intussusception with saline: Safe and effective. J Pediatr Surg 2015; 50:1563-5. [PMID: 25863544 DOI: 10.1016/j.jpedsurg.2015.03.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/01/2015] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The study was undertaken to assess the efficacy of ultrasound-guided saline enema in reducing intussusception and to determine the role of age and duration of symptoms on this event. METHODS The case records of patients who were treated for intussusception at our institutions over the past 10 years were retrospectively analyzed. A total of 419 patients were treated for intussusception and 375 of them were included into the study. Patients were excluded if they had symptoms and signs of acute abdominal disease and required surgery as an initial treatment. RESULTS Hydrostatic reduction was successful in 313 of the 375 patients (83.46%). The procedure-related complication rate was nil. There were 29 episodes of recurrences in 23 patients, and recurrence rates did not differ between patients who responded to hydrostatic reduction and those who required surgery. Younger age [median (range); 11 months (3-108 months) vs. 20 months (1-180 months); p<0.05], rectal bleeding (p<0.01) and long duration of symptoms [mean (range); 1.95 days (1-7 days) vs. 1.44 days (1-10 days); p<0.01] were significantly associated with failed hydrostatic reduction. CONCLUSION Ultrasound-guided hydrostatic reduction is an easy, safe and effective method for the treatment of intussusception in the absence of acute abdominal findings.
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Affiliation(s)
- Çetin Ali Karadağ
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey.
| | - Latif Abbasoğlu
- Acıbadem University Faculty of Medicine, Department of Pediatric Surgery, Istanbul, Turkey
| | - Nihat Sever
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey
| | - Meltem Kaba Kalyoncu
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey
| | - Abdullah Yıldız
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey
| | - Melih Akın
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey
| | - Mustafa Candan
- Acıbadem Kadıköy Hospital, Department of Pediatric Surgery Istanbul, Turkey
| | - Ali İhsan Dokucu
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey
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Amouzeshi A, Amouzeshi Z, Naseh G, Vejdan SA, Tanha AS, Hosseinzadeh M, Vagharseyyedin SR. The comparison of saline enema and bisacodyl in rectal preparation before anorectal surgery. J Surg Res 2015; 199:322-5. [PMID: 25979561 DOI: 10.1016/j.jss.2015.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/13/2015] [Accepted: 04/09/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the limited data on the need of mechanical bowel preparation application before anorectal surgeries and the preferred method for bowel preparation, we aimed to compare saline enema and bisacodyl in rectal preparation before anorectal surgery. MATERIALS AND METHODS This is a randomized clinical trial study. Seventy-nine hospitalized patients for anorectal surgery (hemorrhoid, fissure, and fistula) were recruited by convenient sampling and then randomly allocated to receive 500 cc Saline by rectal enema or six bisacodyl tablets (Sobhan company) beginning from a day before the operation in order to prepare the bowel. After surgery, surgeons' satisfaction of the surgery and patients' satisfaction of the preparation process were evaluated in the ward using Likert score by a nurse blind to the study. Also, the patients were interviewed for pain after the first defecation, using numeric rating scale based on a 0-10 scores. All patients were actively followed-up after discharge for 1 mo concerning postoperative complications. The obtained data were analyzed by SPSS software (version 16), Mann-Whitney, chi-squared, and Fisher exact tests at the significant level of P < 0/0.5. RESULTS A total of 79 patients participated in the study, 38 received 500-cc saline by rectal enema and 41 bisacodyl tablets. No significant differences were observed between the two groups in most variables except for pain after the first defecation (P = 0.032). CONCLUSIONS According to the results, the bisacodyl approach results in less pain in the first postoperative defecation and fewer complications than the rectal enema. Thus, bisacodyl can be suggested as a superior counterpart for enema.
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Affiliation(s)
- Ahmad Amouzeshi
- Department of Cardiovascular Surgery, Surgery and Trauma Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Zahra Amouzeshi
- Surgery and Trauma Research Center, Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran.
| | - Ghodratollah Naseh
- Department of General Surgery, Surgery and Trauma Research Center, Birjand University of Medicine Sciences, Birjand, Iran
| | - Seyyed Amir Vejdan
- Department of General Surgery, Surgery and Trauma Research Center, Birjand University of Medicine Sciences, Birjand, Iran
| | - Amir Saber Tanha
- Department of Anesthesiology, Surgery and Trauma Research Center, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran
| | - Mahmood Hosseinzadeh
- Department of Cardiovascular Surgery, Surgery and Trauma Research Center, Birjand University of Medical Sciences, Birjand, Iran
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