Efficacy of LIFT for recurrent anal fistula

AIM

Ligation of the intersphincteric fistula tract (LIFT) is a novel sphincter-preserving technique for anal fistula. This pilot study was designed to evaluate the results in patients with a recurrent fistula.

METHOD

Seventeen patients [nine men; median age 49 (range, 30-76) years] with a recurrent trans-sphincteric fistula were treated with a LIFT procedure between June 2008 and February 2011. All were followed prospectively for a median of 16 (range, 5-27) weeks with clinical examination. Fifteen followed for 13.5 (range, 8-26) months by clinical examination also had three-dimensional (3D) anal ultrasound.

RESULTS

The duration of the procedure was 35 (range, 18-70) min. One patient developed a small local haematoma and one had a subcutaneous infection, but otherwise there was no morbidity. At follow up, 11 (65%) patients had a successful closure, two (12%) had a remaining sinus and four (23%) had a persistent fistula. The incidence of persistent or recurrent fistulae at 13.5 months was six (40%) of 15 patients. No de novo faecal incontinence was reported.

CONCLUSION

LIFT is a safe procedure for patients with recurrent anal fistula, with healing at short-term and medium-term follow-up comparable with or superior to that of other sphincter-preserving techniques. Larger studies with a longer follow up are needed to define the ultimate role of LIFT in patients with recurrence.

Effect of local gentamicin-collagen on perineal wound complications and cancer recurrence after abdominoperineal resection: a multicentre randomized controlled trial

AIM

Perineal wound sepsis is a common problem after abdominoperineal resection of the rectum (APR), with a reported incidence of 10-15% in previously non-irradiated patients, 20-30% in patients given preoperative radiation and 50% among patients submitted to preoperative radiation combined with chemotherapy. The local application of gentamicin-collagen was evaluated to determine whether its use in the perineal wound reduced risk complications and had an effect on cancer recurrence.

METHOD

In this prospective multicentre (seven hospitals) randomized controlled trial, 102 patients undergoing APR due to cancer or benign disease were randomized into two groups including surgery with gentamicin-collagen (GS+, n = 52) or surgery without gentamicin-collagen (GS-, n = 50). Patients were followed at 7, 30 and 90 days and at 1 and 5 years.

RESULTS

There were no statistically significant differences between the two groups regarding perineal wound complications, infectious or non-infectious, or cancer recurrence.

CONCLUSION

There was no statistically significant effect on perineal wound complications or cancer recurrence following the local administration of gentamicin-collagen during APR.

Efficacy and quality of life 2 years after treatment for faecal incontinence with injectable bulking agents

BACKGROUND

Stabilized non-animal hyaluronic acid/dextranomer (NASHA Dx) gel as injectable bulking therapy has been shown to decrease symptoms of faecal incontinence, but the durability of treatment and effects and influence on quality of life (QoL) is not known. The aim of this study was to assess the effects on continence and QoL and to evaluate the relationship between QoL and efficacy up to 2 years after treatment.

METHODS

Thirty-four patients (5 males, mean age 61, range 34-80) were injected with 4 × 1 ml NASHA Dx in the submucosal layer. The patients were followed for 2 years with registration of incontinence episodes, bowel function and QoL questionnaires.

RESULTS

Twenty-six patients reported sustained improvement after 24 months. The median number of incontinence episodes before treatment was 22 and decreased to 10 at 12 months (P = 0.0004) and to 7 at 24 months (P = 0.0026). The corresponding Miller incontinence scores were 14, 11 (P = 0.0078) and 10.5 (P = 0.0003), respectively. There was a clear correlation between the decrease in the number of leak episodes and the increase in the SF-36 Physical Function score but only patients with more than 75 % improvement in the number of incontinence episodes had a significant improvement in QoL at 24 months.

CONCLUSIONS

Anorectal injection of NASHA Dx gel induces improvement of incontinence symptoms for at least 2 years. The treatment has a potential to improve QoL. A 75 % decrease in incontinence episodes may be a more accurate threshold to indicate a successful incontinence treatment than the more commonly used 50 %.

Intraoperative hyperthermic versus postoperative normothermic intraperitoneal chemotherapy for colonic peritoneal carcinomatosis: a case-control study

BACKGROUND

Cytoreductive surgery and intraperitoneal chemotherapy has improved prognosis in patients with peritoneal carcinomatosis. The main modes of intraperitoneal chemotherapy treatment are peroperative hyperthermic intraperitoneal chemotherapy (HIPEC) and normothermic sequential postoperative intraperitoneal chemotherapy (SPIC). The aim of this study was to compare HIPEC and SPIC with respect to overall survival, disease-free survival, morbidity, and mortality in patients with peritoneal carcinomatosis from colon cancer.

PATIENTS AND METHODS

A matched case-control study was conducted in patients with surgical macroscopic complete removal of carcinomatosis; matching was according to the peritoneal cancer index score. Thirty-two patients were included, 16 in each group (HIPEC and SPIC). Overall survival, disease-free survival, morbidity, mortality, and clinicopathological parameters were compared.

RESULTS

Median overall survival was 36.5 months in the HIPEC group and 23.9 months in the SPIC group (P = 0.01). Median disease-free survival for these groups was 22.8 (HIPEC) and 13.0 months (SPIC; P = 0.02). Morbidity was not statistically different, 19% in SPIC and 37% in HIPEC. Postoperative mortality was observed in one patient in each group.

CONCLUSION

HIPEC was associated with improved overall survival and disease-free survival compared with SPIC at similar morbidity and mortality, suggesting that HIPEC is the treatment of choice in colonic peritoneal carcinomatosis.

Kinetic analyses of plant water relocation using deuterium as tracer - reduced water flux of Arabidopsis pip2 aquaporin knockout mutants

Due to reduced evaporation and diffusion of water molecules containing heavier isotopes, leaf water possesses an elevated (18)O or (2)H steady-state content. This enrichment has been exploited in plant physiology and ecology to assess transpiration and leaf water relations. In contrast to these studies, in this work the (2)H content of the medium of hydroponically grown Arabidopsis thaliana was artificially raised, and the kinetics of (2)H increase in the aerial parts recorded during a short phase of 6-8 h, until a new equilibrium at a higher level was reached. A basic version of the enrichment models was modified to establish an equation that could be fitted to measured leaf (2)H content during uptake kinetics. The fitting parameters allowed estimation of the relative water flux q(leaf) into the Arabidopsis rosette. This approach is quasi-non-invasive, since plants are not manipulated during the uptake process, and therefore, offers a new tool for integrated analysis of plant water relations. The deuterium tracer method was employed to assess water relocation in Arabidopsis pip2;1 and pip2;2 aquaporin knockout plants. In both cases, q(leaf) was significantly reduced by about 20%. The organ and cellular expression patterns of both genes imply that changes in root hydraulic conductivity, as previously demonstrated for pip2;2 mutants, and leaf water uptake and distribution contributed in an integrated fashion to this reduced flux in intact plants.

A larval key to the Drusinae species (Trichoptera: Limnephilidae) of Austria, Germany, Switzerland and the dinaric western Balkan

A larval key of the Drusinae of Central Europe and the dinaric western Balkan is presented. Phylogeographic relationships are discussed in the light of molecular genetics, feeding ecology and larval morphology.

Ictal delusion of sexual transformation

Psychic and psychotic symptoms can be part of seizure-related symptoms, especially within the postictal phase in partial epilepsies. Among the classic examples are dysmnestic phenomena, visual and acoustic hallucinations, and more rarely delusional syndromes. Here we report about the unique seizure symptom of transformation towards the opposite gender in a patient with a right amygdalar tumor, which we classify as ictal delusional misidentification syndrome.

Postoperative adverse events and long-term survival after cytoreductive surgery and intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) is fatal without special combined cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC). This study was designed to identify factors that may increase the risk of postoperative morbidity and mortality from combined CRS and IPC interventions for PC. Survival based on primary tumour type and extent of surgery is reported.

METHODS

Between May 1991 and November 2004, 123 patients were treated with CRS and IPC for PC. Based on the National Cancer Institute Common Toxicity Criteria for grade 3 and 4, data on 30 days postoperative morbidity and 90 days mortality were analysed.

RESULTS

Grade 3-4 adverse events were observed in 51 patients (41%) and were associated with stoma formation, duration of surgery, peroperative blood loss and peritoneal cancer index (PCI). Excision, or electrocautery evaporation, of tumour from small bowel surface was correlated to bowel morbidity. Five patients had treatment-related mortality (4%) within 90 days. Survival was associated with macroscopic radical surgery, prior surgical score, PCI and primary tumour type.

CONCLUSIONS

CRS and IPC for PC are associated with high morbidity and mortality. However, in light of the potential benefit indicated by long-term survival, the adverse event from this treatment is considered acceptable.

Heterogeneous activity of cytotoxic drugs in patient samples of peritoneal carcinomatosis

AIMS

To investigate if the pattern of cytotoxic drug sensitivity in vitro in patient samples of peritoneal carcinomatosis (PC) is supportive to the current standardized approach for drug selection for perioperative intraperitoneal chemotherapy (IPC).

METHODS

The cytotoxic effect of cisplatin, oxaliplatin, irinotecan, 5-fluorouracil, mitomycin-C, doxorubicin and melphalan was investigated in vitro on tumour cells from 223 patient tumour samples of different PC origins.

RESULTS

Considerable differences in cytotoxic drug sensitivity between tumour types of the PC entity and within each tumour type were observed. Cisplatin showed high cross-resistance with oxaliplatin but low cross-resistance with doxorubicin and irinotecan. No cross-resistance was found between irinotecan and doxorubicin. The dose-response relationships for melphalan and irinotecan in individual samples showed great variability.

CONCLUSIONS

The activity in vitro of cytotoxic drugs commonly used in IPC for PC is very heterogeneous. Efforts for individualizing drug selection for PC patients undergoing IPC seem justified.

Swedish experience with peritonectomy and HIPEC. HIPEC in peritoneal carcinomatosis

BACKGROUND

Peritonectomy with heated intraperitoneal chemotherapy (HIPEC) has shown a survival benefit in selected patients with peritoneal carcinomatosis. This prospective non-randomized study was designed to identify factors associated with postoperative morbidity and survival after peritonectomy HIPEC in patients with this condition.

METHOD

Data were prospectively collected from all patients with peritoneal carcinomatosis treated by means of peritonectomy and HIPEC at Uppsala University Hospital between October 2003 and September 2006. Depending on the primary tumor, mitomycin C or a platinum compound was used as a chemotherapeutic agent for perfusion.

RESULTS

A total of 103 patients were treated. Primary tumors were pseudomyxoma peritonei (47 patients), colorectal cancer (38 patients), gastric cancer (6 patients), ovarian cancer (6 patients) and mesothelioma (5 patients). Postoperative morbidity was 56.3% and was significantly lower in patients treated with mitomycin C for pseudomyxoma peritonei (42%) than in those with another diagnosis treated with platinum compound (71%, P < 0.05). Postoperative mortality was less than 1%. At 2 years, overall survival was estimated to be 72.3%, and disease-free survival was 33.5%. Factors influencing overall and disease-free survival were tumor type and optimal cytoreduction.

CONCLUSION

Postoperative morbidity is dependent mainly on a tumor type; however, the chemotherapeutic agent used might also influence morbidity. Survival is determined by optimal cytoreduction and tumor type. Irrespective of age, patients with good performance status benefit from this treatment.

Anorectal manovolumetry in the decision making before surgery for slow transit constipation

BACKGROUND

Colectomy with ileorectal anastomosis for slow transit constipation (STC) is being challenged by other operations, such as segmental resections. The importance of preoperative anorectal physiology testing may therefore be increased. The aim of this study was to identify anorectal abnormalities in patients with STC, which may influence the surgical approach.

METHODS

Fifty consecutive patients with STC (43 women; median age, 49 years) and 28 controls (23 women; median age, 50 years) were examined with anorectal manovolumetry. Anal pressures and rectal volumes were recorded, at stepwise rectal distension.

RESULTS

Anal resting pressure was lower in patients (median, 54 cm H(2)O; range, 22-130) than in controls (median, 68 cm H(2)O; range, 35-100) (p<0.05). Squeeze pressure tended to be lower in patients (median, 147 cm H(2)O; range, 53-382) than in controls (median, 177 cm H(2)O; range, 65-423) (p=0.09). Rectal sensory thresholds did not differ significantly between patients and controls, although 10 patients had a threshold for filling above the 95(th) percentile of controls. Rectal compliance was increased in patients in the pressure interval 5-35 cm H(2)O (p<0.05-0.01). The threshold and amplitude of the recto-anal inhibitory reflex did not differ significantly, but the recovery of resting pressure after eliciting the reflex was lower in patients than in controls in the pressure interval 10-50 cm H(2)O (p<0.05-0.001).

CONCLUSIONS

More than half of the patients with STC deviated in some parameter. An impaired internal sphincter function and increased rectal compliance were seen. One fifth of the patients had impaired rectal sensation.

Segmental colonic transit studies: comparison of a radiological and a scintigraphic method

OBJECTIVE

Colonic transit studies are used to diagnose slow transit constipation (STC) and to evaluate segmental colonic transit before segmental or subtotal colectomy. The aim of the study was to compare a single X-ray radio-opaque marker method with a scintigraphic technique to assess total and segmental colonic transit in patients with STC.

METHOD

Thirty-one female patients (median age 46 years) with severe constipation and a prolonged or borderline prolonged colonic transit time on radio-opaque marker study were included in the study. They were subsequently investigated with (111)Indium-DTPA colonic transit scintigraphy, with a median time between the investigations of 4(range 1-27) months. Normal values of healthy female controls were used for comparison.

RESULTS

There was no difference between the two methods in terms of prolonged or normal total colonic transit time. Twenty-nine of 31 female patients had a prolonged transit time only in one or two segments on the marker study. On scintigraphy, the transit time was prolonged for patients in the left (P < 0.05 to P < 0.001), but not in the right colon. With respect to prolonged or normal segmental transit time, there was a significant difference between the two methods only in the descending colon (P = 0.02). However, the results varied considerably for individual patients.

CONCLUSION

Segmental colonic delay was a common finding. The two methods gave similar results for groups of patients, except in the descending colon. The variation of the results for individuals suggests that a repeated transit test may improve the assessment of total and segmental transit.

The Larva of Drusus nigrescens Meyer-Dür, 1875 (Trichoptera: Limnephilidae: Drusinae) with notes on its ecology, genetic differentiation and systematic position

The paper presents a description of the hitherto unknown larva of Drusus nigrescens Meyer-Dür, 1875. Information on the morphological and genetic identification of this species is given, and the most important diagnostic features are illustrated. Its systematic position within the genus Drusus is affirmed and some zoogeographical and ecological notes are added.

Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula

BACKGROUND

Endoanal advancement flap repair is widely used in sphincter-preserving surgery for anal fistula, but the high recurrence rate is a major problem. A possible cause of non-healing is local infection of the flap. The aim of this study was to evaluate whether local antibiotic treatment with gentamicin-collagen improves healing after endoanal advancement flap repair for anal fistula.

METHODS

Eighty-three patients (52 men and 31 women; mean age 47 (range 17-71) years) who had endoanal advancement flap repair for anal fistula between September 1998 and January 2004 were randomized to surgery with (42 patients) or without (41 patients) application of gentamicin-collagen beneath the flap. Patients were evaluated at 1-3 and 12 months after surgery for healing and/or recurrence.

RESULTS

The overall healing rate with no recurrence at 1 year after surgery was 57 per cent (47 of 83). Twenty-six of 42 patients randomized to gentamicin-collagen healed primarily compared with 21 of 41 patients randomized to surgery only. There were no overall differences in healing rate according to sex, previous fistula surgery, complexity of fistula, smoking habit or body mass index.

CONCLUSION

Endoanal advancement flap repair for anal fistula has a fairly high primary recurrence rate. Healing was not significantly improved by local application of gentamicin-collagen.

Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy

BACKGROUND

Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy.

METHODS

A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale.

RESULTS

Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047).

CONCLUSION

Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.

Oculomotor areas of the primate frontal lobes: a transneuronal transfer of rabies virus and [14C]-2-deoxyglucose functional imaging study

We used the [14C]-2-deoxyglucose method to study the location and extent of primate frontal lobe areas activated for saccades and fixation and the retrograde transneuronal transfer of rabies virus to determine whether these regions are oligosynaptically connected with extraocular motoneurons. Fixation-related increases of local cerebral glucose utilization (LCGU) values were found around the fundus of the inferior limb of the arcuate sulcus (AS) just ventral to its genu, in the dorsomedial frontal cortex (DMFC), cingulate cortex, and orbitofrontal cortex. Significant increases of LCGU values were found in and around both banks of the AS, DMFC, and caudal principal, cingulate, and orbitofrontal cortices of monkeys executing visually guided saccades. All of these areas are oligosynaptically connected to extraocular motoneurons, as shown by the presence of retrogradely transneuronally labeled cells after injection of rabies virus in the lateral rectus muscle. Our data demonstrate that the arcuate oculomotor cortex occupies a region considerably larger than the classic, electrical stimulation-defined, frontal eye field. Besides a large part of the anterior bank of the AS, it includes the caudal prearcuate convexity and part of the premotor cortex in the posterior bank of the AS. They also demonstrate that the oculomotor DMFC occupies a small area straddling the ridge of the brain medial to the superior ramus of the AS. Our results support the notion that a network of several interconnected frontal lobe regions is activated during rapid, visually guided eye movements and that their output is conveyed in parallel to subcortical structures projecting to extraocular motoneurons.

Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay

OBJECTIVE

Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side-effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right- or left-sided delay.

METHODS

Twenty-three constipated patients (19 women, mean age 50 years) with slow colonic transit on radio-opaque marker studies and 13 healthy individuals (11 women, mean age 46 years) were studied. All subjects were examined with oral (111)Indium-DTPA scintigraphy. The scintigraphic results for patients and controls were presented as geometric centre of radioactivity and percent activity over time in the right, the left and the recto-sigmoid colon. The inter-observer variation in the interpretation of the scans was also evaluated.

RESULTS

There was no difference in transit time between the groups of patients and controls in the right colon whereas the patients had a significant delay in the left colon (P < 0.05). Two patients had a marked delay in the right colon followed by relatively rapid transit in the left colon. The inter-observer correlation was good comparing the right, the left and the recto-sigmoid colon (r = 0.58-0.98, P < 0.01-0.001).

CONCLUSION

The results indicate that colonic scintigraphy with oral (111)Indium-DTPA may help to select patients for a left or, in a few cases, a right hemicolectomy for slow transit constipation.