[Digital transformation for more equitable and sustainable public health in the age of digital interdependenceTransformação digital para uma saúde pública mais equitativa e sustentável na era da interdependência digital]

This article describes eight guiding principles for the digital transformation of the health sector and identifies their relationship with the COVID-19 pandemic, as well as highlighting their importance to countries undergoing digital transformation processes. In the Region of the Americas, among other gaps, 30% of people do not have access to the Internet, which is why it is mandatory to develop policies and actions to deliver public health interventions equitably and sustainably to ensure that no one is left behind. The eight principles focus on the four areas of a sustainable health system - human, social, economic and environmental - and highlight the broader possibilities using digital technology to impact the sustainability of health systems.

Digital Transformation for More Equitable and Sustainable Public Health in the Age of Digital Interdependence

This article describes 8 guiding principles for the digital transformation of the health sector and identifies their relationship with the COVID-19 pandemic, as well as highlights their importance to countries undergoing digital transformation processes. In the Region of the Americas, among other gaps, 30% of people do not have access to the Internet, which is why it is mandatory to develop policies and actions to deliver public health interventions equitably and sustainably to ensure that no one is left behind. The 8 principles focus on the 4 areas of a sustainable health system-human, social, economic, and environmental-and highlight the broader possibilities for using digital technology to have an impact on the sustainability of health systems. (Am J Public Health. 2022;112(S6):S621-S624. https://doi.org/10.2105/AJPH.2022.306749).

[Information systems for health: an analysis of design from a public policy perspectiveSistemas de informação para a saúde: uma análise do design na perspectiva das políticas públicas]

In 2019, the Pan American Health Organization approved a regional policy known as the Plan of Action for Strengthening Information Systems for Health 2019-2023, the design of which is the subject of this article. This analysis was carried out from the point of view of the development of the plan of action, as well as its implementation, in the light of the theoretical concepts of Harold Lasswell and Charles Lindblom. In the study of this policy, consideration was given to context, focus on problems, diversity, and the variety of methods used. The impartial search for the public interest, design of practical policies, needs of public officials, and provision of recommendations are discussed. The policy can be implemented regardless of the administrative configuration of countries and territories, or the political power that other institutions may exercise. Its design is oriented toward universal access to health services in the countries of the Americas, taking into account cultural and linguistic diversity, including indigenous populations, which shows that it was contextualized for a region with high rates of inequities.

[Implementation of telemedicine in the Americas: Barriers and facilitatorsBarreiras e facilitadores para a implementação da telemedicina nas Américas]

Con millones de personas en el mundo en situación de distanciamiento físico por el COVID-19, las tecnologías de la información y comunicaciones (TICs) se han posicionado como uno de los medios principales de interacción y colaboración. Ya al inicio de este milenio se empezaban a mencionar las siguientes ventajas: mayor acceso a la información y a la prestación de servicios; fortalecimiento educativo; control de calidad de los programas de detección y reducción de los costos de la atención de en salud. Sin embargo, entre las principales barreras de adopción de la telemedicina se encuentran las de índole: tecnológicas; humanas y sociales; psico-sociales y antropológicas; de Gobernanza y económicas. En estos 20 años se logró un aumento en los recursos y capacidad técnica, una mejora en la educación digital, un empoderamiento del paciente en su tratamiento y un mayor interés público en esta área. En especial se considera exitosa la conformación de equipos interdisciplinarios, las redes académicas y profesionales y las consultas médicas virtuales. Después de revisar el estado de la telemedicina en la Región de las Américas, los autores recomiendan adoptar medidas urgentes para poner en práctica políticas y programas nacionales de telemedicina, incluyendo el marco normativo y presupuesto necesario, cuya implementación se realice de manera integral e interoperable y que se sustente de redes académicas, de colaboración e instituciones especializadas. Dichas políticas deben generar un contexto habilitante que den sostenibilidad al avance logrado, considerando los aspectos mencionados en las posibles barreras.

Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries

Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs.

Comparison of transanal and external perineal ultrasonography

Anal endosonography with rotating endoprobes provides state-of-the-art imaging of sphincter integrity; however, the technique is not widely available and requires expensive equipment. Since pelvic anatomy permits the use of standard external ultrasound probes, we tested the feasibility, tolerance and reproducibility of uniplanar perineal sonography, with respect to visualisation of the anal sphincter, using both convex and linear 3.5- to 7.5-MHz and 360 degree rotating 7-MHz probes. Twenty healthy nulliparus female volunteers were investigated. Two operators performed endosonography and perineal sonography in duplicate, each blinded to the findings of the other. We then used this technique to examine 20 postpartum primiparus patients. The examination was well tolerated by all subjects. The internal anal sphincter appeared in perineal sonography as a hypoechogenic ring surrounded by an echogenic ring representing the external anal sphincter. Endosonography revealed six sphincter tears, four external and internal sphincter tears, one isolated external tear and one isolated internal tear. Perineal sonography recognised in all cases external sphincter tears. In one case the internal sphincter defect was missed. Perineal sonography appears to be a feasible alternative to anal endosonography in female patients and provides good information on external sphincter defects suggesting that this procedure might be particularly useful in incontinence screening. Perineal sonography gives a good image of internal sphincter. The lack of an isolated internal defect cannot be considered as relevant to our study.

[Multidisciplinary management of hereditary colorectal cancer]

AIM

The aim of this study was to assess the feasibility and success of multidisciplinary approach for the management of hereditary colorectal cancer.

MATERIAL AND METHODS

From November 1998 to November 2000, 32 individuals with putative familial/hereditary predisposition to colorectal cancer were investigated for adenomatous polyposis (attenuated or classical familial adenomatous polyposis coli, FAP) or for hereditary nonpolyposis colorectal cancer (HNPCC). Amsterdam criteria (I and II) and Bethesda guidelines were used to select putative HNPCC kindreds. Clinical data including endoscopy, pathological and operative reports as well as family history were collected. Pre- and post-test genetic counseling was offered to at-risk individuals. Genetic testing included microsatellite instability (MSI) and search for germline mutations in the APC, hMSH2 and hMLH1 genes. Immunohistochemistry (IHC) of hMSH2 and hMLH1 protein expression in tumour samples was also performed.

RESULTS

11 APC mutations were characterized, whereas four mutations in HNPCC genes were found in hMSH2 (2) and in hMLH1 (2). MSI and IHC correlated completely for cases with identified pathogenic mutation (100%).

CONCLUSION

A thorough evaluation and management of hereditary colorectal requires a multidisciplinary approach. Thus, more mutation carriers can be identified and benefit from appropriate genetic counselling, while non-carrier individuals are relieved from unnecessary surveillance.

Intra-arterial chemotherapy in locally advanced or recurrent carcinomas of the penis and anal canal: an active treatment modality with curative potential

The prognosis of locally advanced or recurrent carcinomas of the penis (PE) and of the anal canal (AC) after conventional treatment is dismal. We report 16 patients (eight with AC carcinomas and eight with PE cancers) treated by intra-arterial (IA) chemotherapy. Fifteen of them were treated for locally advanced or recurrent disease and one in an adjuvant setting. The chemotherapy was administered via a femoral IA catheter with its tip located above the aortic bifurcation, under the inferior mesenteric artery. It consisted of eight push injections, given over a 48-h period, of the following drug combination: cisplatin 8.5 mg m(-2), 5-FU 275 mg m(-2), methotrexate 27.5 mg m(-2), mitomycin C 1.2 mg m(-2), and bleomycin 4 mg m(-2). Leucovorin was given po, 4 x 15 mg day(-1), during the chemotherapy and for 3 days thereafter. A total of 52 cycles of treatment were administered. Of the 15 patients evaluable for response, six obtained a CR (three PE, three AC) and eight a PR. Among the complete responders, four are alive and disease-free 2-15 years after treatment. The other patients enjoyed an objective response lasting 3-25 months (median 7 months). Four patients developed grade III/IV haematological toxicity with three episodes of febrile neutropenia, one of them with a fatal outcome due to patient's failure to obtain medical attention at the onset of his fever, one a grade III mucositis of the glans, and four a grade III/IV cutaneous toxicity, the latter caused by the IA administration of bleomycin. In conclusion, IA chemotherapy is effective and potentially curative in locoregionally advanced or recurrent carcinomas of the penis and of the anus. Its contribution in the primary management of advanced penile or anal carcinoma should be prospectively investigated.

Effectiveness of surgical salvage therapy for patients with locally uncontrolled anal carcinoma after sphincter-conserving treatment

BACKGROUND

Locally persistent or recurrent anal carcinoma represents a clinically significant problem, the management of which remains the subject of some controversy. Although the few current data suggest that radical surgery remains the sole salvage treatment able to provide some chance of cure, some authors have reported disappointingly low success rates. The current study presents the outcome of patients who failed locally after receiving radiotherapy or chemoradiotherapy for anal carcinoma.

METHODS

Of 185 consecutive patients treated between January 1976 and December 1996 with sphincter conservation, 42 subsequently presented with local failure, either alone (27 patients) or with regional or distant metastases (15 patients). Nine patients (21%) received supportive care only, 7 patients (17%) received palliative therapy, and 26 patients (62%) underwent potentially curative surgical salvage treatment, including 23 abdominoperineal resections (APR) and 3 local excisions. The median follow-up after local failure for all patients was 21.5 months (range, 1-231 months).

RESULTS

With the exception of 2 patients who committed suicide, all patients who did not undergo surgical salvage therapy died of progressive disease. Among 26 patients who received curative treatment, 11 ultimately achieved disease control. The 5-year overall survival rate after the diagnosis of local failure was 28% for all patients and 44.5% for those receiving curative salvage treatment. For the latter group the 5-year actuarial secondary local and locoregional control rates were 53% and 43%, respectively.

CONCLUSIONS

Although APR no longer is the first-line treatment of patients with anal carcinoma, it continues to play an essential role in salvage therapy, resulting in ultimate disease control in approximately 50% of patients with isolated local failure. The curative potential of secondary surgical treatment suggests the possible importance of early detection of persistent or recurrent local disease after nonsurgical, sphincter-conserving therapy.

Effectiveness of surgical salvage therapy for patients with locally uncontrolled anal carcinoma after sphincter-conserving treatment

BACKGROUND

Locally persistent or recurrent anal carcinoma represents a clinically significant problem, the management of which remains the subject of some controversy. Although the few current data suggest that radical surgery remains the sole salvage treatment able to provide some chance of cure, some authors have reported disappointingly low success rates. The current study presents the outcome of patients who failed locally after receiving radiotherapy or chemoradiotherapy for anal carcinoma.

METHODS

Of 185 consecutive patients treated between January 1976 and December 1996 with sphincter conservation, 42 subsequently presented with local failure, either alone (27 patients) or with regional or distant metastases (15 patients). Nine patients (21%) received supportive care only, 7 patients (17%) received palliative therapy, and 26 patients (62%) underwent potentially curative surgical salvage treatment, including 23 abdominoperineal resections (APR) and 3 local excisions. The median follow-up after local failure for all patients was 21.5 months (range, 1-231 months).

RESULTS

With the exception of 2 patients who committed suicide, all patients who did not undergo surgical salvage therapy died of progressive disease. Among 26 patients who received curative treatment, 11 ultimately achieved disease control. The 5-year overall survival rate after the diagnosis of local failure was 28% for all patients and 44.5% for those receiving curative salvage treatment. For the latter group the 5-year actuarial secondary local and locoregional control rates were 53% and 43%, respectively.

CONCLUSIONS

Although APR no longer is the first-line treatment of patients with anal carcinoma, it continues to play an essential role in salvage therapy, resulting in ultimate disease control in approximately 50% of patients with isolated local failure. The curative potential of secondary surgical treatment suggests the possible importance of early detection of persistent or recurrent local disease after nonsurgical, sphincter-conserving therapy.

Treatment of anal carcinoma in the elderly: feasibility and outcome of radical radiotherapy with or without concomitant chemotherapy

BACKGROUND

For most cancers, information on treatment tolerance and results for elderly patients is quite limited. This study was conducted to investigate the feasibility and results of curative nonsurgical treatment of patients age 75 years or older with anal carcinoma.

METHODS

From January 1976 through June 1996, invasive anal squamous cell carcinoma was diagnosed in 58 patients age > or = 75 years. Curative treatment was administered to 47 patients (81%), of whom 42 received radiotherapy (RT), either used alone (21) or associated with concomitant chemotherapy (CT). RT was administered in two sequences, the first in which a median dose of 39.6 gray (Gy) was delivered with megavoltage photon beams, followed (after a median interval of 43 days) by a boost with either brachytherapy or external beam (median dose, 20 Gy). CT started on Day 1 and generally consisted of 1 cycle of mitomycin C (MMC; median dose, 9.5 mg/m2) and a 96-hour infusion of 5-fluorouracil (5-FU; median dose, 600 mg/m2/day). The median follow-up for all patients was 48 months (range, 5-163 months).

RESULTS

Of 40 patients (95%) who completed curative treatment, acute toxicity resulted in shortening of the planned first irradiation sequence in 2 patients (1 in each group) and an unplanned treatment break in 11 patients (4 in the RT group and 7 in the RT-CT group). Grade 2 and 3 acute reactions (RTOG) were observed in 43% and 54% of patients, respectively. Among all Grade 3 reactions, 32% occurred in the RT group and 68% in the RT-CT group. In patients receiving RT-CT, Grade 2-3 leukopenia was observed in 25% of patients, Grade 2-3 fatigue was observed in 58% of patients, and Grade 2 cardiac toxicity related to 5-FU occurred in 1 patient. At 5 years, the overall survival was 54% (49% and 59% for the RT and RT-CT groups, respectively, P = 0.28), and the actuarial local control rate was 78.5% (73% and 83% for the RT and RT-CT groups, respectively, P=0.36). Five patients presented with Grade 3-4 late complications, all of them in the RT-CT group.

CONCLUSIONS

The current series confirms the feasibility of sphincter-conserving treatment for elderly patients who present with anal carcinoma. Rates of acute or late complications appeared similar to those observed in younger patients, and the oncologic results were at least as favorable as those commonly reported.

[Traumatic lesions of the anorectum]

Injuries of the colon and rectum are common surgical problems. Lesions can be classified into four groups according to the site of damage and the presence of sphincter tears: 1. intraperitoneal perforation without sphincter damage 2. intraperitoneal perforation with sphincter damage 3. extraperitoneal perforation without sphincter damage 4. extraperitoneal perforation with sphincter damage From 1990 to 1998, 11 patients, 7 males and 4 females presenting an anal and/or rectal trauma were admitted in Geneva University Hospital. 8 patients were admitted as an emergency, the 3 others had been transferred to correct an incontinent post traumatic pathology. No mortality. A terminal colostomy was performed in all patients with intraperitoneal injury and in 5 patients with combined extraperitoneal and anal sphincter injury. All sphincter lesions were sutured as an emergency (6 cases). In 3 patients we performed an overlapping sphincteroplasty. 2 patients with persisting incontinence were cured by a dynamic stimulated graciloplasty. The choice of treatment of anorectal trauma includes broad spectrum antibiotherapy, cleaning of the rectum, sphincter repair. A terminal diverting colostomy and laparotomy must be achieved in case of intraperitoneal injury, large extraperitoneal lesion, severe perineal laceration with or without pelvic fracture.

Rubber band ligation of hemorrhoids: relapse as a function of time

Rubber band ligation is a well established treatment of internal second-degree hemorrhoids. Up to now, the long-term results (> 5 years) of this method have not been assessed. The aim of this study was to determine the long-term success rate of rubber band ligation in patients with a first episode of second-degree hemorrhoids not responding to medical treatment (local cream with laxative). A total of 92 patients who were treated between 1979 and 1997 for second-degree hemorrhoids responded to a questionnaire. The need for complementary conservative (sclerotherapy, cryotherapy or rubber band ligation) or surgical treatment was considered indicative of relapse. The collected data were analyzed according to the Kaplan-Meier method. The average follow-up time was 5.6 years. There were 21 patients who suffered a relapse. The probability of successful treatment was 0.77 (range: 0.67-0.88) after 5 years and 0.68 (range: 0.5-0.86) after 10.6 years. We conclude that rubber band ligation represent an efficient long-term treatment for second-degree hemorrhoids. Approximately two thirds of the patients are cured after 5 years and more than a half after 10 years.

Papillomavirus and anal carcinoma

Human papilloma virus (HPV; 16 and 18) is known to play an important etiologic role in cervical dysplasia, but its relationship with anal carcinoma is still unclear. Surgical samples from 80 female patients treated for anal epidermoid carcinoma in the Polyclinic of Surgery in Geneva between 1976 and 1989 were retrospectively studied. Of these, HPV detection was performed in 41 whose DNA was preserved well enough to allow such an analysis. Seventeen (42%) samples contained HPV, with a high percentage of high risk HPV (15/41, 36%). Thirty-eight of the 80 patients had a cervical smear, of which 18% revealed cervical carcinoma. When compared with epidemiological data, the results of this study suggest that genital HPV infection predisposes not only to cervical cancer, but also to anal carcinoma, possibly by means of contiguous contamination.

[Treatment of fecal incontinence by overlapping sphincteroplasty]

The authors describe overlapping sphincteroplasty for the reconstruction of injuried anal sphincters. This technique was applied for obstetric, surgical and traumatic injuries i 57 patients. Both anal sphincters were injuried in 37 cases. A single damage of the external sphincter was observed in 20 cases. The anal sphincteric function has been evaluated pre and postoperatively according to Miller's scale (clinical criteria) and by manometry. The manometric studies were performed in 49 patients. Maximal resting tone, maximal squeeze pressure and the anal canal length were studied preoperatively and 6 months after the reconstruction. The functional results were excellent and good in 93% of patients. The improvement of maximal squeeze pressure and anal canal length were statistically significant.

Impact of clinical and therapeutic factors on major late complications after radiotherapy with or without concomitant chemotherapy for anal carcinoma

PURPOSE

To investigate factors potentially influencing major late morbidity after sphincter-conserving treatment for anal carcinoma.

METHODS AND MATERIALS

Grade 3-4 complications were retrospectively analyzed in 144 evaluable patients (pts), 55 pts after split-course radiotherapy (RT), and 89 after concomitant chemo-RT. First sequence RT delivered a median dose of 39.6 Gy using megavoltage photon beams. Boost treatment used either 192Ir implantation or external beam RT (median dose 20 Gy). Chemotherapy started on day 1 and in 83% of pts consisted of Mitomycin-C (10 mg/m2) and a 5-day infusion of 5-fluorourcil (600-800 mg/m2/day). Uni- and multivariate analyses tested the association of following factors with complication rate: age, gender, stage, anatomic tumor extent, type of biopsy, external RT technique (dose, fraction size, field arrangement), boost type (brachytherapy vs. external), brachytherapy dose and dose rate, overall treatment time, and addition of chemotherapy.

RESULTS

Five-year actuarial complication rate was 16%. Two variables were significantly associated with complication rate: anatomic tumor extent (canal or margin vs. both +/- rectum; 10 vs. 31% complications, p = 0.0004) and first sequence prescribed dose (< 39.6 Gy vs. > or = 39.6 Gy; 7 vs. 23% complications, p = 0.012), confirmed as independent factors by Cox analysis. Grade 4 anal morbidity correlated significantly with prior local excision. All six bone complications were observed in pts treated by chemo-RT using large pelvic fields, five occurring in pts older than 66.

CONCLUSION

Pts with tumors involving more than one anatomic subsite or treated with the higher first sequence RT dose are at greater risk of major complications. Prior tumor excision and combined modality therapy in older pts appear to favor major anal and bone complications, respectively.

The impact of treatment factors on local control in T2-T3 anal carcinomas treated by radiotherapy with or without chemotherapy

BACKGROUND

This study was conducted to investigate the influence of therapeutic parameters on local control (LC) in the sphincter-conserving treatment of T2-T3 anal carcinoma.

METHODS

From 1976 to 1993, 137 patients with anal carcinoma classified as T2 (85 patients) or T3 (52 patients) were treated curatively by radiotherapy (RT) alone (54 patients) or by concomitant chemotherapy and RT (83 patients). RT was delivered in two sequences, with a median gap of 46 days between the sequences. The first sequence was delivered at a median dose of 39.6 gray (Gy) using megavoltage photon beams. Boost treatment consisted of either 192Ir implantation or external beam RT (median dose, 20 Gy). Chemotherapy started on Day 1 and generally consisted of 1 cycle of mitomycin C (10 mg/m2) and a 5-day infusion of 5-fluorouracil (600-800 mg/m2/day). For surviving patients, median follow-up was 83 months. Univariate and multivariate analyses were performed to determine therapeutic parameters affecting LC after adjustment for clinical factors.

RESULTS

The 5-year actuarial LC was 76%. Factors associated with poorer LC (univariate) were as follows: age < 66 years (LC was 67% with the factor vs. 85% without), male gender (65% vs. 81%), tumor extent > 1/3 canal circumference (67% vs. 90%), lymph node involvement (64% vs. 81%), use of external beam boost (62% vs. 79%), and overall treatment time (OTT) > or = 75 days (69% vs. 85%). In multivariate analysis, no therapeutic parameters remained significant when adjusted for significant clinical factors, although OTT was of borderline significance (P = 0.09).

CONCLUSIONS

The results of this multivariate analysis suggest that therapeutic factors have a less marked effect on LC compared with clinical parameters; the only factor that appeared to have some effect was OTT. Efforts to improve LC in patients with poor prognoses should concentrate on optimizing OTT and the chemotherapeutic aspects of treatment (in other words, attempts should be made to provide more effective agents and optimize scheduling).

The impact of treatment factors on local control in T2-T3 anal carcinomas treated by radiotherapy with or without chemotherapy

BACKGROUND

This study was conducted to investigate the influence of therapeutic parameters on local control (LC) in the sphincter-conserving treatment of T2-T3 anal carcinoma.

METHODS

From 1976 to 1993, 137 patients with anal carcinoma classified as T2 (85 patients) or T3 (52 patients) were treated curatively by radiotherapy (RT) alone (54 patients) or by concomitant chemotherapy and RT (83 patients). RT was delivered in two sequences, with a median gap of 46 days between the sequences. The first sequence was delivered at a median dose of 39.6 gray (Gy) using megavoltage photon beams. Boost treatment consisted of either 192Ir implantation or external beam RT (median dose, 20 Gy). Chemotherapy started on Day 1 and generally consisted of 1 cycle of mitomycin C (10 mg/m2) and a 5-day infusion of 5-fluorouracil (600-800 mg/m2/day). For surviving patients, median follow-up was 83 months. Univariate and multivariate analyses were performed to determine therapeutic parameters affecting LC after adjustment for clinical factors.

RESULTS

The 5-year actuarial LC was 76%. Factors associated with poorer LC (univariate) were as follows: age < 66 years (LC was 67% with the factor vs. 85% without), male gender (65% vs. 81%), tumor extent > 1/3 canal circumference (67% vs. 90%), lymph node involvement (64% vs. 81%), use of external beam boost (62% vs. 79%), and overall treatment time (OTT) > or = 75 days (69% vs. 85%). In multivariate analysis, no therapeutic parameters remained significant when adjusted for significant clinical factors, although OTT was of borderline significance (P = 0.09).

CONCLUSIONS

The results of this multivariate analysis suggest that therapeutic factors have a less marked effect on LC compared with clinical parameters; the only factor that appeared to have some effect was OTT. Efforts to improve LC in patients with poor prognoses should concentrate on optimizing OTT and the chemotherapeutic aspects of treatment (in other words, attempts should be made to provide more effective agents and optimize scheduling).

Tailgut Cyst, an unusual evolution

Developmental Tailgut Cyst (TGC) arise in the presacrococcygeal space. Most of these cysts are discovered during rectal examination. They may be the source of chronic perirectal symptoms but rarely undergo malignant change. There is a female predominance and TGC may grow to a considerable size. Biopsy and drainage lead to recurrence and infection. TGC, even when asymptomatic, should be totally excised.

Application of formaldehyde for treatment of hemorrhagic radiation-induced proctitis

Radiation-induced proctitis with hemorrhage is not a common complication of radiotherapy to the pelvis for carcinoma. In the most severe forms, massive hemorrhage may necessitate repeated transfusions and inpatient treatment. In severe cases medical treatment has not been proved effective. Surgery may lead to serious complications and is technically difficult. Six patients who showed a hemorrhagic radiation-induced proctitis have been treated as outpatients with application of formaldehyde 4%. In four cases the bleeding ceased after the first formaldehyde application; two patients continued to bleed, but another application of formaldehyde 3 weeks later definitively controlled the hemorrhage. Follow-up evaluation at 12 months showed in each case that the hemorrhage was controlled and treated. There were no complications, such as burns or late stenoses of the deep layers of the rectum. This inexpensive technique is well tolerated by the patient, gives good long-term results, and is available at every hospital. Local application of formaldehyde 4% to the rectum may be the treatment of choice for hemorrhagic radiation-induced proctitis.

[Pelvic pain of proctological origin]

Pelvic pain of anorectal origin should be carefully investigated. The detailed clinical history may be sufficient to establish diagnosis and determine the etiology of anorectal pain. The diagnosis should be confirmed by complementary clinical investigations. The diagnosis of essential anorectal pain can be established only after failure of measures instituted to correct organic lesions and if pain persists. Among types of essential anorectal pain, coccygodinia and nervus pudendus entrapment are responsive to precise and effective management.

Results of sphincter repair in postobstetric fecal incontinence

BACKGROUND

Postobstetric fecal incontinence is a rare and severe complications of vaginal delivery. Most often, it is the result of a tear of the anal sphincter, pudendal neuropathy, or a combination of the two.

STUDY DESIGN

Thirty-six patients operated upon at our institution for postobstetric fecal incontinence during a ten year period (1983 to 1992) were questioned (score) and examined to assess the operative results.

RESULTS

Preoperatively, all 36 patients (mean age of 37 years, range of 24 to 70 years) had sphincter tears and 32 patients were totally incontinent (score of 16 to 18). Three patients were moderately incontinent (score of 9) and one patient was incontinent of flatus only (score of 3). Eighty percent of the patients were referred with delay. Thirty-six sphincteroplasties with various degrees of rectovaginal and perianal reconstructions were performed. Twenty-eight women (78 percent) are continent (score of zero to 3), seven patients (19 percent) are partially incontinent (score of 4 to 6), and one patient (3 percent) is totally incontinent (score of 18). There was no mortality. Among the six postoperative complications, there were two sphincter breakdowns with persistent incontinence and four minor local complications.

CONCLUSIONS

Careful assessment and operative management of sphincter damage at the time of delivery as well as counseling of all women at risk for fecal incontinence are essential. Sphincteroplasty is a simple and safe procedure that offers symptomatic relief in almost all patients with sphincter lesions and cure in 80 percent.

Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison

PURPOSE

To evaluate the effect of adding one cycle of concomitant chemotherapy to curative radiotherapy on tumor control and toxicity in the treatment of anal cancer.

METHODS AND MATERIALS

One hundred twenty-five patients completed curative sphincter-conserving treatment, 57 with radiotherapy alone and 68 with concomitant chemo-radiotherapy. Compared with chemoradiotherapy patients, radiotherapy patients were older (median age 71 vs 63) and had less advanced tumors (T3-4 26% vs 51%). Radiotherapy patients were usually treated with a direct perineal cobalt field (mean dose 31 Gy at 5 cm/10 fractions/3 weeks), complemented in most cases by a sacral are field, followed (mean split 54 days) by Iridium-192 implantation (mean dose 23 Gy, Paris system). The large majority of chemoradiotherapy patients received antero-posterior opposed 10 MV photon fields, including pelvic and inguinal nodes (mean dose 38 Gy/19 fractions/4 weeks), followed (mean split 42 days) by implant boost (mean dose 18 Gy). In addition, chemo-radiotherapy patients received starting on day 1 an IV bolus of Mitomycin-C, 0.4 mg/kg (maximum 20 mg) and a 5-day continuous infusion of 5-fluorouracil 600-800 mg/m2/day. Median follow-up was 65 months for radiotherapy and 48 months for chemo-radiotherapy patients.

RESULTS

For all 125 patients at 5 years, overall survival was 65.5%, definitive local control 83% and local control with sphincter preservation 68%. Overall and stage for stage, there was no difference in overall, progression-free or cancer-specific survival, nor in local control, local-regional control, or sphincter preservation rates between patients treated with chemoradiotherapy vs. radiotherapy alone. There was no significant difference between the two groups regarding acute or late toxicity.

CONCLUSION

This retrospective analysis does not confirm the efficacy of one course of simultaneous Mitomycin-C and 5-fluorouracil, at least in association with full-dose radiotherapy incorporating Iridium-192 boost.

[Multiple tumors of colon and rectum]

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was 1.1% and that of metachronous carcinomas 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinoma was observed. The 5-year actuarial survival in case of curative resection was 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

[Multiple tumors of the colon and rectum]

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with a carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was of 1.1% and that of metachronous carcinomas of 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinomas was observed. The 5-year actuarial survival in case of curative resection was of 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

[Ambulatory proctologic surgery]

An increasing number of proctological procedures may be performed on outpatients under extensive local anesthesia or by posterior perineal bloc. Precise selection criteria should be observed. Results of 1233 outpatients procedures are reported.

[Mucosal flap in the treatment of anal fistula]

A technique of sliding flap repair for the treatment of anal fistulae is described. This technique may prevent sphincter damage. Fifty-five consecutive fistulae have been treated: 23 transsphincteric, 26 intersphincteric, 3 suprasphincteric and 3 rectovaginal fistulae. The fistulous tract is excised and cored out. The intersphincteric space is opened: any gland or inflammatory tissue is removed. The internal opening is excised. The gaps in the internal, as well as in the external, sphincter are closed. The endo-anal wound is closed, using a sliding flap of anorectal mucosa. The ischiorectal wound is left open. Healing has been achieved in every case but one within three weeks, without sphincteric functional defect. Only 3 recurrences have been observed in a mean follow-up of 24 months.

[Mucosal flaps in the treatment of anal fistula]

Results in the treatment of transsphincteric et suprasphincteric fistulae have been greatly improved with the use of mucosal sliding flaps. The aims of this surgical procedure are: division of the fistulous tract from the primary opening within the anal canal, closure of the primary opening to prevent any repermeabilisation of the tract, excision and curettage of fistulous tract without section of the sphincters. Technical details of this procedure and results achieved in the treatment of 30 consecutive cases are reported.

[Epidermoid cancers of the anal canal]

The frequency of anal epidermoid carcinoma is constantly increasing. Despite the fact that such cancers are easily detectable through rectal examination, anuscopy or biopsy, diagnosis is delayed in 30 to 50% of the cases due to late and unspecific clinical features, often mistaken for benign lesions. Prognosis of anal epidermoid carcinoma has radically improved due to a better knowledge of the tumour's natural history and of its spreading, to new stage classification (UICC-TNM) and to association fo external or interstitial radiotherapy with chemotherapy. Recovery rates of 80% can be achieved nowadays, 75% of which being obtained with complete sphincter preservation. Subsequent actinic lesions are rare. Surgery is now essentially proposed in these cases of therapeutic failure and consists in a rectal excision. Treatment of such tumours requires a multidisciplinary approach and a close collaboration between surgeon, radiotherapist and oncologist.

[Ambulatory proctologic surgery]

Outpatient surgical proctology is nowadays more and more frequently performed. Between 1986 and 1989, 65% of 1149 anal surgical procedures were performed in our institution on an outpatient basis. The various criteria used to select patients fit for ambulatory surgery seemed adequate, as no complications were observed and no patient required secondary hospitalization.

[The past and future of proctology]

Since antiquity, surgical treatments of anorectal lesions were performed by barbers and surgeons; proctology became with time a surgical speciality well defined and recognized todays. History of proctology is illustrated by some important figures and events: St. Fiacre, Felix the surgeon who operated on King Louis XIV's fistula and the acutely thrombosed hemorrhoidal prolapse of Napoleon.

[Incontinence and supra-continence as complications of anorectal surgery]

Incontinence and supra-continence may complicate various ano-rectal surgical procedures. These troubles result from modifications of the ano-rectal angulation, troubles of rectal sensitivity and neurological pathways, direct or functional sphincter damage and modification of the reservoir function of the rectum. These various disorders should be prevented by careful surgery. If they occur, detailed investigations should help to choose the best therapy: medical and bio-feedback treatment or surgical correction.

Sclerotherapy of rectal varices

Rectal varices represent a rare condition even in cases of portal hypertension. A case of bleeding ano-rectal varices presenting as the first manifestation of portal hypertension is reported. Treatment by sclerotherapy was successful.

Comparative study of ceftriaxone and cefoperazone in the treatment of acute cholecystitis

Forty patients with acute cholecystitis were divided into two randomized groups on the basis of the emergency antimicrobial therapy received, and were treated for a period of 5 days. The first group was given ceftriaxone (Rocephin), the second cefoperazone (Cefobis). This concomitant antimicrobial treatment of acute cholecystitis proved to be effective in 85% of the patients; 15% underwent 'à chaud' surgery on the 6th day because of a lack of response to the treatment. Ceftriaxone and cefoperazone proved to be equally effective. Use of ceftriaxone, however, was simpler (one injection a day) and the cost of treatment substantially lower.

Mallet fractures

Contrary to our observations, reports in the literature maintain that only a third of mallet finger deformities are caused by intra-articular fractures of the posterior margin of the distal phalanx. As functional impairment sometimes remains after treatment, there is still much discussion as to the relative merits of conservative and surgical management of this lesion. This article presents 21 cases of mallet finger deformities with fracture of the distal phalanx, of which 17 received surgical treatment. The operative technique is described, followed by a discussion of the results.

Traumatic lesions of the rectum

Twenty-two patients treated for rectal trauma between 1975 and 1985 were reviewed. There were 13 males and nine females, of mean age 38 years (18-72 years). Causes included gunshot (2), sexual trauma (8), road accident (5), impalement (5), polypectomy (2). Two patients died, giving a treatment mortality of 9%. Cases with peritonitis or sphincter injury were treated by defunctioning colostomy and immediate repair of rectum and sphincter. Of 14 such patients the colostomy had been closed in all but one, who accounted for the only failed sphincter repair out of eight performed. The results show the success of a policy of faecal diversion for intraperitoneal rectal injury and sphincter damage and of local repair without diversion for most cases with extraperitoneal rectal injury.