[Fecal incontinence - symptoms are guiding therapy]

Fecal incontinence (FI) is an escalating medical problem. Due to increasing life expectancy FI becomes more evident, especially in the geriatric population. The prevalence varies from 4 % in the adult population reaching > 50 % in the octogenerians, yet most probably associated with a significant based error due to underreporting. Diagnosis is depending primarily upon history taking and gathered information from the patient and caregivers. Additional technical diagnostic procedures are of secondary importance. In most cases no single cause for FI can be identified, mostly multifactorial disorders contribute to a progressive loss of anorectal continence. The mainstay in therapeutic approaches to control symptoms comprise changes in lifestyle patterns, physiotherapy and medical therapy, but depend on the patient's compliance. Invasive or even surgical treatments are circumstantial, although sacral neuromodulation has proofed to be a successful treatment modality during the past decades. Ultimately a permanent stoma may lead to symptom control and result in an increased quality of life.

German S3 guidelines: anal abscess and fistula (second revised version)

BACKGROUND

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.

METHODS

This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.

RESULTS

Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.

CONCLUSION

In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

[The anal fistula disease and abscess]

There are two forms of anal fistulas arising from its pathogenesis: the acute stage is the abscess, whereas the chronic stage is the fistula in ano. The classification of the fistula in ano is named after Parks. Pathogenesis and classification are explained. For complete cure, every abscess needs precise examination to be able to show the course and shape of the fistula. The surgical procedure depends on the fistula tract. Most fistulas can be operated by means of a fistulotomy or fistulectomy. Recovery depends on locating the total fistula tract.

Serum free prostate specific antigen: isoenzymes in benign hyperplasia and cancer of the prostate

Prostate specific antigen (PSA) in serum of patients with benign prostatic hyperplasia (BPH) or prostate cancer (P-CA) not bound to alpha-1-antichymotrypsin (ACT) was analyzed by chromatofocusing. The procedure allowed the simultaneous separation of complexed and free PSA and the fractionation of the free PSA fraction into several isoenzymes. The detection of the isoenzymes was strongly dependent on the combination of antibodies introduced in the applied commercially available immunoassays (Cobas Core, Delfia). Isoenzymes in sera of patients with benign prostatic hyperplasia were mainly situated in the pI range of 6.6 to 7.3. Isoenzymes in sera of prostate cancer patients or in PSA from LNCAP cells were mainly situated in the pI range 7.0 to 8.3. Neuraminidase treatment of the sera shifted the isoelectric points of all three sources towards more basic pHs. An irregular glycosylation process in the dysplastic cells of the prostate is suggested to be the cause for the shift of the isoelectric points. The difference of isoenzyme distribution along the pH axis is discussed as a diagnostic tool to differentiate between BPH and P-CA.

In vivo and in vitro complex formation of prostate specific antigen with alpha 1-anti-chymotrypsin

Complex formation of prostate specific antigen (PSA) with its inhibitor alpha 1-anti-chymotrypsin (ACT) in vivo and in vitro was studied. Patients with benign prostatic hyperplasia (BPH) were treated with the computer assisted device "Prostatron." This instrument acts by means of thermal destruction of prostatic tissue. The effect of the treatment was followed by measurement of serum PSA concentrations using commercially available immunoassays from Roche (Cobas Core), Wallac (Delfia) and Abbot (IMx) and Hybritech Tandem. Serum samples were further analyzed by molecular sieving on S.300 (Pharmacia) and analyzed for PSA by immuno assay. The complex formation of PSA with ACT in serum was studied, demonstrating this process to be influenced by external stimulus. Patient sera revealing initially normal PSA levels (3 to 5 ng/ml) were stimulated to very high levels of PSA (> or = 140 ng/ml) by Prostatron treatment. The absolute PSA level depends on the assay system and not only on the staging of the prostate tumor. In addition, complex formation was studied in athymic nude mice and in vitro revealing the possible pathways of PSA release. PSA from LNCAP cells kept in vitro show predominantly uncomplexed (free) PSA, whereas PSA from LNCAP cells injected into nude mice appears in the serum of the animals in complexed form. This demonstrates how in the immunization process free and complexed PSA serve as antigens in the standard procedure for the production of antisera for PSA. This model system also can be used for studies of the release mechanism of PSA into blood circulation.

[Obstetric complications, incidence and indications of cesarean section in uterus myomatosus]

An increasing percentage of patients with uterine leiomyomas was observed in the Department of Obstetrics, University of Freiburg, on comparing the years 1970-79 (0.25%) and 1980-89 (0.64%). While first trimester bleeding, pain and premature labour, being typical obstetrical complications, were encountered in a comparable frequency, atonic bleeding was observed more often during the nineteen-eighties. Pain and premature labour were often present, if the leiomyomas were large, irrespective of both their number or localization. Atonic bleeding was observed more frequently, if large leiomyomas were present. A correlation between the presence of uterine leiomyomas and placental deficiency, premature birth, and EPH gestosis seems uncertain. The total complication rate among all pregnant patients with uterine leiomyomas was 65% from 1980-89. The Caesarean section rate among patients with uterine leiomyomas increased during the evaluated time span, and reached 51% during the 1980's, as compared to a general frequency of Caesarean sections of 19% during the latter time period; this increase in frequency seems to be rather in keeping with a generally increasing Caesarean section rate as opposed to a changing indication for surgery in patients with myomas. The myomas themselves caused Caesarean sections in 50% of cases, while in the remaining 50% of patients, Caesarean sections were performed for general obstetrical reasons. The probability to be delivered by Caesarean section was especially high amongst patients with multiple myomas or with an isthmic myoma. Our study supports a conservative approach in the case of pregnancy and uterine leiomyomas.

[Sonographic acute and follow-up diagnosis after blunt abdominal trauma]

Experience with ultrasonographic acute and follow-up diagnostic as noninvasive imaging procedure for blunt abdominal trauma was analysed in a retrospective study. Between 1986 and 1989 166 organ lesions were noticed in 440 patients with clinically regarded diagnosis of a blunt abdominal trauma. 107 patients were laparotomised. Retrospectively, the sensitivity concerning free fluid in the abdominal cavity caused by lesion of an intrabdominal organ was 0.96 and the specifity 0.98. The predictive value of a positive test was 0.91 and the predictive value of a negative test was 0.99. The rate of negative laparotomy was 1.3%. Thus the sole use of ultrasonographic diagnostic and the non-use of peritoneal lavage seems justified in case of blunt abdominal trauma. Some figures illustrate typical cases and our own results.

[Postoperative hemorrhage]

Postoperative hemorrhage is the second most frequent indication for early relaparotomy. The incidence depends on the level of care in a given hospital. It is highest, therefore, in institutions delivering maximal care with many trauma cases. We performed 3443 laparotomies from January 1988 to March 1991. 214 (5.9%) patients had to be reoperated, 48 of them because of postoperative bleeding. This amounts to 1.3% of the total number of laparotomies. Bleeding was identified through drains, ultrasonography or endoscopy, ultrasonography having the highest sensitivity and specificity. Total mortality was 30%. Analysis of the literature shows that mortality is lowest when relaparotomies are performed on 3%-6% of patients.

[Injuries of the small and large intestine following blunt abdominal trauma]

From 1979 to 1987 1428 patients with blunt abdominal trauma were treated in the Department of Surgery of the University of Freiburg; 119 patients had intestinal injuries. They were mainly young adults who had sustained a car accident. 71.3% of the small bowel injuries were overseen, 14.2% needed resection, and in 14.5% an operative procedure was not necessary. The surgical procedure for colonic injuries has to be chosen with regard to the age and general condition of the patient, to the severity of the trauma, to associated injuries and to the stage of peritonitis. Accordingly, 18% of the patients were treated with and 58% without a protective colostomy, 24% could be treated conservatively. Mortality and morbidity correlated with the severity of associated injuries. Morbidity was also dependent on the time interval between accident and operative therapy.

[Ultrasound diagnosis following blunt abdominal trauma. Sonography in acute and follow-up diagnosis]

Experience with ultrasonography as a non-invasive imaging procedure for acute and follow-up diagnostic evaluation of blunt abdominal trauma was analysed in a retrospective study. Between 1980 and 1988, more than 2,000 ultrasonographic investigations were performed for blunt abdominal trauma; 246 patients were laparotomized. Retrospectively, false results based on ultrasonography were less than 1% of all cases, so that the sole use of ultrasonographic diagnosis and the non-use of peritoneal lavage seems justified in cases of blunt abdominal trauma. A number of figures illustrate typical cases.

[The value of ultrasound diagnosis in blunt abdominal and thoracic injuries]

In a prospective study, real-time ultrasonography was applied as the initial imaging procedure in 103 consecutive patients with blunt abdominal or thoracic trauma. Additional peritoneal lavage was not performed. Pathological findings were present in 22 patients (21%). Sensitivity of the examination was 95.5%, with two false positive results, specificity was 97.5% with one false negative result. Lesions of intraabdominal or thoracic organs were demonstrated directly by ultrasonography in 14 patients. In the remaining patients free fluid was discovered in the abdominal cavity. Splenic and hepatic lesions occurred most frequently followed by hematothorax. Ultrasonography can be recommended as the initial imaging procedure, giving a high amount of information in the primary diagnosis of blunt abdominal thoracic trauma.

[Aortic aneurysm with rupturing into the stomach following salmonella sepsis]

This case report deals with an infected aortic aneurysm, caused by salmonella: a typical gastroenteritis with fever and diarrhoea led after a short remission period to septic reacerbation and rupture of infected aneurysm into the stomach. The patient died of an haemorrhagic shock. Nomenclature, pathogenesis and prognosis of infected aneurysms are discussed.

Progesterone and estrogen receptors in GH3 cells

GH3 cells are shown to contain cytosolic progesterone receptor in a mean concentration of 270 fmol/mg protein with a dissociation constant (K(D)) for promegestone of 3 times 10(-9) M (4 degrees C). Estrogen receptor (K(D) = 1.8 times 10(-10) M) is demonstrated in cytosol (121 fmol/mg protein) as well as in 0.4 M KCl extracts (89 fmol/mg protein) of crude nuclear fractions. No progesterone receptor was detectable in the nuclear fraction. Both receptors are characterized by isoelectric focussing and by competition experiments. Addition of 10(-8) M estradiol to the growth medium increases progesterone receptor levels up to five, suggesting that the progesterone receptor is under estrogenic control.