[Proctological diseases in routine urologic practice]. / Proktologische Erkrankungen im urologischen Alltag

Nearly two third of adults will suffer from proctologic complaints. The same symptoms could also indicate or mask an anorectal carcinoma. Therefore, the first priority should be to exclude the possibility of a neoplasm of the colon, rectum and the anal canal. Knowledge of the specific anatomy of the anal canal and the patient's history will lead to an exact proctologic diagnosis: perianal thrombosis, acute thrombosed prolapsed haemorrhoidal plexus, an anal fissure, abscess and fistula are located within the highly sensitive anoderma and are characterized by pain. Perianal thrombosis, chronic fissure, abscess and fistula require surgery. Conservative treatment is the choice for an acute anal fissure, haemorrhoids grade I-II. Haemorrhoids II-III require surgery, e.g. by haemorrhoidal artery ligation, open or closed resection of the haemorrhoidal plexus, reconstruction of the anal canal or stapled mucosectomy. Perianal diseases such as perianal tags, fibroma or condylomata acuminata are easily diagnosed and treated. Secondary perianal eczema requires treatment of the underlying proctologic disease. If it persists, a biopsy is required.

A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures.

BACKGROUND: Anal fissure is a common painful condition affecting the anal canal. The majority of acute fissures heal spontaneously. However, some of these acute fissures do not resolve but become chronic. Chronic anal fissures were traditionally treated by anal dilation or by lateral sphincterotomy. However, both of these surgical treatments may cause a degree of incontinence in up to 30% of patients. Several recent trials have shown that nitric oxide donors such as glyceryl trinitrate (GTN) can reduce sphincter pressure and heal up to 70% of chronic fissures. AIM: This study addressed the dose-response to three different concentrations of GTN ointment compared with placebo in a double blind randomised controlled trial. METHOD: A double blind, multicentre, randomised controlled trial was set up to compare placebo ointment against three active treatment arms (0.1%, 0.2%, and 0.4% GTN ointment applied at a dose of 220 mg twice daily) in chronic anal fissures. The primary end point was complete healing of the fissure. RESULTS: Two hundred patients were recruited over an eight month period from 18 centres. After eight weeks of treatment the healing rate in the placebo group was 37.5% compared with 46.9% for 0.1%, 40.4% for 0.2%, and 54.1% for 0.4% GTN. None was significantly better than the placebo response. A secondary analysis excluded fissures without secondary criteria for chronicity. Healing rates were then found to be 24% in the placebo group compared with 50% in the 0.1% GTN group, 36% in the 0.2% group, and 57% in the 0.4% GTN group. These values were statistically significantly different for the placebo group compared with 0.1% GTN, 0.4% GTN, and for the GTN treated group as a whole. CONCLUSIONS: The results of this study have demonstrated the significant benefit of topical GTN when applied to patients suffering from chronic anal fissures but acute fissures showed a tendency to resolve spontaneously. The high proportion of fissures which healed in the placebo group suggests that the definition of "chronicity" needs to be reassessed. Further studies are required to confirm the optimal therapeutic strategy.

[Stage-adjusted therapy of hemorrhoids--ambulatory or inpatient treatment?]. / Stadienadaptierte Therapie des Hämorrhoidalleidens--ambulant oder stationär?

The aim of the therapy of piles is to cure the complaints of the patient by reducing the enlarged haemorrhoidal plexus according to the stage (1 degree to 3 degrees) to a nearly physiological size and in case of a prolapse to replace the sensitive anoderma. The basic therapy consists of regulating the bowel function and avoiding straining. A high fibre diet or bulk laxatives may be necessary. If this fails 1 degree haemorrhoids should be treated in the office by sklerotherapy, 2nd or 2nd to 3rd degree haemorrhoids by rubber band ligation from the very beginning. The Haemorrhoidal Artery Ligation (HAL) and the circular mucosectomy with a stapling device can be done as an office procedure too. An anal prolapse of 1 or 2 segments should be treated as outpatient surgery in an "open" technique (Milligan-Morgan), more than 2 segments in a "closed" (Ferguson) or better in a "semi-closed submucosal" technique (Parks) in the hospital. A cicular anoplasty preserves the anoderma and enables its reposition as well as the excision of perianal skin tags and fibromata. This is not an office procedure.

[Perianal precancerous conditions (Bowen disease, Paget disease, Carcinoma in situ, Buschke-Lowenstein tumor)]. / Perianale Präkanzerosen (M. Bowen, M. Paget, Carcinoma in situ, Buschke-Löwenstein-Tumor).

Perianal premalignant lesions are rare. Any suspicious perianal lesion or any perianal exanthema, that does not heal by non-surgical treatment has to be biopsied for histology. Many premalignant lesions are diagnosed as an incidental finding after anorectal surgery: any anorectal specimen must be examined by the pathologist. Leukoplakia is a facultative premalignant condition. High-grade anal intraepithelial neoplasia (AIN) is an in situ squamous cell carcinoma, associated with papillomavirus infection. Bowen's disease and Bowenoid papulosis are clinical variations of high-grade AIN. Buschke-Löwenstein tumour (giant condyloma) is a locally destructive tumour, that does not infiltrate or cause metastases. Paget's disease is a premalignant lesion like AIN, associated with other malignancies.

Keratoacanthoma in the differential diagnosis of anal carcinoma: difficult diagnosis, easy therapy. Report of three cases.

Three male patients who had an anal keratoacanthoma are described. Anal keratoacanthoma is a rapidly growing skin tumor that invades the dermis but remains locally and can mimic clinically and histologically a squamous-cell carcinoma.

[Functional disorders of the rectum and pelvic floor. Ambulatory/conservative therapy]. / Funktionelle Störungen des Enddarmes und des Beckenbodens. Ambulante/konservative Therapie.

Early diagnosed functional disorders of the ano-rectum or pelvic floor can be treated in the office by conservative treatment or out-patient surgery. The normal anatomy of the anal canal must be restituted by reducing enlarged haemorrhoids, removing a prolapse of the anterior rectal wall with rubber-band ligation, excision of chronic fissures and prolapsing tumours. The basic therapy then consists of normalisation of bowel habits and stool consistency. An anal stenosis must be dilated. Training of the sphincter, gymnastics of the pelvic floor, electrostimulation and biofeedback are the therapy for the sphincter and pelvic floor insufficiency.

[Diagnostic and therapeutic procedures in fecal incontinence in general practice of the surgically educated proctologist]. / Diagnostisches und therapeutisches Vorgehen bei der Stuhlinkontinenz in der Praxis des chirurgisch ausgebildeten Proktologen.

Age related, about 10% of the general population suffer from faecal incontinence. In a surgical, proctological office diagnosis is possible with carefully taken history, physical examination, digital examination of the anorectum, rigid rectosigmoidoscopy, and anoscopy. Together with special examinations (endoanal ultrasound, electromyography, pudendal nerve terminal motor latency [PNTML], anorectal manometry, defaecography, transit time of the colon) the plan for medical and surgical treatment can be made. The basic medical conservative therapy consists of regulating the form of stool (high fibre diet and/or loperamid), training of the sphincter and pelvic muscles electrical stimulation or biofeedback training. Outpatient surgery is possible for small prolapsing tumors of the lower rectum or anal canal, hemorrhoids grade 2 or segmental anal prolapse. Inpatient surgery is needed for any form of reconstruction of the sphincter or the sensitive area of the anal canal, post- and preanal repair, anal and rectal prolapse, (dynamic) gracilis sphincteroplasty, or for a terminal stoma in those patients, whose uncontrolled incontinence cannot be managed otherwise. After surgery it is needed to continue the medical therapy (regulating the bowel movements, biofeedback training, electrical stimulation of the sphincter).

[Proctologic surgery in ambulatory care]. / Proktologisches Operieren in der Ambulanz.

The principles for operations in the outpatient department are similar for proctology and general surgery. The trained and experienced surgeon is able to perform operations above the pectinate line, for example, polyps, prolapsing tumors etc. without stretching the anal sphincters and without anaesthesia being necessary. Below the dentate line local anaesthesia is sufficient for operative treatment of the following diseases: perianal thromboses, tumors of the skin and the connective tissue, skin tags, second degree hemorrhoids, segmental anal prolapses, anal fissures, cryptitis, uncomplicated anal fistulas and perianal abscesses. The postoperative treatment follows the rules of healing by second intention.

[Technique, procedure and value of ambulatory hemorrhoid therapy]. / Technik, Vorgehen und Wertigkeit bei ambulanter Haemorrhoidentherapie.

The treatment of piles should aim to reduce the abundant hemorrhoidal tissue in accordance with the stage (1. degree-3. degrees). In all cases an attempt should be made to regulate bowel function while avoiding straining. A high fibre diet is advised or a bulk laxative may be necessary. Advice on anal hygiene is given. If this treatment fails, infrared coagulation or injection sclerotherapy is indicated. Second or second to third degree hemorrhoids should be treated with rubber band ligation from the very beginning. In view of their possible complications, both methods should be used only by trained and experienced physicians.

[Surgical problems of iatrogenic esophagus perforations (author's transl)]. / Zur chirurgischen Problematik iatrogener Oesophagusperforationen.

With increase of invasive investigations of the upper digestive tract an increase of complications is also expected. From 1968--1977 eleven patients with iatrogenic esophagus perforation were referred to the department of general surgery, University of Kiel. Symptoms, diagnosis and different treatment, depending on localization and time of perforation and underlying disease are described.