[3T-AI: a new treatment algorithm for anal incontinence with a higher evidence level]. / 3T-AI: Ein neuer, mit höherer Evidenz versehener Behandlungsalgorithmus bei analer Inkontinenz.

BACKGROUND: The evidence for conservative treatment of anal incontinence is poor. In our first publication [Schwandner et al. Dis Colon Rectum 2010; 53: 1007-1016] we demonstrated that a novel therapeutic concept, termed triple target treatment (3T), combining amplitude-modulated medium frequency stimulation and electromyography biofeedback (EMG-BF) was superior to EMG-BF alone. Questions about the required treatment duration and the relevant subgroups of patients with sphincter damage and damaged anal sensibility were not addressed. METHODS: We enrolled 158 patients with anal incontinence in this randomized study. Here, we -report on the important subgroup analyses of patients with and without sphincter damage and damaged anal sensibility for the endpoints Cleveland Clinic Score (CCS) and success record. Using the results of this study we propose a novel treatment algorithm which is open for discussion. RESULTS: In patients with sphincter damage, the median difference on the CCS from baseline to 9 months was 5 points higher for 3T than for EMG-BF (95 % confidence interval 0-8; p = 0.0168). While 47 % of the patients with sphincter damage became continent with 3T, only 18 % did with EMG-BF (p = 0.0036). Ten of 17 patients in the 3T group regained anal sensibility after 3 months stimulation. There was tendency towards improved continence in patients with neuropathy upon 3T treatment (p = 0.1219). CONCLUSIONS: 3T is superior to EMG-BF alone for patients with sphincter damage and neuropathic anal incontinence. It is a successful key element within our treatment algorithm, even in patients with sphincter damage and neuropathic anal incontinence.

[Evaluation of Longo's technique for haemorrhoidectomy by doppler ultrasound measurement of the superior rectal artery]. / Evaluation der Ergebnisse der geschlossenen Staplerhämorrhoidektomie nach Longo durch dopplersonografische Untersuchung der Arteria rectalis superior.

UNLABELLED: Stapler-haemorrhoidectomy causes theoretically a durable reposition of the prolapsed haemorrhoidal cushions and a reduction of the arterial inflow by clipping mucosa and submucosa. Until now, however, no exact data exist with respect to a potential reduction of the arterial inflow. METHODS: The question of a sufficient interruption of the end branches of the superior rectal artery should be answered with doppler ultrasound measurements before and after stapler-haemorrhoidectomy. RESULTS: The measurements were performed on 45 patients before and one month after stapler-haemorrhoidectomy. Preoperatively in all patients the three main branches of the artery at three, seven and eleven o'clock could be detected by doppler ultrasound. In 67 % of the patients a fourth, in 16 % a fifth and in 13 % a sixth vessel could be located. One month postoperatively in 80 % of the patients all main branches were further seen. In 16 % of the cases two main vessels, in 4 % only one main vessel could be identified. There was no correlation between postoperative outcome and number of vessels detected postoperatively. CONCLUSION: It is concluded that the postoperative outcome after stapler-haemorrhoidectomy does not depend on the complete interruption of the arterial inflow of the haemorrhoids. The complete reposition of the haemorrhoidal prolapse and thereby the improvement of the venous reflux out of the haemorrhoidal cushions might be more important.

Scanning electron microscopy study including maceration techniques of an absorbable alloplastic implant designed for the reconstruction of ventral abdominal wall defects.

The interposition of synthetic material represents the most generally acknowledged method for achieving a tension-free surgical repair of major abdominal wall defects. As permanent materials are frequently associated with severe complications (rejection, peritonitis, enterocutaneous fistula, erosive invasion into the intestine), a newly designed absorbable prosthetic (polydioxanone, PDS) has been developed. The ellipsoid implant is composed of a knitted envelope and a filling of loosely arranged filaments. Interpositioning of the implant into an artificial circular abdominal wall defect was carried out on 30 Wistar rats. Explantation was performed 21 days post implantationem (p.i.), 42 days p.i. and 180 days p.i. The aim of the study was to evaluate the use of scanning electron microscopy (SEM) combined with maceration techniques (2 N NaOH for 1, 3 and 5 days) for a spatial assessment of the interactions between the implanted material and the ingrowing tissue components. Application of 2 N NaOH caused the complete dissolution of the PDS-material and a concomitant gradual disappearance of cellular and amorphous tissue components, thereby unmasking the remaining collageneous network. SEM of non-macerated specimens demonstrated that 21 days p.i. the entire implant has been filled with connective tissue components. Additionally, the ventral and dorsal surfaces of the implant were covered by a collageneous layer (neo-fascia). 21 days p.i. the PDS-filaments had developed minor clefts, which increased in number and depth 42 days p.i., and were transformed into small remnants 180 days p.i. Alkali treatment revealed the three-dimensional arrangement of collagen fibers, which ensheathed the PDS-filaments and formed interconnecting networks between them. At the ventral portion of the implant the fibrous network was more elaborate and densely distributed. 180 days p.i. the implant has been transformed into a membranous structure (neo-membrane) composed of the ventral and dorsal neofascia, remnants of PDS-filaments and a continuous connective tissue layer containing wave-like collagenous structures. Whereas 21 and 42 days p.i. no herniation was observed, 130 days p.i. the implant began to bulge out of the ventral abdominal wall. It is therefore concluded that inspite of the advantages of absorbable materials, longer resorption times may be required to allow a sufficient consolidation of the ingrowing connective tissue to resist the tensile forces of the abdominal muscle coat. SEM combined with 2N NaOH maceration proved to be a usefull tool in addition to conventional histological techniques for a three-dimensional assessment of fibrous connective tissue components ingrowing into alloplastic implants.

[Functional and oncological results of sphincter preserving rectal resection]. / Funktionelle und onkologische Resultate der sphinktererhaltenden Rektumresektion.

Most of the patients with a carcinoma of the middle and distal third of the rectum can now be operated on with a low anerior resection in consideration of all aspects of cancer surgery. Our experience with 59 resections with coloanal or low colorectal anastomosis was reviewed. The mean distance of the distal edge of the tumor to the L. anocutanea was 5.7 +/- 1.9 cm. Within the first 30 days the postoperative mortality rate was 3.4% (2/59). The most common postoperative complication was urinary retention, which affected 13.5%. The insufficiency rate of the anastomosis was 13.5%. Fecal continence was complete in 85% of the patients: we observed minor leaks in 6% and major leaks in 9%. Local recurrence occurred in 2 cases (3.8%), metastasis was noted in 6 cases (11.3%). Sphincter-preserving rectal resection is in our opinion an excellent treatment for low rectal cancer.

[Results of deep rectum resection and intersphincteric rectum excision]. / Ergebnisse der tiefen Rectumresektion und intersphinctärer Rectumexstirpation.

Low resection and intersphincteric extirpation of rectal cancer in the distal third of the rectum has become an accepted sphincter-saving method. From December 1990 to December 1994, 42 patients (17 women and 25 men) with a mean age of 67.2 years had a low resection or extirpation of the rectum at our institution. Eighteen patients received a transanal sutured anastomosis, 24 a stapler anastomosis. We had a lethality rate of 2.5% and a anastomotic insufficiency rate of 14%.

[Pelvic exenteration--indications, radical nature and follow-up demonstrated with 33 clinical cases]. / Beckenexenteration--Indikation, Radikalität und Follow-up demonstriert an 33 klinischen Fällen.

From March 1983 to March 1997, 24 posterior pelvic exenterations and 9 total pelvic exenterations were performed in 18 patients with recurrent cancer and 15 patients with primary cancer. In 85%, we saw major complications, 78% in primary operations and significantly higher--96%--in recurrent cancer operations. R0 resections we figured out in 67% of primary operations and 40% of recurrent operations. We saw recurrent cancer in 45% of the patients with a mean follow-up of 18.2 months.

Ocular sarcoidosis and Graves' ophthalmopathy.

Sarcoidosis, a granulomatous disease first recognized as a dermatologic disorder, is now known to involve multiple organs, including the eye. Indeed, ocular involvement may be the only clinical manifestation of this protean disease; it may involve any part of the visual apparatus and its adnexal structures. In this paper we report on the concurrence of sarcoidosis of the lid with Graves' ophthalmopathy in the same patient.