Muscle-derived cell injection to treat anal incontinence due to obstetric trauma: pilot study with 1 year follow-up

OBJECTIVE

To treat anal incontinence due to obstetric external anal sphincter disruption via injection of autologous myoblast cells.

DESIGN

Observational pilot study.

SETTING

University hospital and district hospital

PATIENTS

10 women suffering from anal incontinence due to obstetric anal sphincter injury, refractory to conventional non-surgical therapy.

INTERVENTIONS

Autologous myoblasts were cultured from a pectoralis muscle biopsy, harvested, and injected into the external anal sphincter defect using direct ultrasound guidance.

MAIN OUTCOME MEASURES

Wexner incontinence score, anal squeeze pressures, and quality of life 12 months after injection. Safety and technical feasibility.

RESULTS

The procedure was well tolerated and no adverse events were observed. At 12 months the Wexner incontince score had decreased by a mean of 13.7 units (95% CI, -16.3 to -11.2), anal squeeze pressures were unchanged, and overall quality of life scores improved by a median of 30 points (95% CI, 25 to 42). Anal squeeze pressures did rise significantly at 1 month and 6 months post-injection (p = 0.03).

CONCLUSIONS

Injection of autologous myoblasts is safe, well tolerated, and significantly improves symptoms of anal incontinence due to obstetric anal sphincter trauma.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

Anorectal manometry: are fatigue rate and fatigue rate index of any clinical importance?

BACKGROUND

Loss of voluntary contraction of the external anal sphincter is thought to be a factor in fecal incontinence. During anal manometry, computerized systems produce several parameters including fatigue rate (FR), which is the basis for calculating the fatigue rate index (FRI). Our aim was to evaluate FR and FRI and their clinical importance in patients suffering from fecal incontinence or severe constipation.

MATERIALS AND METHODS

All patients scheduled for an anal physiology work-up were included in the study. FR was determined by a computer program and FRI was calculated manually with the following equation: FRI (minutes) = [squeeze pressure (mm Hg) - resting pressure (mmHg)] / - FR (mmHg/min). FR and FRI were compared in patients suffering from fecal incontinence (group I) and severe constipation (group II). Furthermore, subgroups (<50 and > or = 50 years of age) were compared. Lastly, a possible relation between length of the high-pressure zone (HPZ) and FR and FRI was assessed.

RESULTS

Between January 2000 and December 2004, 131 patients (96 with fecal incontinence, 35 with constipation) were studied. Both FR and FRI were similar between groups I and II; no significant differences were found when younger and older patients were compared within the same group. We also did not find any relation between HPZ length and either FR or FRI.

CONCLUSIONS

FR and FRI do not seem to be helpful in routine colorectal practice for evaluating the strength of the external anal sphincter.

Quality of life after sphincteroplasty

The operative technique of sphincteroplasty is only for isolated disruption of the sphincter muscle. Patients best suited for surgical corrections are those in whom incontinence is secondary to an anterior (obstetrical) sphincter defect. Due to the disappointing long-term results, the operation may be postponed if appropriate. At present, firstline treatment often is a biofeedback training program. It is well known that a persistent defect after repair is associated with an immediate poor outcome From 1995 - 2003 we have performed 40 sphincteroplasty on 38 patients with a mean age of 34 (range 19 - 71) years. The long-term results the of sphincteroplasty are not so promising. 3 techniques are available for measuring quality of life: Descriptive measures. Severity measures, Impact measures Sphincteroplasty, despite poor long-term results, is the best surgical treatment option for isolated, preferably anterior sphincter defects.

Should we treat hemorrhoids according to the stage

Hemorrhoidal disease is a very common and widespread disease, and it is estimated that about one subject out of three may suffer from this pathology. Hemorrhoids generally cause symptoms when enlarged, inflamed, thrombosed, or prolapsed. Internal hemorrhoids arise above the dentate line (in comparison to external hemorrhoids perianal phlebothrombosis) and are covered by transitional or columnar epithelium. Scleotherapy is one of the oldest therapy forms mainly for bleeding hemorrhoids. The so called Barron ligature is an office procedure in which a small rubber band is placed at the base of the internal hemorrhoid with a special applicator.

Acute pseudo-obstruction of the small intestine following high-dose chemotherapy and stem cell support

BACKGROUND

Acute intestinal pseudo-obstruction is a potentially life-threatening disease which is characterized by massive dilation of the colon or small intestine without mechanical obstruction and may develop after surgery or severe illness.

PATIENTS AND METHODS

We report 2 cases in which acute small intestinal pseudo-obstruction occurred after high-dose chemotherapy and autologous stem cell support. In 1 patient explorative abdominal laparoscopy was performed to rule out mechanical ileus. However, after having initiated treatment with acetylcholinesterase inhibitors a prompt small intestinal decompression was observed in both patients.

CONCLUSIONS

Acetylcholinesterase inhibitors should be considered as an early conservative intervention in the treatment of acute intestinal pseudo-obstruction to avoid surgery of patients undergoing high-dose chemotherapy with autologous stem cell support.

Partial splenectomy in cystic fibrosis patients with hypersplenism

We report three cystic fibrosis (CF) patients with hypersplenism who underwent partial splenectomy. The postoperative course was uneventful in two patients; one patient developed a complication necessitating resection of the rest of the spleen. Haematological parameters improved and oesophageal varices regressed in all patients. On follow up, one patient showed a normal spleen, the other a normally functioning accessory spleen; the third patient again developed splenomegaly with hypersplenism. Partial splenectomy is a promising therapeutic option for CF patients with hypersplenism.

Nonoperative treatment of blunt splenic injury

A spleen-preserving program was implemented at the author's institution during the mid-1980s using a five-part injury-grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl-Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.

A polymorphism in the endothelin-A receptor gene predicts survival in patients with idiopathic dilated cardiomyopathy

AIMS

The endothelin system plays a role in the complex pathophysiology of idiopathic dilated cardiomyopathy. We investigated whether genetic polymorphisms of the endothelin system might be associated with dilated cardiomyopathy-related cardiac phenotypes and differences in disease outcome.

METHODS

One hundred and twenty-five unrelated dilated cardiomyopathy patients of a well characterized dilated cardiomyopathy cohort were genotyped for six common polymorphisms of the endothelin-1, endothelin-A (ETA) and endothelin-B (ETB) receptor genes using hybridization with allele-specific oligonucleotides.

RESULTS

The H323H (C/T) polymorphism in exon 6 of the ETA receptor gene was significantly associated with a shorter survival time after diagnosis. The odds ratio for carriers of the less frequent ET(A)T allele to die within 2 years after diagnosis was 5.5 (95% confidence interval, 1.4 to 21.0, P=0.013) compared to non-carriers. Kaplan-Meier analysis revealed a significantly different survival time for T allele carriers as compared to non-carriers as tested by logrank (P=0.0196), Breslow (P=0.0195), and Tarone tests (P=0.020). The influence of the ETA H323H polymorphism on survival remained significant when known predictors of prognosis such as left ventricular ejection fraction, left ventricular end-diastolic diameter, age and NYHA functional classification were entered in a Cox proportional hazards analysis. In this model, end-diastolic diameter showed a trend to influence survival (P=0.07) but only the ETA H323H polymorphism (P=0.0029) was a significant independent predictor of survival.

CONCLUSIONS

Our results suggest that genetic variation in the ETA receptor predicts survival in dilated cardiomyopathy patients, which might have important consequences for the identification of high-risk individuals.

Chromosome 22q dosage in composite extrarenal rhabdoid tumors: clonal evolution or a phenotypic mimic?

Composite extrarenal rhabdoid tumors (CERTs) represent a diverse group of neoplasms with rhabdoid shape in combination with one of several distinctive tumor types. Like the classic renal and extrarenal malignant rhabdoid tumor (MRT), as well as the atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system, CERTs typically show aggressive clinical behavior. Deletions and mutations of the INII gene on 22q11.2 have been identified in most classic MRTs and AT/RTs; however, it is not known whether the rhabdoid components in CERTs have similar genetic abnormalities. Using fluorescence in situ hybridization (FISH) on archival, paraffin-embedded tissue with a commercially available probe in close proximity to the INII locus (bcr), as well as other chromosome 22 probes, we studied 4 cases of MRT, 13 of AT/RT, and 16 of CERT (3 melanoma, 4 meningioma, 7 carcinoma, 1 rhabdomyosarcoma, and 1 neuroblastoma). Deletion of the 22q11.2 locus was demonstrated in 10 (77%) of 13 AT/RTs and 3 (75%) of 4 MRT, including 1 congenital MRT. Of the 16 CERTs, only 2 (a rhabdoid meningioma and a carcinoma with rhabdoid features; 13%) harbored a deletion at this locus. This difference was statistically significant (P <.001). We conclude that deletion of 22q11.2, typical of most classic MRTs and AT/RTs, is infrequently seen in CERTs. This suggests that the rhabdoid component of CERTs does not evolve by way of the genetic alteration characteristic of MRTs or AT/RTs, but represents instead a distinct phenotype shared by a number of tumors as they undergo anaplastic progression.

New approaches to molecular profiling of tissue samples

Figures on http://www.esacp.org/acp/2000/20-1/best.htm.

Laparoscopic cholecystectomy using 2-mm instruments

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.

Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients

PURPOSE

The aim of this study was to compare the intra-anal sponge electrode with the conventional needle electrode for electromyography of the pelvic floor in constipated patients.

MATERIALS AND METHODS

Forty consecutive patients (27 females) with a mean age of 64.3 (range, 15-87) years who had chronic constipation were prospectively evaluated for electromyographic evidence of nonrelaxation or paradoxical contraction of the puborectalis and external anal sphincter during simulated defecation. The soft intra-anal sponge electrode and then the concentric needle electrode were used in each patient as an internal control. Furthermore, in all patients, cinedefecography was used as an independent standard to confirm the diagnosis. Agreement was calculated using the kappa statistic.

RESULTS

Confirmation of needle electromyography was noted in 19 of 20 patients (95 percent) who had sponge electromyographic evidence of paradoxical activity. Similarly, concurrence was noted in 19 of 20 patients (95 percent) with normal relaxation of the puborectalis observed with the sponge electrode. Agreement between needle and sponge electromyography was very good (kappa = 0.9), between needle electromyography and cinedefecography was fair (kappa = 0.4), and between sponge electromyography and cinedefecography was moderate (kappa = 0.5). Furthermore, needle electromyography was more painful in all patients compared with sponge electromyography.

CONCLUSION

The soft sponge surface intra-anal electrode is an excellent alternative to the needle electrode for assessment of puborectalis activity in constipated patients. Sponge electromyography has the advantage of being as accurate as, but less painful than, needle electromyography.

Laceration of a benign adrenal adenoma mimicking a splenic rupture

Lacerations of adrenal tumors are very rare events and have been described for myelolipoma, pheochromocytoma, and cortisol-producing adenoma. We report on a patient who was admitted with suspected splenic rupture. Computed tomography showed a mass 14 cm in diameter adjacent to the spleen, but selective angiography revealed blood supply by the left suprarenal artery. A ruptured adrenal tumor was therefore diagnosed and resected. No hormone production was detected. Histologically a benign adrenal adenoma was found. Frequency, diagnosis and therapy of adrenal masses are discussed.