Search

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively. [ABSTRACT FROM AUTHOR]

TNM staging in colon cancer has several limitations. Prognostic molecular markers are now being developed to address these limitations. The aim of this study was to identify a combination of genes and markers whose expression is predictive of nodal status and outcome in colon cancer. The expression of 12 genetic markers were examined in 66 node-positive and 65 node-negative T3 colon cancers. Gene expression was quantified using real-time polymerase chain reaction. Microsatellite instability status was available through the registry. Association with lymph node status was examined using univariate and multivariate logistic regression. Thymidylate synthase expression was statistically significantly associated with lymph node status (odds ratio 0.36; 95% confidence interval: 0.16–0.81). Microsatellite instability and the other genes were not associated with nodal status. Multiple logistic regression did not identify a significant multivariate predictive model. Decreased expression of thymidylate synthase is associated with a higher risk of lymph node metastasis in patients with T3 colon cancers. Microsatellite instability and the expression of other genes are not predictive of nodal status in this population. Thymidylate synthase gene expression may help identify patients at greater risk for progression of disease. [Copyright &y& Elsevier]