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The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas. A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin. The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days. Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.

Aim The OTSC Proctology is a surgical device for anorectal fistula closure. It consists of a super-elastic nitinol clip, which is placed (with the aid of a transanal applicator) on the internal fistula opening to achieve healing of the fistula track. A prospective, two-centre clinical pilot study was undertaken to assess the efficacy and safety of the OTSC Proctology in patients with a complex high anorectal fistula. Method In patients with a complex anorectal fistula the primary track was debrided using a special brush and the clip was applied to the internal fistula opening. After 6 months the postoperative clinical course and fistula healing were assessed. Results Twenty patients with a cryptoglandular anorectal fistula (14 with a transsphincteric fistula and six with a suprasphincteric fistula) were included in the study. There were no intra-operative technical or surgical complications. Postoperatively no patient reported intolerable discomfort or a sensation of a foreign body in the anal region. At 6 months after surgery, 18 (90%) patients had no clinical signs or symptoms of fistula and were considered healed, whereas in two the fistula persisted. In 13 (72%) of these 18 patients, the clip was still in place without causing problems, whereas in three patients the clip had spontaneously detached. In the two remaining patients it was necessary to remove the clip due to discomfort and delayed wound healing. Conclusion Anorectal fistula closure with the OTSC Proctology is an innovative, sphincter-preserving minimally invasive procedure with promising initial results and a high rate of patient satisfaction.

Background. Sacral neuromodulation (SN) is an emerging treatment for constipation. This review evaluates the mechanism of action, techniques, efficacy, and adverse effects of SN in the management of constipation. Methods. Electronic searches for studies describing the use of SN were performed in PubMed, MEDLINE and Embase. Abstracts were reviewed and full text copies of all relevant articles obtained. Results. Fifty-nine results were obtained on the initial searches. Ten studies discussed the results of SN in patients with constipation. A total of 225 temporary neuromodulations and 125 permanent implants were performed. Bowel diaries showed improvement in assessment criteria in more than 50% of patients on temporary neuromodulation and the results were maintained in approximately 90% of patients who underwent permanent implantation over medium to long-term follow-up. The rate of adverse effects was high, but the majority of them were related to electrode position. Improvements in transit studies and anorectal physiology after neuromodulation were noted in some studies. The recognized limitations included a lack of randomized studies and an inability to perform meta-analysis. Conclusion. Sacral neuromodulation may be an effective treatment in selected patients with constipation and should be a part of the management repertoire. Improvement in defecatory frequency with temporary wire placement is a good predictor of subsequent response following permanent implant. Further research into predictive factors for success would improve patient selection.

Aim Surgical closure of high or complex anal fistulae is often a difficult challenge. A special Nitinol clip, the OTSC clip (Ovesco AG), was evaluated for fistula closure in a porcine model. Method A total of 20 fistulae were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC clip using a specially developed transanal clip applicator. The safety and technical feasibility of the clip application were tested. Another 4 weeks later, fistulae were macroscopically assessed for closure. For histological examination, the anorectum including the fistula tract was excised en bloc. Results Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% of residual tracts and a more intense chronic inflammation were seen in the untreated control fistulae. After clip placement, 10% of the fistulae persisted associated with a higher density of collagen fibres indicating a better fistula scarring and healing. No unexpected side-effects or complications caused by the clip were observed. Conclusion Fistula closure using the OTSC clip represents a promising sphincter-preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the ‘anal fistula claw’ for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.

Analkarzinome sind maligne Tumoren des Analkanals und des Analrands. Analkarzinome sind selten. Sie machen nur 1–2% aller kolorektalen Karzinome bzw. 2,1% der Malignome des Verdauungstrakts aus. Die Atiologie ist noch nicht vollstandig geklart, jedoch wird in der jungsten Vergangenheit die Virusgenese (HPV, humane Papillomviren) zunehmend favorisiert, da eine direkte Abhangigkeit nachgewiesen ist. Je nach Grose und Sitz des Tumors kann die Symptomatik auserst vielfaltig sein. Die Patienten klagen meist uber eher unspezifische Beschwerden. Die Klassifikation der Analkarzinome erfolgt nach dem TNM-System der UICC. Durch Anamnese und klinische Untersuchung mit Inspektion und Palpation des Analkanals sowie Rektoskopie und Proktoskopie lasst sich der Primartumor beurteilen. Mit Hilfe einer Tumorbiopsie wird die maligne Veranderung histologisch gesichert. Zur Beurteilung eines fortgeschrittenen Tumorstadiums sind CT oder MRT von Abdomen und Becken insbesondere zur Beurteilung der iliakalen, inguinalen und paraaortalen Lymphknoten gefordert.

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.Bei den humanen Papillomviren (HPV) handelt es sich um weitverbreitete Erreger, die auch im Kindesalter eine Vielzahl von Haut- und Schleimhautinfektionen verursachen können. Infektionen mit unterschiedlichen HPV-Typen können Hautwarzen oder anogenitale Kondylome hervorrufen. Condylomata acuminata bei Kindern können, aber müssen nicht hinweisend für sexuellen Missbrauch sein. Daher bedarf es unter Berücksichtigung anderer Übertragungsmöglichkeiten einer sehr sorgfältigen Überprüfung des Einzelfalls. Die Diagnose anogenitaler Kondylome wird in der Regel durch die klinische Untersuchung gestellt. Histologische, serologische oder molekulargenetische Zusatzdiagnostik ist nur in Einzelfällen sinnvoll. Bei der Indikation zur Therapie sind die hohe Spontanremissionsrate sowie die posttherapeutische Rezidivrate zu berücksichtigen. Die zur Verfügung stehenden topischen und chirurgischen Therapieoptionen werden dargestellt.

A soft shell crayfish operation consists of an indoor molting system for immature crayfish. The molted crayfish could be sold as food or bait. Such systems have been operated on a small-scale in Kentucky and neighboring states, although traditionally the industry has been centered in Louisiana. This article investigated profit-maximizing management conditions and economic feasibility of a small-scale soft shell crayfish operation. Results showed that a minimum facility size of 25–30 culture trays was essential for realizing a profit by selling product to bait shops. This facility size was also amenable to be operated by two full-time workers, making family-run enterprises a strong possibility. Other results showed that larger facilities, with more than 50 culture trays, were necessary to reduce the minimum equity in fixed investment to be less than 70%. Direct marketing at retail prices is often the only profitable option for small-scale aquaculture; this article gives an example of a small-scale aquacult...

Bei einer Hyperplasie des Corpus cavernosum recti und Vorliegen einer analen Beschwerdesymptomatik, die aus transanaler Blutung, perianalem Pruritus, Nassen, Stuhlschmieren oder der Wahrnehmung eines Druck- oder Fremdkorpers bestehen kann, spricht man von einem Hamorrhoidalleiden. Je nach morphologischer Veranderung unterscheidet man zwischen Hamorrhoiden I°, II°, III° und IV°. Die Therapieoptionen werden an den Schweregrad der Erkrankung angepasst und bestehen in den fruhen Stadien aus konservativen Masnahmen wie Stuhlregulation, Sklerosierung und Gummibandligaturen, in den fortgeschrittenen Stadien werden operative Verfahren (z. B. die Segmentexzision und die Staplerhamorrhoidopexie) angewendet. Die gesundheitsbezogene Lebensqualitat wird zunehmend haufiger als Qualitatsmerkmal einer konservativen oder operativen Therapie definiert. Nicht nur die morphologische und funktionelle Wiederherstellung von Korperstrukturen oder -funktionen, sondern die subjektive Einschatzung der Beschwerdebesserung durch den Patienten wird als relevanter Behandlungserfolg gewertet. Entsprechend wird dieses Kriterium zunehmend als primarer oder sekundarer Endpunkt klinischer Studien gewahlt. Trotz der hohen Inzidenz des Hamorrhoidalleidens, die mit jahrlich 4 % in Industrienationen angegeben wird, und aus der in Deutschland 40 000–50 000 operative Eingriffe und ca. 3,5 Millionen Behandlungsfalle pro Jahr resultieren, liegen nur sehr limitierte Daten zur Beeinflussung der Lebensqualitat durch diese Erkrankung vor. Auch aus gesundheitspolitischen Aspekten gewinnt die Kosten-Nutzwert-Analyse unter Verwendung des Mases der lebensqualitatsadjustierten Lebensjahre zunehmend an Bedeutung. In der vorliegenden Arbeit werden Definitionen der gesundheits- und krankheitsbezogenen Lebensqualitat erlautert. Die zur Verfugung stehenden psychometrischen Instrumente zur Lebensqualitatsmessung werden dargestellt und deren Qualitatskriterien und Grenzen diskutiert.

Analabszesse und Analfisteln sind unterschiedliche Verlaufsformen ein und derselben Grunderkrankung, wobei der Abszess die akute Form, die Fistel die chronische Form darstellt. In Deutschland gibt es ca. 15 000 Fistelerkrankte pro Jahr, die Rezidivrate liegt zwischen 10 und 50 %. Etwa 90 % aller Abszesse und Fisteln sind auf eine unspezifische Infektion der rudimentar angelegten Proktodealdrusen, am haufigsten im Bereich der hinteren Kommissur, zuruckzufuhren. Die Einteilung der Abszesse und Fisteln richtet sich nach der anatomischen Lokalisation bzw. dem Verlauf in Bezug auf die Sphinktermuskulatur.

The aim of this paper is to review diagnostic techniques which are useful and applicable in the evaluation of constipation. Besides widely-spread available techniques such as taking a specific and structured history and performing a clinical examination sophisticated diagnostic tools such as colon transit time, anal manometry, defecography endorectal ultrasonography as well as electrophysiological investigations such as anal sphincter electromyography and pudendal nerve terminal motor latency measurement are illustrated.

During pregnancy the anatomy and physiology of the pelvic floor and the perianal region is modified, due to endocrine, metabolic and immunologic changes. This can lead to a change in the observed incidence of coloproctologic disorders or an alteration of pre-existing coloproctologic diseases. In patients requiring specific treatment prior to or during pregnancy the possibility of adverse effects on the antenatal or postnatal development of the child has to be considered carefully. It is necessary to evaluate whether the therapeutic strategy needs to be modified or even discontinued. The aim of this review is to present the current state of knowledge on the medical care and treatment of coloproctologic disorders during pregnancy. Diagnostic approaches and therapeutic options for haemorrhoids, anal fissures, perianal thrombosis, perianal abscesses and fistulas, anogenitals warts, colorectal malignomas and inflammatory bowel diseases are presented. Therapeutic options are discussed with regard to their applicability during pregnancy and in the postpartum period.

Die STARR („stapled transanal rectal resection“) -Operation nach Longo ist eine neue Operationstechnik zur Behandlung eines obstruktiven Defakationssyndroms. Ein groser Vorteil ist das komplett transanale Vorgehen. Hierdurch kann sowohl eine Rektozele als auch eine bestehende Intussuszeption behoben werden. Komplikationen wie Nachblutungen, Infektionen, Stenosen und Fisteln sind beschrieben. Bei der vorgestellten Patientin fand sich eine mit Rektumwand ausgekleidete Hohle im Spatium rectovaginale, welche auf eine unzureichende Erfassung der zu raffenden Rektumwand zuruckzufuhren ist und nach Dilatation einer Nahtstenose Anschluss an den Enddarm fand. Durch wiederkehrende Stuhlinkrustierungen bildeten sich in dieser Hohle dann Kotsteine aus. Zur Resektion der Hohle wurde eine modifizierte Rehn-Delorme-Operation durchgefuhrt. Die STARR-Operation ist ein neues operatives Verfahren, das wie alle neuen Operationstechniken nach sorgfaltiger Ausbildung und im Wissen um potenzielle Komplikationen anzuwenden ist.

Die Lokalrezidivraten des Analkarzinoms schwanken in der Literatur zwischen 5 und 33%. Aufgrund der Heilungsrate von bis zu 41% im Falle eines fruhzeitig erkannten Rezidivs ist daher eine sorgfaltige Tumornachsorge im Rahmen eines strukturierten Programms erforderlich. Hierbei kommen unterschiedliche diagnostische Vorgehensweisen zur Anwendung. Dieser Beitrag informiert uber die Wertigkeit der einzelnen Untersuchungsverfahren anhand deutscher Leitlinienempfehlungen.

Pyomyositis is in the moderate climate zone a rare and acute bacterial infection of the skeletal muscles without an obvious origin of infection. Initial symptoms contain muscle pain and localized swelling and tension. As different causes are taken into account first, the diagnosis of a pyomyositis is often delayed. We report on three cases of pyomyositis and discuss diagnosis and therapy against the background of the available and recent literature.

AIM The purpose of the present study was to define the diagnostic value of anal endosonography in the diagnostic work-up of fistula-in-ano. METHODS A retrospective study was carried out on 191 consecutive patients (m: 121; f: 70; mean age: 44.0 +/- 12.5 years; range: 0.5-77 years) who were diagnosed to suffer from fistula-in-ano by performing anal endosonography in an outpatient setting. All images were obtained with a Combison 310A ultrasound scanner (Kretz GmbH, Zipf, Osterreich) and 5-Mhz and 7.5-MHz transducer. 131 patients underwent surgery. According to the endosonographic findings fistulas were classified as transsphincteric in 44 %, intersphincteric in 22 %, subanodermal in 16 %, anovaginal in 8 %, suprasphincteric in 5 %, extrasphincteric in 1 % and others in 4 %. RESULTS In 125 patients (95 %) the preoperative diagnosis was confirmed intraoperatively. This cohort included 12 patients with a complex fistula system. In only 6 patients the preoperative ultrasound finding was misinterpreted. CONCLUSION In conclusion this study has shown that anal endosonography is a useful and reliable tool in the preoperative evaluation of uncomplicated and complicated anorectal fistulas.

AIM We tried to evaluate the role of anorectal functional diagnostic tools according to the judgement of German coloproctologists. METHOD Questionnaires concerning accuracy of different diagnostic tests were sent to 585 physicians specialized in coloproctology. RESULTS 261 (44.6 %) completed forms were returned. An analysis of the answers revealed that endorectal sonography is widely (73 %) regarded as useful and reliable diagnostic tool. Though manometry is still frequently used, only 50.5 % of the coloproctologists made their decision concerning the further treatment depending on the results of this method. Other radiologic methods as defecography and colon transit time are still regularly performed, though video-defecography is not accepted by most coloproctologists. Neurological investigations as pudendal nerve terminal latency, surface-EMG and needle-EMG are exclusively applied in specialized departments. DISCUSSION Regarding the variety of diagnostic tools and its different appraisal a consensus should be defined. The usefulness of neurological examination techniques needs to be clarified before their performance can be recommended for a wide-spread routine work up.

This study was designed to evaluate the healing and complications rates in surgically and conservatively treated patients with chronic anal fissure. Conservative treatment consisted of nitrate or diltiazem ointment. In case of surgery, fissurectomy was performed. In total, 340 patients were included in the study. Among them, 162 patients had surgery and 178 patients had conservative treatment. The healing rate at surgically treated group of patients varied between 95 and 98 % depending on previous treatment. Group treated with nitrate ointment and group treated with diltiazem ointment showed, respectively 62 % and 52 % healing rates. Difference between ointments was not statistically significant. Average healing time was between 105 and 123 days and complication rates were between 1.7 and 5.4 %. The surgical treatment showed much higher healing rates and thus should recommended as primary treatment option for the chronic anal fissure, especially if there are chronic secondary lesions already present. In case of conservative treatment, either nitrate or diltiazem ointment could be used with similar efficacy.

Most anal abscesses are caused by anal fistula and invasion of the surrounding tissues by a mixed colonic flora. The treatment comprises excision of the abscess and. if appropriate, fistulectomy. Primary anorectal actinomycosis and perianal actinomycosis are very rare and are caused by Actinomyces, which is a ubiquitous microaerophilic bacterium. Here we report a case of perianal actinomycosis. The patient had a short history of painless perineal induration without fever or leucocytosis with normal routine blood tests. After excision sulphur granules drained from the cavity and the pathological investigations were indicative of perianal actinomycosis. Appropriate surgery and antibiotic treatment healed the perianal infection. After elimination of other diagnoses, e.g. Crohn's disease, tuberculosis and malignant growths, this rare case of perianal actinomycosis should be kept in mind in the differential diagnosis of a painless perianal mass.

Purpose: The aim of our study was to evaluate the effects of combined contraceptive vaginal rings on serum concentrations of folate and cobalamin in healthy users. Material and Methods: Case-control study on cobalamin and folate status of 45 healthy female nulligravidae using a combined contraceptive vaginal ring for > 3 months and 45 healthy controls. Factors interfering with vitamin metabolism were thoroughly controlled. Results: Cobalamin and folate levels did not differ between the groups. Vegetarian diet, smoking or obesity did not have a significant influence. Conclusions: The use of a combined contraceptive vaginal ring provides an appropriate hormonal contraception in women with pre-existing cobalamin deficiency or restrictive diet habit in order to avoid interferences between vitamin B12 metabolism and exogenously applied estrogens.

Surgical closure of high or complex anal fistulae is often a difficult challenge. A special Nitinol clip, the OTSC clip (Ovesco AG), was evaluated for fistula closure in a porcine model.A total of 20 fistulae were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC clip using a specially developed transanal clip applicator. The safety and technical feasibility of the clip application were tested. Another 4 weeks later, fistulae were macroscopically assessed for closure. For histological examination, the anorectum including the fistula tract was excised en bloc.Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% of residual tracts and a more intense chronic inflammation were seen in the untreated control fistulae. After clip placement, 10% of the fistulae persisted associated with a higher density of collagen fibres indicating a better fistula scarring and healing. No unexpected side-effects or complications caused by the clip were observed.Fistula closure using the OTSC clip represents a promising sphincter-preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the 'anal fistula claw' for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.

In patients suffering from haemorrhoidal disease a hyperplasia of the corpus cavernosum recti is accompanied by various symptoms such as anal bleeding and minor continence disorders as well as itching, soiling and burning. According to the morphological findings, haemorrhoids are staged from grade I up to IV. Therapy strategies are adjusted to this staging. Early stages are treated by conservative measures, such as regulation of defaecation, sclerosis and rubber band ligations. Advanced stages require operative methods, such as segmental excision and stapled haemorrhoidopexy. Since patients demand a greater regard to the subjective experience of their disease and its treatment, quality of life evaluation has become an important issue in medical care. Therefore health-related quality of life is increasingly becoming a relevant primary or secondary end point of clinical studies. Since up to 4 % of the general adult population in industrial nations is annually diagnosed to suffer from haemorrhoidal disease, in Germany per annum 3.5 Mio patients seek medical advice due to this condition and 40 000-50 000 surgical procedures are performed. Nevertheless only very few studies have been carried out to investigate the influence of this widespread disease on the quality of life of those patients. Additionally cost-effectiveness analyses measuring quality-adjusted life years are becoming more and more decisive in health politics. The present article discusses the definitions of health-related as well as disease-related quality of life. Different psychometric tests applied to evaluate the quality of life are summarised, quality criteria are outlined and limitations discussed. Several studies were analysed in regard to the quality of life in patients with haemorrhoidal disease and the specific influence of different operative techniques was reviewed.

The aim of this paper is to review diagnostic techniques which are useful and applicable in the evaluation of constipation. Besides widely-spread available techniques such as taking a specific and structured history and performing a clinical examination sophisticated diagnostic tools such as colon transit time, anal manometry, defecography endorectal ultrasonography as well as electrophysiological investigations such as anal sphincter electromyography and pudendal nerve terminal motor latency measurement are illustrated.

Longo's STARR operation is a new surgical technique for the management of obstructive defecation syndrome. A major advantage is the repair of rectocele and intussusception in a single transanal approach. Complications such as bleeding, infection, anal stenosis, and fistulas are known. In the described patient we detected a cavity in the spatium rectovaginale which was lined by rectum mucosa and connected to the rectum as a result of an incomplete resection of rectum wall and dilatation of the stapler suture. Recurrent stool incrustration in the cavity led to preformation of coproliths. We performed a modified Rehn-Delorme operation to resect the cavity. The STARR operation is a technique which should be used carefully and performed only by surgeons with experience and full knowledge of the potential complications.

Pyomyositis is in the moderate climate zone a rare and acute bacterial infection of the skeletal muscles without an obvious origin of infection. Initial symptoms contain muscle pain and localized swelling and tension. As different causes are taken into account first, the diagnosis of a pyomyositis is often delayed. We report on three cases of pyomyositis and discuss diagnosis and therapy against the background of the available and recent literature.

The purpose of the present study was to define the diagnostic value of anal endosonography in the diagnostic work-up of fistula-in-ano.A retrospective study was carried out on 191 consecutive patients (m: 121; f: 70; mean age: 44.0 +/- 12.5 years; range: 0.5-77 years) who were diagnosed to suffer from fistula-in-ano by performing anal endosonography in an outpatient setting. All images were obtained with a Combison 310A ultrasound scanner (Kretz GmbH, Zipf, Osterreich) and 5-Mhz and 7.5-MHz transducer. 131 patients underwent surgery. According to the endosonographic findings fistulas were classified as transsphincteric in 44 %, intersphincteric in 22 %, subanodermal in 16 %, anovaginal in 8 %, suprasphincteric in 5 %, extrasphincteric in 1 % and others in 4 %.In 125 patients (95 %) the preoperative diagnosis was confirmed intraoperatively. This cohort included 12 patients with a complex fistula system. In only 6 patients the preoperative ultrasound finding was misinterpreted.In conclusion this study has shown that anal endosonography is a useful and reliable tool in the preoperative evaluation of uncomplicated and complicated anorectal fistulas.

Treatment of anastomotic fistulas generally implies an individualized concept. The origin of these complications is multifactorial and comprises such factors as primary operation, oncologic situation, comorbidity, and patient age as well as fistula-specific considerations such as anatomic localization, secretion volume, etc. In the case of high-output fistulas, it is of great importance to counteract fluid and electrolyte imbalances. Furthermore, skin maceration due to aggressive secretion needs to be averted. Therapeutic options include operative and endoscopic interventions. Octreotide plays a role in high-output and pancreatic fistulas. Any underlying ailment (e.g., Crohn's disease) requires an optimal disease-specific treatment which characterizes an interdisciplinary approach to such fistulas. The following article discusses general and site-specific considerations in the diagnosis and treatment of anastomotic fistulas.

For determination of histology of small solid and microbiology of liquid pararectal tumors there is no other method than endorectal ultrasound-guided biopsy. Also for therapy of abscesses or seromas drainage application is possible. With this technique an operation may be prevented. In awareness of possible complications such as major injury of rectal wall, bleeding, persistent fistula and sepsis, teaching and training in this method is consequently necessary. For a training program a lifelike model of the rectum was developed. It has been used by 780 participants in 20 training courses organized by the Surgical Department of University Hospital Wiirzburg.

Tumescent local anesthesia (TLA) was introduced to facilitate liposuction and other procedures mainly in plastic surgery. The aim of our study was to evaluate if this new technique can also be safely applied in proctologic surgery.The following 50 proctologic procedures were performed using TLA as day surgery cases: perianal vein thrombectomy (n=15), subanodermal fistula resection (n=7), anal polyp resection (n=7), fissurectomy ( n=6), perianal abscess revision (n=6), excision of anal skin tags (n=3), hemorrhoidectomy for thrombosed piles (n=3), intersphincteric fistula extirpation (n=1), pilonidal sinus (n=1), and perianal tumor excision (n=1). The subcutaneously infused solution contained 200 ml of Ringer's solution, 50 ml of 2% Mepivacain, and 2.5 ml of epinephrine diluted 1:10,000.During an average application time of 14.3+/-4.9 min, a mean of 93.1+/-40.7 ml tumescent solution was infused. This dosage resulted in complete pain relief after 18.3+/-5.0 min. Local anesthesia was maintained up to 14 h postoperatively, with a mean duration of 6.7+/-1.9 h. Two patients developed moderate hematomas which required no further treatment.Our pilot study demonstrates that slow infusion tumescent local anesthesia can be widely and safely applied in proctologic surgery and enables the performance of these procedures on an outpatient basis.

We tried to evaluate the role of anorectal functional diagnostic tools according to the judgement of German coloproctologists.Questionnaires concerning accuracy of different diagnostic tests were sent to 585 physicians specialized in coloproctology.261 (44.6 %) completed forms were returned. An analysis of the answers revealed that endorectal sonography is widely (73 %) regarded as useful and reliable diagnostic tool. Though manometry is still frequently used, only 50.5 % of the coloproctologists made their decision concerning the further treatment depending on the results of this method. Other radiologic methods as defecography and colon transit time are still regularly performed, though video-defecography is not accepted by most coloproctologists. Neurological investigations as pudendal nerve terminal latency, surface-EMG and needle-EMG are exclusively applied in specialized departments.Regarding the variety of diagnostic tools and its different appraisal a consensus should be defined. The usefulness of neurological examination techniques needs to be clarified before their performance can be recommended for a wide-spread routine work up.

Bei 24 Patienten wurden insgesamt 28 transrektal endosonographisch gesteuerte Punktionen von liquiden Raumforderung im kleinen Becken durchgefuhrt. Es traten keine punktions-assoziierten Komplikationen auf. In 20 Fallen (71%) handelte es sich um postoperative Flussigkeitsansammlungen. In 13 Fallen (46%) konnte kein Keim isoliert werden. Hierbei handelte es sich um Hamatome (n=6), Serome (n=4), Peritonealzysten (n=2) und einer Mukozele. Bei 15 Punktionen (54%) gelang ein Keimnachweis, i.S. eines Abszesses (n=12) bzw. infizierten Hamatoms (n=3). Bei 12 dieser Patienten wurde in gleicher Sitzung transrektal (n= 10) oder transvaginal (n=2) ein Pigtail-Katheter eingebracht. Eine Operation zur Herdsanierung war nur bei 2 Patienten notwendig.

Using the Gastrointestinal Quality of Life Index (GIQLI) we investigated the quality of life in a consecutive series of 35 patients with faceal incontinence compared with patients suffering from haemorrhoidal disease (n = 96), fissure in ano (n = 38) and healthy controls (n = 75). The mean score for the different groups were as follows: incontinence 93 (65% of best possible score of 144), haemorrhoids 120 (83%), fissure 104 (72%) and controls 134 (93%). Incontinent patients had the significantly lowest overall GIQLI.

Background Benign proctological conditions are very common in Western civilization. However, to date quality of life in these patients has not been evaluated comprehensively. The aim of this study was to investigate whether the Gastrointestinal Quality of Life Index (GIQLI) is a useful instrument for measuring quality of life in these patients, and subsequently to establish baseline values for different anorectal disorders. Methods The questionnaire was completed by 325 consecutive patients (182 men; mean age 49 years) seen at the proctology outpatient clinic. For further analysis patients were classified into nine subgroups according to the primary diagnosis: group 1, haemorrhoids (n = 96); group 2, anal fissure (n = 38); group 3, fistula in ano (n = 22); group 4, severe constipation (n = 14); group 5, faecal incontinence (n = 35); group 6, symptomatic anterior rectocele (n = 12); group 7, perianal abscess (n =7); group 8, perianal thrombosis (n = 7); and group 9, miscellaneous conditions (e.g. skin tags, anal papillomas, mild constipation, rectal polyps) (n = 94). The GIQLI scores were compared between the subgroups. In addition the GIQLI scores of age-matched healthy controls, derived from data in the literature, were compared with the patients' scores. Results The mean GIQLI score for all patients was 113 (78·5 per cent of the maximum score of 144). Mean scores for the nine diagnostic subgroups were: group 1, 120; group 2, 104; group 3, 119; group 4, 94; group 5, 93; group 6, 112; group 7, 115; group 8, 129; and group 9, 117. Age-matched controls from a series published previously had a significantly higher GIQLI score compared with all patients (P < 0·0001). However, only the subgroups of patients with miscellaneous conditions, fissures, severe constipation and faecal incontinence had a significantly poorer quality of life than age-matched healthy individuals. Conclusion The GIQLI is a valuable instrument for measuring quality of life in patients with benign anorectal disorders. Although certain diseases do not seem to affect quality of life profoundly, certain subgroups of patients, most notably those with incontinence and severe constipation, are extremely compromised. Severely constipated individuals exhibit the same poor quality of life as patients with faecal incontinence.

A survey among coloproctologists was performed to assess current therapeutic concepts for the treatment of hemorrhoidal disease and anal fissure. A total of 261 clinical and non-clinical proctologists participated, representing the entire range of therapies in hospital and practise. A wealth of widely differing, in some aspects contradictory concepts were recorded, leaving almost no subject entirely undisputed. There are controversies regarding the different therapeutic alternatives as well as indications for surgery and choice of operative procedure. Future research has to address the existing controversies in order to reach a higher degree of standardization in the therapy of these common proctological disorders.

Anorectal manometry has been developed from an object of clinic oriented scientific interest to an established tool within the spectrum of proctologic diagnostics. At present it represents the only objective diagnostic method with regards to continence disorders; it is routinely applied in the evaluation of constipation, of incontinence, of pre- and postoperative conditions in diseases of the anorectum as well as in the indication and therapeutic control investigations during biofeedback training of the anal sphincter. The new technique of determination of the anal sphincter pressure vector volume allows for the most sensitive functional separation of patients with different degrees of continence; this method delivers a 3-dimensional graphic imaging of the sphincter pressure profile, thus allowing for an objective visualisation of the present mechanic defect and an aid in planning a surgical correction.

From 1982 to 1992, 33 patients underwent adrenalectomy for disease of the adrenal gland: 18 patients with adrenal cortex adenoma or hyperplasia (Cushing's syndrome n = 11, Conn's syndrome n = 6, adrenogenital syndrome n = 1), 3 with pituitary-dependent Cushing's disease, 7 with pheochromocytoma (malignant n = 1), 2 with a metastasis of lung cancer and 1 with cystic adrenal necrosis. Multiple endocrine neoplasia existed in four cases. Various preoperative symptoms were noted, including complaints typical of the respective syndromes and general abdominal symptoms. Other patients were symptom-free with incidental findings. An intercostal approach was used in 30 cases, a transabdominal approach in 3 cases. In 6 cases bilateral and in 27 cases unilateral adrenalectomy was performed. In two cases additional nephrectomy became necessary because of extensive adhesions. Intraoperatively, one patient suffered a blood pressure crisis. 31 patients are still alive and symptom-free after a mean follow-up of 5.4 years (range 1-11 years). Two patients have died (one with benign pheochromocytoma and one with a metastasis of lung cancer). Detailed preoperative hormone analysis and adequate preoperative medication substantially lowers the risk involved in adrenal surgery. However, the indications for surgical treatment of hormonally inactive, symptom-free adrenal tumors that are found incidentally remain controversial, and surgery should perhaps be restricted to large tumors.

Twenty-three patients with advanced renal cell carcinoma were treated with subcutaneous injections of interleukin-2 (IL-2) and interferon-alpha (IFN-alpha). IFN-alpha (5-10(6) U/m2) was injected on day 1 of the 1st week of a treatment cycle of 6 weeks and high doses of IL-2 (20.10(6) IU/m2) on days 3, 4 and 5. In the 2nd and 3rd week IFN-alpha (dose as above) and low doses of IL-2 (5.10(6) IU/m2) were injected on days 1, 3 and 5. The treatment from the 4th to the 6th week corresponded to that of the 1st to 3rd week. In cases of remission or stable disease the treatment schedule was repeated as a rule once or twice. In 12 of the 23 cases nephrectomy had been carried out previously. Complete remission lasting 4 + months and partial remission lasting 2 months were achieved in two patients with lung and skeletal metastases. A stable state of the disease lasting 1-7 + months was observed in 11 cases. Ten patients showed progression of the disease after the first treatment cycle. Thus, the overall objective response rate was 9%. The side effects were only slight and corresponded to WHO toxicity grade I (n = 8) and grade II (n = 15). In two cases the first treatment cycle could not be finished.