Predictors of long-term healing for endorectal advancement flap for anorectal fistulas

Introduction: Anorectal fistulas are some of the commonest surgical proctologic disorders treated by surgeons. Despite the recent introduction of various sphincter preserving techniques, the search for the optimal operation continues. The purpose of this study was to determine the predictors of long-term healing for the endorectal advancement flap. Methods: A retrospective review of a single surgeon experience with the endorectal advancement flap for anorectal fistulas over an 18-year period. The impact of various patient and fistula related factors were analyzed for their impact on the primary endpoint of long-term fistula healing. Results: 87 patients underwent endorectal advancement flap (Male/Female 42.5/57.5%). Median age was 41 years. Sixty-nine patients (79.3%) had anal fistula while 18 patients had rectal fistula (20.7%). An anterior based fistula was noted in 45 patients (51.7%). The most common etiology was cryptoglandular disease (87.4%). The median operative time was 75minutes (range 36-250). Postoperative septic complications were noted in 4 patients (4.6%). Fistula healing was documented in 80 patients (93%). During a median follow-up of 4 months (range 1-38, 1 patient lost to follow-up), recurrence was noted in 8 patients (9.3%), yielding an overall long-term success rate of 83.7%. The long-term healing rate was higher in patients with fistulas from cryptoglandular etiology (86.6%) compared to fistulas from other etiologies (63.6%) [p = 0.027]. Conclusions: The endorectal advancement is associated with a high healing rate, a low postoperative septic complication rate, and infrequent risk for recurrence. Long-term healing without recurrence is achieved more frequently in patients with cryptoglandular etiology of the fistula compared to patients with non-cryptoglandular etiology. (AU)

The Response to Therapy and Outcome in Adult Focal Segmental Glomerulosclerosis / 대한내과학회지

BACKGROUND: The response to therapy in adult patients with nephrotic syndrome caused by rimary focal segmental glomerulosclerosis (FSGS) was discouraging, but recent reports have shown high remission rate. Of these patients in remission, few progressed to end stage renal disease. METHODS: we analyzed author's experiences in 42 Korean adults with primary FSGS between January 1986 and December 1995 in attempt to know the response to therapy and outcome. RESULTS: 1) Twenty-six of 42 patients(62%) had nephrotic range proteinuria, and renal insufficiency (serum creatinine>1.4 mg/dL) was present in 14 patients(34%). Nephrotic patients had higher serum level of creatinine than that of nonnephrotic patients, and there was no difference between the two groups in blood pressure, age, and hematuria. 2) Twenty-six patients with nephrotic range proteinuria received combined treatment with prednisolone and cyclophosphamide. Complete remission (proteinuria300 mg/d) was observed in 10 cases(39%), and partial remission(2.50g/d) in 11 cases(42%), with mean remission time of 4.12.2 months after initiation of treatment. They had remission within 6 months of therapy except one. Relapse was noticed in 11 cases (52%) during follow-up. 3) None of responder group progressed to ESRD, while two of 5 non-responders progressed to ESRD, but there was no significant difference in slope of inverse creatinine between two groups. 4) The degree of proteinuria, initial serum creatinine, age, and sex did not affect the patient's response to therapy 5) The risk factors related to progression of renal failure were the initial serum creatinine level and degree of proteinuria. CONCLUSION: Nephrotic adult patients with primary FSGS may benefit from a more prolonged course of therapy with prednisolone and cyclophosphamide.