Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study.

AIM: The aim of the study was to evaluate the impact of three-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula. METHOD: This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination 1 year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS) and anorectal manometry, at baseline and 1 year after surgery. RESULTS: A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At 1 year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anaesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% vs 22.5%; P = 0.26). The WIS in the EUA group significantly worsened (0.35 ± 0.94 vs 1.07 ± 1.59; P = 0.003) with a decreased the number of fully continent patients (82.5% vs 55%; P = 0.008) while neither the WIS nor the proportion of fully continent patients changed in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% vs 33.3%; P = 0.012) and they had better maximum resting pressure and maximum squeeze pressure than the EUA group. CONCLUSIONS: Preoperative use of 3D-EAUS had a favourable impact on the outcome of surgical treatment for anal fistulae, especially in those with complex anal fistula. It should be routinely used in the clinical setting.

Cellular isolation, culture and characterization of the marrow sac cells in human tubular bone.

The goal of this study is to characterize the epithelioid-like human marrow sac cells that separate the myeloid and osteoblast populations in situ and to determine if they express osteoblast cytoplasmic markers. Tubular segments of femoral diaphyseal bone were obtained from healthy young (4-8 yr) male and female patients undergoing femoral shortening surgeries. The interface between bone and marrow was examined by scanning (SEM) and transmission electron microscopy (TEM). The marrow sac cells were isolated and cultured in a-MEM medium with and without dexamethasone, glycerophosphate, and ascorbic acid [DGPA]. Alkaline phosphatase (ALP), bone morphogenetic protein-2 (BMP-2) and osteocalcin were evaluated. In the SEM, the marrow sac presented a distinctive pattern of large overlapping cells. TEM studies showed that marrow sac was one or two cells thick, which were attenuated with elongated nuclei, few cellular organelles, and appeared to display intercellular gap junctions. In culture, the marrow sac cells stained positively for ALP and BMP-2, and their expression was enhanced two- to three- fold when the cells were grown in DGPA. DGPA did not enhance osteocalcin expression. The cells of the human marrow sac reside proximate to endosteal osteoblasts and express osteoblastic markers. It is possible that these stromal cells constitute an osteoprogenitor pool from which replacement osteoblasts are recruited, and that they are involved in normal bone formation and in bone diseases (e.g., osteoporosis and osteopenia).

Comparative morphology of the marrow sac.

Electron microscopic techniques have been used to profile the morphologies of marrow sacs in different laboratory species. These structures all comprise a condensed layer of overlapping fibroblast-like stromal cells and apparently confine the medullary and endosteal osteoblast/lining cells to separate histiotypic compartments. There were some variations in the morphology of the sac cells in the different species. In rats, cats, and sheep, scanning electron microscopy (SEM) showed a seamless arrangement of marrow sac cells which resembled a thin, flat simple squamous epithelium; they displayed few intercellular cytoplasmic processes. In the rabbit and pigeon, the sac comprised a more woven, multilayered fabric of broadly elongate flat fibroblast-like cells which displayed numerous intercellular processes. Transmission electron microscopy (TEM) showed that all marrow sac cells were attenuated with elongated nuclei, a few small round mitochondria, and a sparse rough endoplasmic reticulum. In the majority of animals, the sac was one to two cell layers thick. The rabbit and pigeon sacs were multilayered, and never less than three to four cells deep. The cell layers were not closely apposed. Tight or gap junctions were absent at the points of intercellular contact. These morphological results suggest that marrow sacs are common elements of the vertebrate skeleton with species specific morphologies.

Expression of BMP-2 by rat bone marrow stromal cells in culture.

To investigate the role of bone morphogenetic protein (BMP-2) in ossifying rat bone marrow stromal cell cultures, we determined the population of fibroblast-like stromal cells that expressed BMP-2 immunocytochemically (anti-rhBMP-2 monoclonal antibody), and compared that to alkaline phosphatase (AP) and collagen synthesis formed in culture over a 4-week period in control and dexamethasone-supplemented mineralizing media. In control media, the percentage of BMP-2-positive stromal cells (BMP-2(+)) increased from 12 to 25% within the first 4 days of culture. In mineralizing media, the level of BMP-2(+) cells was significantly increased (43-44%). The intensity of immunostaining gradually increased with time. The levels of AP were undetectable at 1 week in both control and mineralizing media, but increased gradually over the next 2 weeks and peaked at 3 weeks. ALP levels were significantly greater in cultures grown in mineralizing medium (P < 0.05 at 3 weeks, P < 0.01 at 4 weeks). Collagen synthesis peaked and was significantly greater at 3 weeks (P < 0.05) in cultures grown in mineralizing medium. The levels of AP and collagen synthesis most closely reflected the changes in the percentage of BMP-2(+) cells from 7 to 28 days. Though these changes may reflect a primary action of BMP-2 on marrow osteoprogenitor-like stromal cells, they do not exclude a mechanism that involves the induction of other members of the BMP family known to stimulate AP and collagen synthesis. We conclude that BMP-2 expression in cultures of fibroblast-like marrow stromal cells is enhanced when those cells are induced to become osteoblasts by exposure to dexamethasone.

Torsional injury resulting in disc degeneration: I. An in vivo rabbit model.

Torsional injuries may be a precursor to intervertebral disc degeneration, but published rabbit models indicate a latent time of 6 months. We describe a rabbit model in which instability and disc degeneration appear within 3 months. Sixty-five male New Zealand rabbits underwent presurgical irradiation to inhibit heterotopic bone formation. Control animals then underwent either a soft-tissue release or facetectomy and capsulotomy, whereas experimental animals received surgery and an acute 30 degrees torsional lumbar injury. Capsulotomy, as well as facetectomy without torsion, failed to effect disc degeneration. However, the rabbits that received torsion exhibited clear indications of degenerative disc changes (thinning, increased PLA2 levels, and decreased nucleus pulposus volume) within 60-90 days. The observations associate disc degeneration with a destabilizing acute torsional injury.

Torsional injury resulting in disc degeneration in the rabbit: II. Associative changes in dorsal root ganglion and spinal cord neurotransmitter production.

The mechanism mediating the chronic pain associated with lumbar disc degeneration may involve neurotransmitters elaborated by dorsal root ganglion (DRG). This hypothesis has been tested in an applicable rabbit model of disc degeneration. Twenty control male rabbits underwent a soft-tissue release; 20 experimental rabbits sustained a facetectomy and capsulotomy and received an acute torsional lumbar injury. The levels of calcitonin gene-related peptide, vasoactive intestinal peptide, and substance P were measured in the DRG, spinal cord, and disc at 10, 30, 60, and 90 days postoperatively. Torsional injury was associated with a statistically significant increase in most DRG and spinal cord neurotransmitter values after 60-90 days. These points in time marked the periods of maximum biomechanical instability and disc narrowing. Such data support concepts about the association between chronic lumbar spinal instability, disc degeneration, and pain.