Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence.

INTRODUCTION: Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen. METHODS: Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained. RESULTS: Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery. CONCLUSIONS: We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.

Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence.

BACKGROUND: Percutaneous, transcutaneous and sham transcutaneous posterior tibial nerve stimulation was compared in a prospective blinded randomized placebo-controlled trial. METHODS: Patients who had failed conservative treatment for faecal incontinence were randomized to one of three groups: group 1, percutaneous; group 2, transcutaneous; group 3, sham transcutaneous. Patients in groups 1 and 2 received 30-min sessions of posterior tibial nerve stimulation twice weekly for 6 weeks. In group 3, transcutaneous electrodes were placed in position but no stimulation was delivered. Symptoms were measured at baseline and after 6 weeks using a bowel habit diary and St Mark's continence score. Response to treatment was defined as a reduction of at least 50 per cent in weekly episodes of faecal incontinence compared with baseline. RESULTS: Thirty patients (28 women) were enrolled. Nine of 11 patients in group 1, five of 11 in group 2 and one of eight in group 3 had a reduction of at least 50 per cent in weekly episodes of faecal incontinence at the end of the 6-week study phase (P = 0·035). Patients undergoing percutaneous nerve stimulation had a greater reduction in the number of incontinence episodes and were able to defer defaecation for a longer interval than those undergoing transcutaneous and sham stimulation. These improvements were maintained over a 6-month follow-up period. CONCLUSION: Posterior tibial nerve stimulation has short-term benefits in treating faecal incontinence. Percutaneous therapy appears to have superior efficacy to stimulation applied by the transcutaneous route. REGISTRATION NUMBER: NCT00530933 (http://www.clinicaltrials.gov).

Sacral nerve stimulation in the elderly.

AIM: Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years. METHOD: Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively. RESULTS: Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6). CONCLUSION: SNS is an effective treatment for faecal incontinence in patients over 65 years.

A network approach to assessing cognition in disorders of consciousness.

OBJECTIVE: Conventional assessments of consciousness rely on motor responses to indicate awareness. However, overt behaviors may be absent or ambiguous in patients with disorders of consciousness (DOC) resulting in underrating capacity for cognition. fMRI during a silent picture-naming task was evaluated as an indicator of command following when conventional methods are not sufficient. METHODS: A total of 10 patients with and without conventional evidence of awareness, who met diagnostic criteria for the minimally conscious state (MCS) (n = 5), vegetative state (VS) (n = 3), emerged from MCS (EMCS) (n = 1), and locked-in syndrome (LIS) (n = 1), participated in this observational fMRI study. RESULTS: The LIS and EMCS patients engaged a complete network of essential language-related regions during the object-naming task. The MCS and 2 of the VS patients demonstrated both complete and partial preservation of the object-naming system. Patients who engaged a complete network scored highest on the Coma Recovery Scale-Revised. CONCLUSIONS: This study supports the view that fMRI during object naming can elicit brain activations in patients with DOC similar to those observed in healthy subjects during command following, and patients can be stratified by completeness of the engaged neural system. These results suggest that activity of the language network may serve as an indicator of high-level cognition and possibly volitional processes that cannot be discerned through conventional behavioral assessment alone.

Closure of loop ileostomies: is early discharge safe and achievable?

A prospective audit of the complications associated with reversal of a loop ileostomy was carried out between March 2000 and March 2005. The complication rate, length of inpatient hospitalisation and re-admission rate were assessed in 100 patients, in a single clinical practice. The median (interquartile range) length of time between the primary procedure and closure was 133 days (120-270) days. Median length of inpatient stay was two days (one - three) days. The overall complication rate was 18%. One patient had a post-operative leak leading to local abscess formation. This was drained surgically after initial failure with radiological drainage. A second patient had a late leak, three weeks after closure, leading to fistula formation. This patient required surgical resection of the anastomosis after failure of conservative management. Twelve patients were re-admitted with small bowel obstruction (12%), of whom 11 were managed conservatively, while one underwent further surgery. There was one post- operative death as a result of acute cardiac failure secondary to undiagnosed hypertensive cardiomyopathy. Thus early discharge following closure of a loop ileostomy, can be achieved with an acceptably low serious complication rate.

Predictors of short-term outcome in brain-injured patients with disorders of consciousness.

OBJECTIVES: To investigate predictors of recovery from the vegetative state (VS) and minimally conscious state (MCS) after brain injury as measured by the widely used Disability Rating Scale (DRS) and to explore differences in rate of recovery and predictors of recovery during inpatient rehabilitation in patients with non-traumatic (NTBI) and traumatic brain injury (TBI). DESIGN: Longitudinal observational cohort design and retrospective comparison study, in which an initial DRS score was collected at the time of study enrollment. Weekly DRS scores were recorded until discharge from the rehabilitation center for both NTBI and TBI patients. SETTING: Seven acute inpatient rehabilitation facilities in the United States and Europe with specialized programs for VS and MCS patients (the Consciousness Consortium). PARTICIPANTS: One hundred sixty-nine patients with a non-traumatic (N=50) and a traumatic (N=119) brain injury who were in the VS or MCS states. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: DRS score at 13 weeks after injury; change in DRS score over 6 weeks post-admission; and time until commands were first followed (for patients who did not show command-following at or within 2 weeks of admission). RESULTS: Both time between injury and enrollment and DRS score at enrollment were significant predictors of DRS score at week 13 post-injury but the main effect of etiology only approached significance. Etiology was however a significant predictor of the amount of recovery observed over the 6 weeks following enrollment. Time between injury and enrollment was also a good predictor of this outcome, but not DRS score at enrollment. For the time until commands were first followed, patients with better DRS scores at enrollment, and those with faster early rates of change recovered command following sooner than those with worse DRS scores or slower initial rates of change. The etiology was not a significant predictor for this last outcome. None of these predictive models explained sufficient variance to allow their use in individual clinical decision making. CONCLUSIONS: Time post-injury and DRS score at enrollment are predictors of early recovery among patients with disorders of consciousness, depending on the outcome measure chosen. Etiology was also a significant predictor in some analyses, with traumatically injured patients recovering more than those with non-traumatic injuries. However, the hypothesized interaction between etiology and time post-injury did not reach significance in any of the analyses suggesting that, within the time frame studied, the decline in prognosis with the passage of time was similar in the two groups.

Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up: a new surgical procedure.

BACKGROUND: Although laparoscopic repair of large, mostly paraesophageal hiatal hernias is widely applied, there is a great concern regarding the higher recurrence rate associated with this procedure. In order to reduce this high recurrence rate, several techniques have been developed, mostly applying a mesh prosthesis for hiatal reinforcement. METHODS: We have recently introduced a new laparoscopic technique in which the hiatal closure is reinforced with the teres ligament. To date 26 patients have been entered into this ongoing prospective study. After the operation patients were called back on a regular basis for symptom evaluation and barium swallow. All 26 patients agreed to undergo barium swallow, with a mean follow-up of 35 months. RESULTS: The mean operative time was 115 min. Perioperative morbidity was 11.5%, and conversion to an open procedure was performed in six cases. No mortality was registered. Anatomic recurrence, investigated by barium swallows was observed in four patients (15.3%). Of those four, only one (3.85%) had a symptomatic recurrent paraesophageal hernia; the other three had asymptomtic sliding hernias. In three of the four patients with anatomic recurrence, the diameter of the hiatal hernia was greater than 9 cm at the original operation, and the fourth patient underwent reoperation for recurrent hiatal hernia. No symptomatic recurrence was found in patients with diameter of hiatal hernia between 6 and 9 cm. CONCLUSIONS: Laparoscopic reinforcement of the hiatal closure with the ligamentum teres is safe and effective treatment for large hiatal hernias. However, it appears that patients with extremely large hiatal hernias are at greater risk of recurrence, and therefore large hernias are not suitable for this new technique.

Behavioural improvements with thalamic stimulation after severe traumatic brain injury.

Widespread loss of cerebral connectivity is assumed to underlie the failure of brain mechanisms that support communication and goal-directed behaviour following severe traumatic brain injury. Disorders of consciousness that persist for longer than 12 months after severe traumatic brain injury are generally considered to be immutable; no treatment has been shown to accelerate recovery or improve functional outcome in such cases. Recent studies have shown unexpected preservation of large-scale cerebral networks in patients in the minimally conscious state (MCS), a condition that is characterized by intermittent evidence of awareness of self or the environment. These findings indicate that there might be residual functional capacity in some patients that could be supported by therapeutic interventions. We hypothesize that further recovery in some patients in the MCS is limited by chronic underactivation of potentially recruitable large-scale networks. Here, in a 6-month double-blind alternating crossover study, we show that bilateral deep brain electrical stimulation (DBS) of the central thalamus modulates behavioural responsiveness in a patient who remained in MCS for 6 yr following traumatic brain injury before the intervention. The frequency of specific cognitively mediated behaviours (primary outcome measures) and functional limb control and oral feeding (secondary outcome measures) increased during periods in which DBS was on as compared with periods in which it was off. Logistic regression modelling shows a statistical linkage between the observed functional improvements and recent stimulation history. We interpret the DBS effects as compensating for a loss of arousal regulation that is normally controlled by the frontal lobe in the intact brain. These findings provide evidence that DBS can promote significant late functional recovery from severe traumatic brain injury. Our observations, years after the injury occurred, challenge the existing practice of early treatment discontinuation for patients with only inconsistent interactive behaviours and motivate further research to develop therapeutic interventions.

Gastroesophageal reflux disease progressing to achalasia.

Two achalasia patients with former complaints of heartburn were examined. Antisecretory drugs were used by the patients when dysphagia occurred. Barium X-ray and esophageal manometry were performed and achalasia was diagnosed in both patients. Twenty-four-hour pH-metry showed significant and long-lasting acid reflux during supine position. Prolonged reflux episodes can be explained not only by the swallow-unrelated transient relaxation of lower esophageal sphincter (LES) and mechanical damage of the esophageal body, but also by its chemical insensitivity. Thus preoperative detection of reflux should determinate either the operational procedure and the postoperative follow up of the patient.

Prevention of recurrence by reinforcement of hiatal closure using ligamentum teres in laparoscopic repair of large hiatal hernias.

UNLABELLED: BACKGROUND. Several attempts were made to develop an effective technique to reduce the high recurrence rate associated with the repair of large hiatal hernias. METHODS: A new laparoscopic technique was introduced to reinforce hiatal closure with the ligamentum teres. Its feasibility, safety, and efficacy were evaluated. Four patients with gastroesophageal reflux disease and large hiatal hernia (>6 cm) entered the study. After closure of the diaphragmatic crura the teres ligament was dissected, brought behind the esophagus, and sutured to the crura. A fundoplication was also added. Patients were followed with barium swallow at 3 months postoperatively. RESULTS: The mean operation time was 109.5 min. No intraoperative complications, perioperative morbidity, or mortality were registered. At the follow-up, barium swallows revealed no recurrence. CONCLUSION: On the basis of these preliminary results laparoscopic reinforcement of the hiatal closure with the ligamentum teres seems feasible and safe; therefore this promising technique should be considered as an option for the treatment of large hiatal hernias.

Prokinetic effect of cisapride on pedicled stomach, small bowel and colon grafts replacing the esophagus after esophageal resection.

Cisapride is a potent third generation prokinetic agent acting on postganglionic receptors by increasing the release of acetylcholine. In a prospective, self-controlled study the prokinetic action of cisapride was tested on pedicled stomach, jejunum and colon grafts used for substitute after esophageal resection. Between 1995 and 1998 15 patients with gastric pull up, 10 patients with colon replacement or bypass and eight patients with free jejunum transplant or jejunum replacement were evaluated. Esophageal transit scintigraphy was performed before and after cisapride administration. From the time-activity curves, the half-life of radiolabeled bolus in the esophagus was calculated and preadministration and postadministration half-lives were compared. Cisapride significantly reduced the half-life of radiolabeled bolus in the substitute in the case of stomach and jejunum replacement, while for colon replacement the results were dispersed too widely to yield significant difference. Cisapride exerts prokinetic effect on pedicled stomach and jejunum substitutes after esophageal resection.

Anti-factor V auto-antibody in the plasma and platelets of a patient with repeated gastrointestinal bleeding.

Development of autoantibody against coagulation factor V (FV) is a rare clinical condition with hemorrhagic complications of varying severity. The aim of this study was to establish the pathomechanism of an acquired FV deficiency and characterize the FV inhibitor responsible for the clinical symptoms. A 78-year-old female was admitted to hospital with severe gastrointestinal bleeding. General clotting tests and determination of clotting factors were performed by standard methods. FV antigen and FV containing immune complexes were measured by ELISA. The FV molecule was investigated by Western blotting and by sequencing the f5 gene. The binding of patient's IgG to FV and activated FV (FVa) was demonstrated in an ELISA system and its effect on the procoagulant activity of FVa was tested in clotting tests and in a chromogenic prothrombinase assay. Localization of the epitope for the antibody was performed by blocking ELISA. FV activity was severely suppressed both in plasma and platelets. FV antigen levels were normal by ELISA using polyclonal anti-FV antibody or monoclonal antibody against the connecting region of FV, but depressed when HV1 monoclonal antibody against the C2 domain in the FV light-chain was used as capture antibody. The FV molecule was found intact. An IgG reacting with both FV and FVa was present in the patient's plasma and its binding to FV was inhibited by HV1 antibody. FV-containing immune complexes were detected in the patient's plasma and platelet lysate. The patient's IgG inhibited the procoagulant function of FVa. An anti-FV IgG was present in the patient's plasma and platelets. The autoantibody reacted with an epitope in the C2 domain of FV light chain and neutralized the procoagulant function of FVa.

Comparison of quality of life and nutritional parameters after total gastrectomy and a new type of pouch construction with simple Roux-en-Y reconstruction: preliminary results of a prospective, randomized, controlled study.

The aim of the study was to introduce a new type of gastric substitute, the aboral pouch, after total gastrectomy and to compare nutritional, motility, and quality of life parameters of patients with an aboral pouch to those undergoing simple Roux-en-Y reconstruction in a prospective, randomized, and controlled trial. To date 40 patients have entered the study. In 22 of them the aboral pouch was created; the remaining 18 patients with simple Roux-en-Y reconstruction served as the control group. Laboratory measurements, passage studies, lipid and carbohydrate absorption tests, and quality of life interviews were carried out as follow-up examinations. Preliminary results suggest that the aboral pouch has some advantages over simple Roux-en-Y reconstruction. Serum immunoglobulin M level and the quality of life estimated by the gastrointestinal quality of life index, yielded significantly better results in the pouch group.

Nutritional and life-quality consequences of aboral pouch construction after total gastrectomy: a randomized, controlled study.

AIMS: The aboral pouch, a new type of gastric substitute, has been introduced after total gastrectomy and compared to simple Roux-en-Y reconstruction in a prospective, randomized study. Anthropometric data, serum nutritional parameters, small intestinal passage, lipid and carbohydrate absorption and quality of life were measured 6 and 12 months after total gastrectomy. PATIENTS AND METHODS: Between September 1997 and April 2000 46 patients entered the study, 24 to the aboral pouch group and 22 to the control, simple Roux-en-Y group. RESULTS: Interim analysis of the data revealed significantly higher serum cholesterol levels, better lipid absorption and quality of life in patients who underwent aboral pouch construction. CONCLUSION: Aboral pouch construction is a feasible reconstruction method after total gastrectomy providing better lipid absorption and quality of life for patients after total gastrectomy.

[Gastric pouch with preserved duodenal passage: attempt to optimize reconstruction after total gastrectomy]. / Aborális pótgyomor a duodenális passzázs megtartásával: az optimális rekonstrukciós típus keresése totális gastrectomia után.

A new method--aboral pouch with preserved duodenal passage--has been introduced for reconstruction after total gastrectomy. After excising the stomach, preparation of the Roux loop and construction of an end-to-side esophago-jejunostomy, the Roux loop is anastomosed to the duodenal stump side-to-end approximately 40-50 cm distal from the esophago-jejunostomy. Right beneath this second anastomosis the Roux limb is closed with a stapler to provide unidirectional passage through the duodenum. An aboral pouch is constructed by a 15 cm long side-to-side anastomosis between the Roux limb under the stapled segment and the aboral end of the Y limb. The advantages of both the reservoir constructing and the interposition methods (duodenal passage preserved) are combined with this new form of reconstruction. The additional benefit is that the reservoir is constructed in aboral position, as previously suggested by the authors.

Larynx-preserving pharyngo-esophagectomy after chemoradiation in the treatment of cancer of the pharyngo-esophageal junction.

Pharyngo-laryngo-esophagectomy in the treatment of advanced tumors of the pharyngo-esophageal junction is associated with a high morbidity and poor quality of life due to loss of the larynx. Neoadjuvant chemoradiotherapy resulted in a considerable tumor reduction in 6 patients allowing radical tumor resection by larynx-preserving pharyngo-esophagectomy. The operation consisted of total esophagectomy and resection of the posterior pharyngeal wall and reconstruction by a pharyngogastrostomy in 5 patients, and ileocolon interposition in 1 patient.

Evidence-based cognitive rehabilitation: recommendations for clinical practice.

OBJECTIVE: To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke. DATA SOURCES: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled. STUDY SELECTION: Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated. DATA EXTRACTION: Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology. DATA SYNTHESIS: Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. CONCLUSIONS: Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

Non-malignant tracheo-gastric fistula following esophagectomy for cancer.

Two cases of neoesophago-tracheal fistula are described. After esophagectomy for cancer a fistula developed between the trachea and the pulled-up stomach probably because of the ischaemic effect of the tracheostomy tube. At single stage repairs, the fistulae were divided and the gastric defects were closed directly. In one case, tracheal resection and anastomosis was necessary. The defect on the membranous trachea in both cases was patched with an autologous fascia lata graft. A left pectoralis major muscle flap was interposed between the suture lines to prevent recurrence of the fistula. Treatment of this potentially life-threatening and rare condition yielded excellent results.

[Comparing aboral pouch construction with Roux-en-Y reconstruction after total gastrectomy]. / Totális gastrectomia után végzett aboralis pouch-képzés összehasonlítása Roux-Y rekonstrukcióval.

The aim of this study was the introduction of a new type of gastric substitute, the aboral pouch after total gastrectomy and comparing the motility, nutritional and quality of life parameters of the patients with aboral pouch to the simple Roux-en-Y group in a prospective, randomized, controlled trial. Between September of 1997 and February of 1999 25 patients entered the study. In the pouch group after Roux-en-Y reconstruction aboral pouch was created as a side to side anastomosis approximately 50 cms distal to the esophagojejunostomy, 15 cms in length. In the control group simple Roux-en-Y reconstruction was performed. During the follow up examinations nutritional measurements, scintigraphic evaluation of the gastrointestinal passage, absorption tests and quality of life interviews were carried out. In the first year of the study 15 patients underwent pouch construction, while 10 patients served as controls. Preliminary results suggest that there is no marked difference in the postoperative adaptation between the two groups. However serum immunoglobulin and serum iron measurements, lipid absorption test and quality of life questionnaires predict a slight superiority of the patients with aboral pouch over the simple Roux-en Y group.