Simple clinical examination predicts complexity of perianal fistula.

OBJECTIVE: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.

Sutureless closed hemorrhoidectomy: a new technique.

OBJECTIVE: To compare a new technique of radical hemorrhoidectomy using an electrothermal device originally devised to seal vessels in abdominal operations, with the conventional open Milligan-Morgan procedure performed with diathermy. SUMMARY BACKGROUND DATA: Hemorrhoidectomy is one of the most commonly performed anorectal operations. Two well-established methods, the "open" Milligan-Morgan excision and the "closed" Ferguson technique, both carry risks of postoperative bleeding, urinary retention, and late anal stenosis. The convalescence is similarly long and difficult after both operations. The quest for an improved technique of radical excision of hemorrhoids is justified. METHODS: In this case-control study, two groups of patients were alternatively allocated into study and control groups. In the study group (n = 40), an electrothermal system was used. The tissue fusion produced by this device consists of melting of collagen and elastin. This technique essentially achieves a sutureless closed hemorrhoidectomy. The operative time, postoperative complications, and time off work were compared with the group undergoing conventional Milligan-Morgan hemorrhoidectomy (control group, n = 40). RESULTS: The operative time and time off work were significantly shorter in the study group. There were also fewer postoperative complications in this group. CONCLUSIONS: The "tissue-welding" properties of this device and the shape of the electrode handpiece may be successfully applied to the performance of an operation most appropriately described as a "modified sutureless closed hemorrhoidectomy." This pilot study shows that this new technique is simple and safe, significantly shortens the operation, and is followed by a significantly easier and shorter recovery.

Abdominal stoma fashioned by a used circular stapler.

A method of application of a used circular stapler in abdominal stoma formation is described. The procedure is rapid, simple, carries less tissue trauma than the conventional methods and does not involve any additional cost. It allows for a precise circular aperture in the abdominal wall which may be optimally adjusted to the bowel diameter. This method seems to minimize the occurrence of stomal complications and particularly the incidence of troublesome parastomal hernias.

Effect of rectal stump washout on the presence of free malignant cells in the rectum during anterior resection for rectal cancer.

PURPOSE: It is possible that implantation of viable malignant cells is one of the mechanisms of anastomotic recurrence in rectosigmoid cancer. The viability of shed intraluminal cells was previously established and malignant cells were retrieved on circular staplers in unwashed rectal stumps. The aim of this study is to evaluate the effectiveness of a defined and uniform washout protocol in eradication of intraluminal malignant cells during anterior resection. METHODS: In 14 consecutive patients the closed rectal stump was washed before insertion of the circular stapler. The washout was performed uniformly by instillation of ten increments of 50 ml of saline through a rectal tube. Samples from the first, fifth, and tenth washings were collected for cytologic examination. The presence or absence of malignant cells was then correlated with rectal stump length, length of the tumor-free distal margin, and differentiation and Dukes staging of the tumor. RESULTS: In 11 patients the first washing was positive for free malignant cells, and the fifth washing was still positive in 7 patients; however, the last (tenth) samples were clear in 10 patients, and malignant cells were recovered in only 4 patients. The rectal stump and the tumor-free distal margin were shorter in patients who still had positive cytology for free intraluminal malignant cells after stump irrigation with 500 ml of saline. No correlation was found with tumor differentiation or staging. CONCLUSIONS: Free malignant cells are shed into the rectal stump during anterior resection. Mechanical lavage with saline effectively eradicates these cells; however, the completeness of cleansing is volume related. Incomplete cleansing with 500 ml of saline correlates with lower tumors. Technically more difficult surgery involves traumatic handling of the tumor and possibly induces shedding of more malignant cells. We suggest that rectal stump washout during anterior resection for carcinoma should be routine, and the volume of the lavage fluid should be larger than 500 ml.

Varicocele treatment in pubertal boys prevents testicular growth arrest.

PURPOSE: There is evidence that varicocele damage, as reflected by loss of testicular mass, is most striking in the pubertal age group. We attempted to evaluate the long-term effect of early varicocele treatment on testicular growth and sperm count and, thus, determine its prophylactic value. MATERIALS AND METHODS: We compared testicular mass and sperm count in 32 men (mean age 28 years) who underwent surgery for varicocele at 11 to 15 years old (mean age 13) to those in 26 untreated, age matched men (mean age 30 years) with varicocele and 27 male controls (mean age 25 years). Mean followup in the treated group was 14.5 years (range 12 to 20). Testicular volumes were measured by ultrasonography. RESULTS: There was no significant difference between left and right testicular volumes in the treated or control group, in contrast to the untreated group, in which the left testicles were significantly smaller. Comparison of testicular mass showed a striking similarity between the treated and control groups, while there was a significant difference when the untreated group was compared to the control and operated groups. Total sperm counts were significantly less in the untreated than the treated and control groups. CONCLUSIONS: These data support the notion that testicular hypotrophy related to varicocele may be reversed by early intervention and they further strengthen the indication for varicocelectomy in children.

A microprocessor temperature-controlled air delivery system for dentinal hypersensitivity testing.

A new microprocessor temperature controlled air delivery system for determining cold and warm temperature thresholds of dentinal hypersensitivity has been designed and built. The temperature range of the unit is -5 degrees to + 85 degrees C. Air is delivered from a typical dental unit air syringe nozzle at a relatively gentle flow rate of 0.2 cu ft/min at operator selected temperatures, with an accuracy of +/- 0.2 degrees C. Within seconds, 1 degree to 5 degrees temperature increments or decrements are accomplished. Larger, i.e., 20 degree increments or decrements, require approximately 15 seconds. The unit can operate from standard 110 V/60 Hz or 230 V/50 Hz outlets and requires a source of compressed air at 60 psig, equivalent to that provided by dental operatory-type air compressors. This report provides a description of the unit, its operation, and data from two clinical studies in which it was used successfully to determine temperature thresholds of dentinal hypersensitivity.

[Changes in the enzyme activity of flavinogenesis in the process of culturing the fungus Eremothecium ashbyii]. / Izmenenie aktivnosti nekotorykh fermentov flavinogeneza v protsesse kul'tivirovaniia griba Eremothecium ashbyii.

The activity of enzymes involved in the beginning (GTP cyclohydrolase) and terminal steps (riboflavin synthase EC 2.5.1.9, riboflavin kinase EC 2.7.1.26 and FMN adenyltransferase EC 2.7.7.2) of flavinogenesis was studied in the mycelium of Erenmothecium ashbyii of different age. The activity of GTP cyclohydrolas, riboflavin kinase and FMN adenyltransferase was low in the young mycelium and increased in the process of growth, which was accompanied by the acceleration of flavinogenesis. The activity of riboflavin synthase was high in the young mycelium and changed only slightly in the process of subsequent cultivation of the fungus. 8-Azaadenine and 8-hydroxyquinoline added to the young culture of E. ashbyii inhibited the flavinogenesis of the mycelium and the increase of the enzyme activity.

Colony stimulating activity in sera of erythroleukemic mice (RLV-A).

RLV-A serum activity was measured by the agar colony assay to determine the effect of this erythroid dyscrasia on the granulopoietic humoral regulator, colony stimulating factor (CSF). In general, the sera of early, midstage and terminal animals not given endotoxin had high cluster forming properties compared to normal sera. The sera of early, midstage, and terminal mice treated with endotoxin had only a fraction of the colony forming ability of serum obtained from normal endotoxin-treated mice (EMS) with the earliest stages of the disease showing least activity followed by a rise in activity paralleling normal EMS, as the disease progressed. Sera from RLV-A endotoxin treated mice retained ability to stimulate cluster growth especially when compared to the slight activity displayed by normal endotoxin treated mouse sera.

The effects of endotoxin on CFU-C clonogenic capacity of marrow and spleen cells from RLV-A infected mice.

Bacterial endotoxin was used as a granulopoietic stressor in the RLV-A infected mouse as a means of studying the marrow and spleen CFU-C response to this agent. A control group of phenylhydrazine (PHZ)-treated mice was also employed to induce a reduction in hematocrit levels equivalent to that observed in the early and mid-stage of the disease course and was used to determine whether the cloning observed was a manifestation of RLV-A disease or could be attributed solely to the resulting anemia. Both RLV-A infected and PHZ marrow from mice maintained at a hematocrit of 40% exhibited similar but higher than normal clonogenic capacities, whereas RLV-A (hematocrit 40%) spleen had an expanded number of CFU-C's when compared to PHZ treated (hematocrit 40%) mice. Examination of spleens of endotoxin-treated RLV-A (hematocrit 30%) infected mice indicated a 6 to 7-fold increase in splenic CFU-C numbers compared to endotoxin-treated normal mice. PHZ plus endotoxin-treated normal animals (hematocrit 30%) had splenic CFU-C values which were approximately half those of RLV-A infected (hematocrit 30%) endotoxin-treated animals. Results of this experiment suggest a fully operable but greater than normal CFU-C storage pool in the RLV-A infected mouse spleen which does not seem to be due entirely to the anemia.

[Genetic classification of riboflavin-dependent mutants of Pichia guilliermondii yeasts]. / Geneticheskaia klassifikatsiia riboflavinzavisimykh mutantov drozhzhei Pichia guilliermondii.

114 riboflavinless mutants were selected from the genetic line of Pichia guilliermondii yeast. By means of accumulation test the mutants were divided into five biochemical groups. In genetic experiments seven complementation classes were found among 106 mutants. The strains of the I biochemical group, accumulating no specific products, corresponded to complementation class rib1; II group, accumulating 2,4,5-triaminopyrimidine - to the class rib2; III group, accumulating 2,6-dihydroxy-4-ribitylaminopyrimidine - to the class rib3; the mutants of the IV group, accumulating 2,6-dihydroxy-5-amino-4-ribitylaminopyrimidine, were divided into three complementation classes rib4, rib5 and rib6; the mutants of the V group, acculumating 6,7-dimethyl-8-ribityllumazine, corresponded to the class rib7. Two mutants of the IV biochemical group within complementation classes rib4 and rib5 were detected could not grow in the medium with diacetyl without riboflavin. Intragenic complementation was found within classes rib6 and rib7. No linkage between mutations of different complementation classes was detected.

[Regulation of the activity of GTP-cyclohydrolase, the enzyme of the first step of flavinogenesis in yeasts]. / Issledovanie reguliatsii aktivnosti GTR-tsiklogidrolazy--fermenta pervogo etapa flavinogeneza u drozhzhei.

The kinetic properties and regulation of activity of GTP-cyclohydrolase, the enzyme of the first step of flavinogenesis in the Pichia guilliermondii yests, partially purified by gel-filtration were studied. It was found that the curve of the dependence of reaction rate on substrate concentration is non-hyperbolic. FAD inhibited the enzyme activity, while riboflavin and FMN had no such effect. In addition to FAD, 5'-AMP, 3',5'-AMP, ADP, ATP, NAD and NADP inhibited the enzyme activity. Under combined action of FAD and AMP on GTP-cyclohydrolase no synergetic or antagonistic effects of the inhibitors on the enzyme activity were observed. The enzyme appreciably lost its sensitivity to FAD and AMP after thermal treatment. The data obtained suggest that GTP-cyclohydrolase from P. guilliermondii is an allosteric enzyme, which is inhibited by the end product of flavinogenesis FAD, as well as by other 5'-AMP-containing nucleotides.

[Activities of some yeast flavogenic enzymes in situ]. / Izuchenie aktivnosti nekotorykh fermentov flavinogeneza u drozhzhei in situ.

Effects of digitonin, dimethylsulfoxide and protamine sulfate on yeast Pichia guilliermondii were studied in order to produce cells with increased permeability and possessing the GTP-cyclohydrolase, riboflavinsynthetase and riboflavinkinase activities. The digitonin-treated cells exhibited a higher cyclohydrolase activity than the cell-free extracts; the activities of riboflavinsynthetase and riboflavinkinase in the cells and cell-free extracts were found to be similar. Treatment of cells with dimethylsulfoxide proved to be most effective to determine the activity of GTP-cyclohydrolase and also helpful to determine that of riboflavinsynthetase. Protamine sulfate had no effect on the cells of P. guilliermondii. The methods developed were used to determine the activities of GTP-cyclohydrolase, riboflavinsynthetase and riboflavinkinase in the cells of flavinogenic (P. guiller-mondii, Torulopsis candida) and non-flavinogenic (Candida utilis, Candida pulcherrima) yeasts grown in iron-rich and iron-deficient media. Derepression of riboflavinsynthetase and GTP-cyclohydrolase syntheses under conditions of Fe deficiency in the flavinogenic yeast cells confirmed previously made assumptions.

[Regulation of synthesis of GTP-cyclohydrolase participating in yeast falvinogenesis by iron]. / Reguliatsiia zhelezom sinteza GTF-tsiklogidrolazy, uchastvuiushchei vo flavinogeneze drozhzhei.

Pichia guilliermondii, Schwanniomyces occidentalis, Torulopsis candida and several riboflavin-dependent mutants of Torulopsis candida were grown in a medium with a low concentration of iron. In these conditions, the activity of GTP-cyclohydrolase which catalyzes the first step of flavinogenesis increases. The activity of the enzyme increases also when the cells of T. candida and P. guilliermondii with a high content of iron are incubated with alpha, alpha'-dipyridyl which induces overproduction of riboflavin; this action of alpha, alpha'-dipyridyl is eliminated by cycloheximide. Therefore, iron deficiency in the cells of these yeasts causes derepression of GTP-cyclohydrolase participating in riboflavin biosynthesis. The activity of the enzyme is inhibited by FAD but not by FMN and riboflavin.

Regulation of 6-hydroxy-2,4,5-triaminopyrimidine synthesis by riboflavin and iron in riboflavin-deficient mutants of Pichia guilliermondii yeast.

The effect of riboflavin and iron on 6-hydroxy-2,4,5-triaminopyrimidine synthesis rate was investigated in the cultures of the yeast Pichia guilliermondii (rib2 mutants) with the blocked second reaction to flavinogenesis. It was shown that riboflavin inhibited the 6-hydroxy-2,4,5-triaminopyrimidine synthesis rate in iron-rich and iron-deficient cells of mutants with low riboflavin requirements. Cycloheximide did not prevent the stimulation of 6-hydroxy-2,4,5-triaminopyrimidine synthesis caused by riboflavin starvation. 7-methyl-8-trifluoromethyl-10-(1'-D-ribityl)isoalloxazine strongly inhibited the 6-hydroxy-2,4,5-triaminopyrimidine synthesis, while 7-methyl-8-trifluoro-methyl-10-(beta-hydroxyethyl)izoalloxazine and galactoflavin exerted only a slight effect on this process. The 6-hydroxy-2,4,5-triaminopyrimidine synthesis rate in iron-deficient cells was significantly higher than in iron-rich cells. The 2,2'-dipyridyl treatment of iron-rich cells caused the stimulation of 6-hydroxy-2,4,5-triaminopyrimidine synthesis and cycloheximide abolished this effect. The results suggest that the activity of the first enzyme of flavinogenesis (guanylic cyclohydrolase) is under the control of feedback inhibition by flavins and the biosynthesis of this enzyme is regulated by iron.

In vitro granulocytic stem cell clonogenic capacity of marrow and spleen cells from mice infected with Rauscher leukemia virus.

Bone marrow and spleen cells from early, midstage, and terminal Rauscher leukemia virus (RLV-A)-infected erythroleukemic mice were assessed for granulocyte stem cell (CFU-c) clongenic capacity in the semisolid agar culture assay. It was found that marrow CFU-c concentrations exceeded normal in early stages of this erythroid disease but returned to near normal values during mid- and terminal phases. Splenic CFU-c concentrations, on the other hand, were generally higher than control values for all stages of the disease. These results are discussed with reference to the pathogenesis of RLV-A disease.