Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature.

OBJECTIVE: Chronic anal fissures are associated with a persistent hypertonia and spasm of the internal anal sphincter. Classic treatment is surgical sphincterotomy to reduce the anal tone and eliminate sphincteric spasm. However, concerns have been raised about the incidence of fecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored. METHODS: We conducted a literature review on MEDLINE database. RESULTS: All treatments address the anomaly of a high anal pressure. Several studies have investigated the effect of topical glyceryl trinitrate ointment. Healing rates range from 30% to 86%. Therapy is limited because of a high incidence of moderate to severe headaches in up to 84% of patients. Comparable results are observed after injection of botulinum toxin into the anal sphincter (43-96%). Minor incontinence for flatus and soiling has been reported in up to 12% of patients. Further pharmacological approaches including treatment via calcium channel blockade and treatment with alpha-adrenoceptor antagonists are still at a developmental stage. CONCLUSIONS: Topical glyceryl trinitrate ointment and injection of botulinum toxin into the anal sphincter are advocated as the first-line treatment for chronic anal fissure. Lateral sphincterotomy should be offered to patients with relapse and therapeutic failure of prior pharmacological treatment.

[Patency of surgically revised ePTFE-dialysis access grafts]. / Ist die chirurgische Revision von ePTFE-Dialyseshunts gerechtfertigt?

UNLABELLED: Native av-fistulas are the access of first choice for long-term hemodialysis. However, a large number of patients require an alternative vascular access, e. g. ePTFE grafts. Patency of ePTFE grafts is inferior to that of native av-fistulas. PURPOSE: To analyse the effectiveness of surgical revisions of occluded straight ePTFE dialysis access grafts. METHODS: Retrospective review of all upper arm dialysis access procedures from 1/94 to 8/99. RESULTS: Redo surgery was performed in 67 patients. Av-fistula dysfunction was caused by venous anastomotic stenoses (22 %), outflow occlusion (9 %), arterial anastomotic stenoses/inflow occlusion (12 %), and intragraft stenoses (6 %). 9 grafts had to be revised due to infection or perigraft hematoma (14 %). In 37 % the cause of graft occlusion could not be identified. Neither the cause of occlusion nor the type of treatment correlated with patency after revision. 6- and 12-months primary patency after surgery were 29 % and 11 %. 59 shunts required up to 12 revisions to maintain patency. Thus, secondary 1 yr-patency after revision was 29 %. CONCLUSION: Patency after redo surgery is disappointing. However, with repeated procedures ePTFE grafts remain open > 1 year in 29 % of the patients.

[Duodenal ulcer presenting as pneumomediastinum and pneumothorax -- case report]. / Pneumomediastinum und Pneumothorax als Manifestation eines Ulcus duodeni -- Fallbeschreibung.

Haemorrhage, penetration and perforation are common complications of peptic ulcers. Free intraabdominal air is seen in 80 % after perforation. Penetration into the retroperitoneum with pneumothorax and mediastinal emphysema are rarely observed. We report the case of a 85-year-old female patient with nausea, vomiting and little appetite. During endoscopy of the upper GI-tract she complained about progressive dyspnea. Chest X-ray revealed mediastinal emphysema and pneumothorax. When performing laparotomy, we found a duodenal ulcer, that had penetrated the retroperitoneal space. The patient underwent partial gastrectomy and reconstruction with Billroth-II anastomosis. The postoperative course was uneventful.

Flow cytometry cross-match: a method for predicting graft rejection.

Long-term graft survival is mainly influenced by early graft rejection and posttransplant graft function. The ability of both complement-dependent cytotoxicity cross-match (CDC) and flow cytometry cross-match (FCXM) to predict acute rejection episodes has been evaluated by cross-matching 40 patients who received cadaveric kidney transplants, before (current serum) and after transplantation (on days 1, 7, 14, 21, 28, 60, and 90). Of the 40 patients, all of whom had a negative CDC before transplant, seven patients had a positive FCXM before transplant: five of them (5/7=71.4%) experienced severe rejection within 2 months after transplantation. In patients with a negative FCXM before transplant, the incidence of acute rejection was lower (25.8%). Pre-transplant FCXM recipients who had a positive FCXM after transplant, experienced more frequent rejection (38.5%) than those pre-transplant FCXM recipients who never had a positive FCXM (15.8%). With respect to the incidence of acute graft rejection, no difference was found between patients who had a positive CDC after transplant and those who had a negative CDC after transplant. Patients who had a positive FCXM before transplant had significantly higher creatinine levels within the first month after transplant. Immediate onset of function and accelerated lowering of the creatinine level were found to be more frequent in patients who had a negative FCXM before transplant. As early graft rejection is the largest contributing factor for the development of chronic rejection and, therefore, of graft loss, we regard FCXM as a sensitive method for predicting long-term prognosis and graft survival, due to its competence in predicting both restricted graft function and early acute rejection, in particular.