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BACKGROUND AND AIMS: It was the aim of this prospective study to analyze the efficacy of the Cook Surgisis AFP anal fistula plug (AFP) for the closure of cryptoglandular and Crohn's disease-associated transsphincteric anorectal fistulas. MATERIALS AND METHODS: All patients with transsphincteric anorectal fistulas who underwent a surgical procedure using the AFP were prospectively enrolled in this study. Inclusion criteria included transsphincteric, single-tract fistulas. Patients' demographics, fistula etiology, surgical variables, continence (Cleveland Clinic Florida incontinence score), quality of life (fecal incontinence quality of life), and success rates were prospectively recorded. Surgery was performed in a standardized technique including irrigation of the fistula tract, placement, and internal fixation of the Cook Surgisis AFP anal fistula plug. No flap or excision of the fistula tract was performed. Success was defined as closure of both internal and external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6, 9, and 12 months postoperatively. RESULTS: Within 6 months (August 2006 to January 2007), a total of 19 AFPs were inserted in 19 patients (8 females, 11 males; mean age, 38 years). Out of 19 patients, 12 had cryptoglandular and 7 had Crohn's associated transsphincteric fistulas. Three patients were smokers, one patient had methicillin-resistant Staphylococcus aureus infection. Mean operative time was 15 min (range, 8-22); no morbidity occurred. After a mean follow-up of 279 days (SD = 68.0) and one patient lost to follow-up, the overall success rate was 61% (12 of 18) at 9 months postoperatively. Focusing solely on cryptoglandular fistulas, the success rate was 45.5% (5 of 11), whereas it was 85.7% (6 of 7) in transsphincteric fistulas associated with Crohn's disease. Five patients with failure of AFP (plug dislodgement, n = 2; persistent secretion, n = 3) had reoperation (27.8%). The reasons for failure were infection requiring drainage (n = 2) and persistent drainage (n = 3). No deterioration of continence was documented. CONCLUSION: The success rate for the Cook Surgisis AFP anal fistula plug for the closure of complex anorectal fistulas both in cryptoglandular and Crohn's associated fistulas was 45.5 and 85.7%, respectively. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques.

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A survey was conducted to determine the inpatient-counseling practices of hospital pharmacists. A questionnaire about the frequency of inpatient counseling, barriers to counseling, and suggestions for increasing the level of inpatient counseling was mailed to 667 hospital pharmacists. Recipients were asked to rate six attitudinal statements about inpatient counseling. The response rate was 30%. The largest group of respondents worked in institutions where discharge counseling was provided to specific populations or as needed. Some 67% of respondents reported not counseling any patients. Barriers to counseling most often cited were lack of time and inadequate staff; facilitators most often cited were decentralization and resource availability. The most frequent suggestions for increasing the amount of counseling were making changes that provide more time, having adequate staff to provide counseling, and having a well-designed counseling program in place. Responses about barriers and facilitators varied with practice setting and frequency of counseling. On average, pharmacists reported a belief that they are the health care professionals most qualified to counsel inpatients about medications and that this is their responsibility. More than two thirds of the responding hospital pharmacists reported counseling no patients; the barrier to counseling most frequently reported was lack of time, and the facilitator most often reported was decentralization; on average, pharmacists reported that they believed they should have a role in inpatient counseling.

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Determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated in 439 curatively resected colorectal cancer patients. The rate of transfusion was significantly higher in rectal cancer, large tumors, advanced pT stage and extended resection but not in tumor stenosis, lower graded tumors, advanced Dukes stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are negatively correlated to survival rates.

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An important intention of flow cytometric investigations is to obtain biochemical and biophysical information about cells which is suitable for automated tumor diagnosis. In this study, the ploidy status, the intracellular pH value, the intracellular esterase activity, and the cell volume of vital cells and the DNA and cell volume of dead cells were measured in cancerous tissue and normal lung tissue of 30 patients by flow cytometry. The cell samples were simultaneously stained with the pH and esterase indicator dye 1.4-diacetoxy-2,3-dicyanobenzene (ADB) and propidium iodide (PI). The flow cytometric measurements were performed in three-parameter list mode. The data were evaluated on an AT-compatible personal computer with the DIAGNOS1 program system for automated diagnosis of flow cytometric list mode data. Significant differences were found between normal and malignant tissue in DNA ploidy, in the intracellular esterase activity, in the cell, volume and in the percentage of inflammatory cells and parameters of necrosis. DNA-aneuploidy was observed in 38% of the lung carcinomas. The simultaneous detection of DNA-aneuploidy and tumor-associated properties in a multifactorial analysis led to correct automatic tumor diagnosis in 85% of cases. DNA-aneuploidy was found at a significant higher frequency in advanced tumors. Adenocarcinomas displayed DNA-aneuploidy more often (80%) than squamous cell carcinomas (33%).

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In 439 curatively resected colorectal cancer patients determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated. The rate of transfusion was significantly higher in women, rectal cancers, large tumors, advanced pT-stage and extended resections but not in tumor-stenosis, lower graded tumors, advanced Dukes-stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are correlated with survival rates.

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Acid gastroesophageal reflux was determined by long-term pH monitoring in 19 consecutive variceal bleeders after 5 to 20 (mean, 10.3 +/- 1 SEM) sclerotherapy sessions with the flexible endoscope using polidocanol 1% as sclerosant. Fifteen cirrhotics with untreated varices served as controls. Percentage time of esophageal pH less than 4 (3.3 +/- 0.7 SEM vs. 5.2 +/- 2.2 in the controls) and mean duration of reflux episodes (2.9 +/- 0.4 vs. 3.0 +/- 0.7 min) showed no significant differences between both groups. The findings indicate that repeated injection sclerotherapy with the flexible endoscope does not lead to an enhancement of acid gastroesophageal reflux.

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Before removing the diverticula (running suture for mucosa, interrupted stitches for the esophageal wall with resorbable material) a myotomy of the upper sphincter (pars inf. of the crycopharyngeal) muscle should be performed to restore the preoperative insufficient relaxation of the upper sphincter. The diffuse spasm shows a normal function of the LES; painful attacks can be treated by calcium antagonists or nitroglycerin. The achalasia can be treated either by endoscopic dilatation or myotomy to reduce the LES-pressure and restore the insufficient relaxation of the LES.

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A new method for the automated flow-cytometric identification of colo-rectal tumour cells was developed. Fresh tissue is cut mechanically to obtain single cell suspensions. The cells are then incubated with antibodies in an indirect immunofluorescence assay for CEA (carcino-embryonic antigen) on the cell surface, and counterstained with the DNA stain propidium iodide. Monosized latex particles are added as internal standard, then cell volume, antibody fluorescence and DNA are measured simultaneously in a FLUVO-METRICELL flow cytometer. A FORTRAN IV computer program was used to determine whether aneuploid cells or cells with high density of CEA on their surface were present in the sample. All relevant data were stored automatically in a self updating data base, which is important for quality control and automated thresholding. The samples were taken from 120 different patients. A tumour sample and a sample of healthy adjacent mucosa of the same patient were available in 88 patients. 97.5% of all tumours and 88.6% of the normal mucosa samples were correctly identified. This shows for the first time that the majority of colo-rectal tumour samples can be identified by a flow cytometric measurement with automated data evaluation. The identification of tumour samples was substantially better when based on the measurement of the three parameters, compared with identification by aneuploidy (59%) or by the CEA antibody alone (91%). It will be possible to automate the measurement of the samples.

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Tube feeding at home is a viable option for maintaining optimum nutriture when oral intake is inadequate or impossible. Qualifying patients and their caretakers can be instructed in formula preparation, feeding administration, and related care techniques. Extra hospital support systems, including insurance agencies, home medical suppliers, and public health nurses, are available to facilitate the transition from hospital to home care. For patients who require enteral nutrition but not acute or extended medical care, home tube feeding can promote a less disrupted family unit, improved quality of life, and diminished health care costs.

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To study the effect of sclerotherapy of varices on esophageal function, the motility of the tubular esophagus and of the lower esophageal sphincter (LES) were recorded in 19 patients after 7 to 13 sclerotherapy sessions and in 15 healthy volunteers. In addition, esophageal functional scintigraphy (EFS) was performed in the patient group. Compared with the volunteers the patients had lower contraction amplitudes in the distal esophagus (30.5 +/- 17.5 mm Hg versus 43.6 +/- 9.1 mm Hg, p less than 0.01) and a higher percentage of non-propulsive simultaneous contractions (NPC) in the distal (33.4 +/- 23.2% versus 9.0 +/- 8.6%, p less than 0.005) and mid-esophagus (15.0 +/- 8.2% versus 8.3 +/- 8.1%, p less than 0.05). There was a negative correlation between the percentage of NPC in the distal and mid-esophagus and radionuclide transit (rs - 0.53, p less than 0.02). Three of 19 patients had a positive reflux index by EFS. The LES tone was only slightly lower in the patients than in the controls (10.7 +/- 3.2 mm Hg versus 13.4 +/- 3.6 mm Hg, p less than 0.05). Our findings indicate that sclerotherapy of esophageal varices may lead to a reduced peristaltic esophageal motility with an impaired transport function. This could contribute to the development of dysphagia or esophagitis.

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About 8%-15% of the patients with organic hyperinsulinism have an islet cell carcinoma (13% in our series). In addition to a history of complaints of relatively recent onset, the patients present clinically the typical intermittent neurologic-psychiatric symptoms concurrently associated with hypoglycemia. The diagnosis is established biochemically on the basis of hypoglycemia, with inadequate incrementation of the insulin concentration subsequent to suppression and provocation tests. Elevated serum proinsulin and, in most patients, an increased insulin secretion rate are usually found after administration of agents such as glucose or leucine. Localization of the tumors is achieved by selective coeliacography as well as abdominal computerized axial tomography. The islet cell carcinoma is found most frequently in the tail of the pancreas, less frequently in the body and head of the pancreas. Metastatic spread is seen early into adjacent lymph nodes and especially in the liver. The treatment of choice is surgical resection of the tumor. Even in cases with advanced metastatic involvement, surgical intervention appears indicated. Medical treatment includes the administration of diazoxide, long-acting glucagon as well as the cytostatic agent streptozotocin. The average survival time is 30-40 months after diagnosis (in our series 79 months). Thus, the prognosis of patients with islet cell carcinoma appears relatively favorable, especially when compared with adenocarcinoma of the pancreas.

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During a controlled study, 55 patients who had an anterior resection of the rectum were thoroughly examined, including by computed tomography. The results verified the following statements: 1. The use of CT as a screening-method for early detection of local tumour recurrence following anterior resection of the rectum appears not to be justified. 2. CT is indicated: a) if there is a laboratory or clinical suspicion of recurrence, despite normal findings on proctoscopy; b) to clarify the question of extramural extension if recurrence has been established by proctoscopy. 3. Following anterior resection of the rectum, CT normally demonstrates no remarkable development of scar tissue, unless the anastomosis is inadequate. 4. Following anterior rectal resection every indefinable tissue thickening in the pelvis must be considered a possible tumour recurrence and must be further investigated by needle biopsy.

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