In a prospective study on 224 patients with so-called high-fistula in ano (189 transsphincteric, 35 suprasphincteric) the long-term results of a sphincter-saving operation technique were assessed. The follow-up period was 1 to 7.5 years. This technique consists of one-stage fistulectomy as well as of drainage of the intersphincteric space by internal sphincterotomy. The site of the former primary orifice of the fistula is adapted by multiple peranally performed single stitches, including mucosal advancement flap distal to the original fistulous opening. Postoperatively, 24 cases of suture leakage occurred (9% with the transsphincteric and 20% with the suprasphincteric fistula). 27 patients developed late complications like fistula recurrences or combinations of fistula and anal abscess (10.7% with the transsphincteric and 19.9% with the suprasphincteric fistula). Anal manometry was carried out preoperatively as well as postoperatively. A significant decrease in the postoperative resting pressure compared to the preoperative value was determined. The two fistula groups differed statistically both with regard to the resting pressure and the contraction pressure. Significant impairment of continence developed in 21% of patients with transsphincteric fistula but in 43% of patients with suprasphincteric fistula (intermittent fecal spoiling/use of perineal pads). The total percentage of complications rose with the number of previous fistula operations.

Transanal rectal advancement flap vs mucosal flap with suture of the internal sphincter muscle for the management of complicated anorectal fistulas. A prospective clinical and manometric studyAbstract A prospective study was carried out on 55 patients with complicated anal fistulas (41 transsphincteric, 5 suprasphincteric and 9 rectovaginal) to evaluate the value of two sphincter-conserving techniques with primary occlusion of the internal ostium and endorectal advancement flap (group A, n=34) or mucosal flap (group B, n=21). Ten of the patients had Crohn's disease. Both techniques consist in one-stage fistulectomy without drainage of the intersphincteric space. The inflamed proctodeal and granulation tissue was carefully cleared. The site of the former primary orifice of the fistula was adapted by means of two or three peranally performed single stitches. The peranally applied suture included the layers of the internal anal sphincter muscle only. A mobilized flap of rectal wall (group A) and rectal mucosa and submucosa (group B) about 4 cm x 3 cm in size was stitched below the muscular sphincter. The perianal part of the wound was left to heal by second intention. Postoperatively there were 16 cases of suture leakage (23.5% in group A, and 38% in group B), and 19 patients (26% or 47% in both groups) had to have revision surgery because of recurrent fistula or sutur leakage; 2 patients (3.6%) developed incontinence with intermittent fecal soiling. Complete incontinence was not observed in any patient. No significant difference in clinical and functional results was determined between the two groups. Key wordsHigh fistulectomy • Rectal advancement vs mucosal flap • Manometry S. Athanasiadis ([]). Zusammenfassung Bei 55 Patienten mit komplizierten Analfisteln (41 transsphinktere, 5 suprasphinktere, 9 rektovaginale Fisteln) wurde eine prospektive Studie zur Bewertung yon 2 sphinktererhaltenden Techniken mit primfirem Verschlug des inneren Fistelostiums and anschlieBender Deckung durch einen endorektalen Verschiebelappen (Gruppe A, n=34) oder Mukosalappen (Gruppe B, n=21) durchgeffihrt. Zehn Patienten hatten M, Crohn. Beide Techniken bestehen aus einer einzeitigen Fistulektomie ohne Drainage des Intersphinkterraumes. Das entzandlich ver~inderte Procdodealdrfisen-und Granulationsgewebe wurde vorsichtig mit dem scharfen L6ffel entfernt.Der Oft der frfiheren Primfir6ffnung der Fistel wurde mit zwei bzw. drei peranal angelegten Einzelknopfn~ihten verschlossen. Die peranal gelegte Naht umfaBte die Schichten des M. spincter ani internus. Ein mobilisierter Rektumwandlappen (Gruppe A) oder ein Mukosa-Submukosalappen (Gruppe B), in einer GrOBe yon ca. 4×3 cm wurde versetzt und fiber den muskul~iren VerschluB gedeckt, Der perianale Tell der Wunde heilte sekund~ir. Postoperativ trat bei 16 F~illen eine Nahtinsuffizienz auf (23,5% in Gruppe A, 38% in Gruppe B). Neunzehn Patienten (26% gegenfiber 47% in beiden Gruppen) erforderten eine erneute Operation aufgrund yon wiederkehrenden Fisteln oder Nahtinsuffizienzen. Zwei Patienten ...

In a prospective study carried out on 78 patients with chronic constipation (31, with slow transit, 47 with obstructive defecation disorders) the evacuation function of the rectum during defecation was assessed by defecoflowmetry. These patients were compared to a control group of normal volunteers (n = 32). The following parameters were evaluated: defecation and retention volume, defecation fraction, defecation time, maximum flow, mean flow rate and time to maximum flow. As expected, there was no difference in evacuation function between the group of patients with slow transit and the control group. Significant differences, however, existed between the two types of constipation, as well as between obstructive defecation disease and controls, regarding all parameters mentioned above. Evacuation function depends neither on rectal neck pressure nor on intrarectal pressure. In patients with obstructive defecation disorders, three subgroups were discernable: one with prolonged time of defecation and satisfactory evacuation, one with prolonged time of defecation and poor evacuation, and one small group of patients who were not able to defecate. Each group is based on a different underlying pathomechanism. We conclude that changes in evacuation function of the rectum refer either to volume or to time of defecation, or to both. Changes are found only in obstructive type constipation, not in slow transit constipation. Therefore, defeconflowmetry as a dynamic procedure can be used in screening for the classification of chronic constipation.

The care of patients with extraclinical mechanical ventilation has to be improved particularly with regard to their specialist care. One care option is the empowering of clinicians at the respiratory centers to enable ambulant care of patients and home visits. An intersectoral linkage in the form of transfer management is the basis for competent coordination. Aim is to ensure the necessary multidisciplinary collaboration in the outpatient care of multimorbid chronically ill patients. For the optimal care of chronically ill patients, sectoral limits should become more permeable.

An 83-year-old man complained of lessened performance ability, weight loss, and febrile episodes of several months' duration. A painful area of partly indurated and squamous erythema with an irregular border was seen on his right arm. Skin biopsy and histopathological examination revealed granulomatous inflammation with focal necroses; a suspected mycobacterial infection could not, at first, be confirmed either by microscopy (Ziehl-Neelsen stain) or by molecular genetic testing. Nonetheless, because the patient had suffered from tuberculosis of the lymph nodes three years before, he was given standard anti-tubercular treatment. The cutaneous and general symptoms improved within one week, and the diagnosis was confirmed four weeks after presentation when a fluid culture turned positive for Mycobacterium tuberculosis. Lupus vulgaris, the most common type of cutaneous tuberculosis (a rare condition in low-incidence countries), is due to post-primary hematogenous seeding of the skin with mycobacteria. The skin changes are generally not contagious and may display psoriasiform scales as a secondary efflorescence (lupus vulgaris exfoliativus). The treatment corresponds to that of pulmonary tuberculosis; as long as no drug resistance is present, it consists of isoniazid, rifampicin, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampicin for four months.