Pilonidalsinus und Analfistel: Indikationen und Methoden der chirurgischen Therapien

Zusammenfassung: Fisteln im Analbereich werden unterteilt in Pilonidalfisteln in der Rima ani und Analfisteln als Verbindung zwischen Anus und perianaler Haut. Bei der Pilonidalfistel erfolgt bei unkompliziertem Befund nach Abheilung akuter Abszesse die minimalinvasive Fistelexzision in Lokalanästhesie. Konservative Therapiekonzepte sowie die radikale Exzision mit offener Wundbehandlung haben sich nicht bewährt. Bei ausgeprägtem, großem Befund erfolgt eine weite Exzision mit plastischer Deckung mittels Limberg-Lappen. Bei der Analfistel muss unterschieden werden zwischen subkutanen und tiefen intersphinktären Fisteln ohne Sphinkterbeteiligung einerseits und hohen intersphinktären, transsphinktären, suprasphinktären und extrasphinktären Fisteln andererseits. Erstere können mit geringer Morbidität und hoher Heilungsrate fistulotomiert werden. Bei der zweiten Gruppe besteht ein erhebliches Inkontinenz- und Rezidivrisiko. Ohne Inkontinenzrisiko, bei allerdings hohem Rezidivrisiko, kann die Fistel mittels "Anal Fistula Plug" verschlossen werden. Bei Versagen dieser Therapie bietet sich eine Fistulektomie mit Verschluss der inneren Fistelöffnung durch einen anorektalen Verschiebelappen a

Humanes Papillomavirus und Analkarzinom: Diagnose, Screening und Therapie

Zusammenfassung: Die Inzidenz des Analkarzinoms nimmt weltweit zu, vor allem bei männlichen homosexuellen Patienten. Als hauptsächlicher Risikofaktor für die Entstehung des Analkarzinoms gilt die anale Infektion mit dem humanen Papillomavirus (HPV). Die Prävalenz der analen HPV-Infektion bei HIV-negativen homosexuellen Männern beträgt 50-60%. Bei HIV-positiven homosexuellen Männern liegt die Prävalenz bei nahezu 100%. Die HPV-assoziierte anale intraepitheliale Neoplasie (AIN) gilt als Vorläuferläsion des Analkarzinoms. Bei etwa 20% der HIV-negativen homosexuellen Männer lässt sich eine AIN diagnostizieren, wobei bei 5-10% eine hochgradige Epitheldysplasie (AINII-III) vorkommt. Die Prävalenz der hochgradigen AIN ist jedoch mit bis zu 50% bei HIV-positiven homosexuellen Patienten bedeutend höher. Trotz der Häufigkeit von HPV-bedingten analen Epitheldysplasien und der zunehmenden Fälle von Analkarzinomen gibt es aber noch immer keinen Konsens bezüglich des Screenings, der Therapie und der Überwachung von Patienten mit AIN. Im Falle eines Analkarzinoms ist unabhängig vom HPV- oder HIV-Status heute noch immer die Radiochemotherapie mit 5-FU und MitomycinC Standar

Visually-Grounded Language Model for Human-Robot Interaction

Visually grounded human-robot interaction is recognized to be an essential ingredient of socially intelligent robots, and the integration of vision and language increasingly attracts attention of researchers in diverse fields. However, most systems lack the capability to adapt and expand themselves beyond the preprogrammed set of communicative behaviors. Their linguistic capabilities are still far from being satisfactory which make them unsuitable for real-world applications. In this paper we will present a system in which a robotic agent can learn a grounded language model by actively interacting with a human user. The model is grounded in the sense that meaning of the words is linked to a concrete sensorimotor experience of the agent, and linguistic rules are automatically extracted from the interaction data. The system has been tested on the NAO humanoid robot and it has been used to understand and generate appropriate natural language descriptions of real objects. The system is also capable of conducting a verbal interaction with a human partner in potentially ambiguous situations

A challenging hernia: primary venous aneurysm of the proximal saphenous vein

Introduction: Primary venous aneurysm is a rare, but essential consideration in the differential diagnosis of an inguinal and femoral hernia. Methods: We report a case of a 43-year-old man who was referred for evaluation and treatment of a femoral hernia. Results: The patient presented with a 3-month history of an asymptomatic tumor on his right upper inner thigh. Physical examination noted a non-tender, non-indurated tumor. Conclusion: Surgical exploration demonstrated a primary venous aneurysm of the proximal saphenous vei

Laparoscopy for small bowel obstruction: the reason for conversion matters

Background: Although laparoscopy is associated with reduced hospital stay, early recovery, and decreased morbidity compared with open surgery, it is not well established for the treatment of small bowel obstruction (SBO). Methods: This study analyzed a prospective nationwide database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Results: From 1995 to 2006, 537 patients underwent laparoscopy for SBO. Matted adhesions were the main cause of obstruction (62.6%). Intraoperative complications occurred for 9.5% of the patients. Postoperative morbidity was 14% and mortality 0.6%. Within 30days, 13 patients (2.4%) were readmitted because of early recurrence or complications. The conversion rate was 32.4%. The conversions resulted from inability to visualize the site of obstruction or matted adhesions (53.4%), intraoperative complications (21.3%), and small target incisions for resection (25.3%). Emergency operations were associated with higher conversion rates (43.6% vs 19.8%; p<0.001) but not with significantly more postoperative complications (15.2% vs 11.9%; p=0.17). Intraoperative complications and conversion were associated with significantly increased postoperative morbidity (39.2% vs 11.3%; p<0.001 and 24.7% vs 8.3%; p<0.001, respectively). Reactive conversion due to intraoperative complications was associated with the highest postoperative complication rate (48.6%). Morbidity for preemptive conversion due to impaired visualization/matted adhesions or a small-target incision was significantly lower (20% and 26.1%; p=0.02 and p<0.001, respectively). American Society of Anesthesiology (ASA) scores higher than 2 also were associated with postoperative morbidity (p<0.001). However, multivariate regression analysis showed that reactive conversion was the only independent risk factor for postoperative morbidity (p<0.001; odds ratio, 3.97; 95% confidence interval, 1.83-8.64). Conclusions: Laparoscopic management of SBO is feasible with acceptable morbidity and low mortality but with a considerable conversion rate. Early conversion is recommended to reduce postoperative morbidit

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

Background and aims: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT). Materials and methods: Between January 2001 and August 2004, 40 patients (21 women), median age 37years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6weeks after the operation. At 1year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results. Results/findings: At 6weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%. Interpretation/conclusion: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rat

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

Background and aims: Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT). Materials and methods: Between January 2001 and August 2004, 40 patients (21 women), median age 37years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6weeks after the operation. At 1year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results. Results/findings: At 6weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%. Interpretation/conclusion: Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rat

Trial of Remote Continuous versus Intermittent NEWS monitoring after major surgery (TRaCINg): protocol for a feasibility randomised controlled trial

Background: Despite medical advances, major surgery remains high risk. Up to 44% of patients experience postoperative complications, which can have huge impacts for patients and the healthcare system. Early recognition of postoperative complications is crucial in reducing morbidity and preventing long-term disability. The current standard of care is intermittent manual vital signs monitoring, but new wearable remote monitors offer the benefits of continuous vital signs monitoring without limiting the patient’s mobility. The aim of this study is to evaluate the feasibility, acceptability and clinical impacts of continuous remote monitoring after major surgery. Methods: The study is a randomised, controlled, unblinded, parallel group, feasibility trial. Adult patients undergoing elective major surgery will be invited to participate if they have the capacity to provided informed, written consent and do not have a cardiac pacemaker or an allergy to adhesives. Participants will be randomly assigned to receive continuous remote monitoring and normal National Early Warning Score (NEWS) monitoring (intervention group) or normal NEWS monitoring alone (control group). Continuous remote monitoring will be achieved using the SensiumVitals® wireless patch which is worn on the patient’s chest and monitors heart rate, respiratory rate and temperature continuously and alerts the nurse when there is deviation from pre-set physiological norms. Participants will be followed up throughout their hospital admission and for 30 days after discharge. Feasibility will be assessed by evaluating recruitment rate, adherence to protocol and randomisation, and the amount of missing data. The acceptability of the patch to nursing staff and patients will be assessed using questionnaires and interviews. Clinical outcomes will include time to antibiotics in cases of sepsis, length of hospital stay, number of critical care admissions and rate of readmission within 30 days of discharge. Discussion: Early detection and treatment of complications minimises the need for critical care, improves patient outcomes, and produces significant cost savings for the healthcare system. Remote continuous monitoring systems have the potential to allow earlier detection of complications, but evidence from the literature is mixed. Demonstrating significant benefit over intermittent monitoring to offset the practical and economic implications of continuous monitoring requires well-controlled studies in high-risk populations to demonstrate significant differences in clinical outcomes; this feasibility trial seeks to provide evidence of how best to conduct such a confirmatory trial. Trial registration: This study is listed on the ISRCTN registry with study ID ISRCTN16601772