Enterocolic phlebitis: a rare cause of bowel ischemia and review of the literature.

Enterocolic phlebitis (EP) is a rare cause of bowel ischemia due to isolated venulitis of the bowel wall and mesentery without arterial involvement. EP is often misdiagnosed as inflammatory bowel disease, carcinoma, or diverticulitis due to non-specific symptoms as well as non-specific clinical and radiological findings. While unresponsive to pharmacotherapy, surgical resection of the affected bowel appears to be the only successful therapy with a very low recurrence rate. Etiology of EP remains unknown. We report a case of EP with rare presentation in the left hemicolon and unusual histological findings emphasizing the heterogeneity of this cause of enterocolic ischemia. The review and comparison of the three entities-EP, mesenteric inflammatory veno-occlusive disease (MIVOD), and idiopathic myointimal hyperplasia of mesenteric veins (IMHMV), all describing patterns of bowel ischemia due to isolated pathology of mesenteric veins-reveal that the current terminology is unclear. EP and MIVOD are very similar and may be considered the same disease. IMHMV, though, differs in localization, symptom duration, and histological findings but also shares features with EP and MIVOD. Further studies and harmonized terminology are inevitable for better understanding of the disease, prevention of unnecessary pharmacotherapy, and reduction in time to diagnosis

Impact of surgical technique on operative morbidity and its socioeconomic benefit in thyroid surgery

Purpose: The aim of this retrospective cohort study was to evaluate the rate of complications in relation to the extent of surgery and some of its consequences. Methods: Between 1972 and 2010, a total of 5,277 consecutive thyroid gland surgeries with 7,383 nerves at risk were performed at our teaching institution. Data of all patients undergoing thyroidectomy were collected prospectively. A total of 2,867 subtotal resections (first study period from 1972 to 1990) were compared with 2,410 extended thyroid resections involving at least a hemithyroidectomy (second period from 1991 to 2010). Results: The incidence of permanent recurrent laryngeal nerve palsy in primary operations was significantly higher in the first period compared to the second period (3.6 vs. 0.9%; p < 0.001). Permanent hypoparathyroidism decreased from 3.2% in the first period to 0.8% in the second period (p < 0.001). The incidence of recurrent goiter surgery decreased from 11.1% in the first period to 8.1% in the second period (p < 0.001). No significant difference was found in permanent recurrent laryngeal nerve palsy in recurrent disease between the two periods. The socioeconomic benefits of an extended thyroid resection in our patient population are 360 preventable operations, 90 preventable permanent recurrent laryngeal nerve palsies, and 58 preventable cancers. Furthermore, 37 preventable radioiodine ablations and 15 preventable deaths were associated with more radical thyroid resection. Conclusion: Improvements in surgical technique and change in surgical strategy significantly decreased the prevalence of recurrent laryngeal nerve palsy, hypoparathyroidism, and recurrent disease as well as reduced public health costs associated with recurrent goite

A novel animal model for external anal sphincter insufficiency

Purpose: Reliable animal models are essential to evaluate future therapeutic options like cell-based therapies for external anal sphincter insufficiency. The goal of our study was to describe the most reliable model for external sphincter muscle insufficiency by comparing three different methods to create sphincter muscle damage. Methods: In an experimental animal study, female Lewis rats (200-250g) were randomly assigned to three treatment groups (n = 5, each group). The external sphincter muscle was weakened in the left dorsal quadrant by microsurgical excision, cryosurgery, or electrocoagulation by diathermy. Functional evaluation included in vivo measurements of resting pressure, spontaneous muscle contraction, and contraction in response to electrical stimulation of the afferent nerve at baseline and at 2, 4, and 6weeks after sphincter injury. Masson's trichrome staining and immunofluorescence for skeletal muscle markers was performed for morphological analysis. Results: Peak contraction after electrical stimulation was significantly decreased after sphincter injury in all groups. Contraction forces recovered partially after cryosurgery and electrocoagulation but not after microsurgical excision. Morphological analysis revealed an incomplete destruction of the external sphincter muscle in the cryosurgery and electrocoagulation groups compared to the microsurgery group. Conclusions: For the first time, three different models of external sphincter muscle insufficiency were directly compared. The animal model using microsurgical sphincter destruction offers the highest level of consistency regarding tissue damage and sphincter insufficiency, and therefore represents the most reliable model to evaluate future therapeutic options. In addition, this study represents a novel model to specifically test the external sphincter muscle function

Severe postoperative wound healing disturbance in a patient with alpha-1-antitrypsin deficiency: the impact of augmentation therapy

Wound healing disturbance is a common complication following surgery, but the underlying cause sometimes remains elusive. A 50-year-old Caucasian male developed an initially misunderstood severe wound healing disturbance following colon and abdominal wall surgery. An untreated alpha-1-antitrypsin (AAT) deficiency in the patient's medical history, known since 20 years and clinically apparent as a mild to moderate chronic obstructive pulmonary disease, was eventually found to be at its origin. Further clinical work-up showed AAT serum levels below 30% of the lower reference value; phenotype testing showed a ZZ phenotype and a biopsy taken from the wound area showed the characteristic, disease-related histological pattern of necrotising panniculitits. Augmentation therapy with plasma AAT was initiated and within a few weeks, rapid and adequate would healing was observed. AAT deficiency is an uncommon but clinically significant, possible cause of wound healing disturbances. An augmentation therapy ought to be considered in affected patients during the perioperative period

Necessary and unnecessary treatment options for hemorrhoids

Up to one third of the general population suffers from symptoms caused by hemorrhoids. Conservative treatment comes first unless the patient presents with an acute hemorrhoidal prolapse or a thrombosis. A fiber enriched diet is the primary treatment option, recommended in the perioperative period as well as a long-term prophylaxis. A timely limited application of topical ointments or suppositories and/or flavonoids are further treatment options. When symptoms persist interventional procedures for grade I-II hemorrhoids, and surgery for grade III-IV hemorrhoids should be considered. Rubber band ligation is the interventional treatment of choice. A comparable efficacy using sclerosing or infrared therapy has not yet been demonstrated. We therefore do not recommend these treatment options for the cure of hemorrhoids. Self-treatment by anal insertion of bougies is of lowrisk and may be successful, particularly in the setting of an elevated sphincter pressure. Anal dilation, sphincterotomy, cryosurgery, bipolar diathermy, galvanic electrotherapy, and heat therapy should be regarded as obsolete given the poor or missing data reported for these methods. For a long time, the classic excisional hemorrhoidectomy was considered to be the gold standard as far as surgical procedures are concerned. Primary closure (Ferguson) seems to be superior compared to the "open" version (Milligan Morgan) with respect to postoperative pain and wound healing. The more recently proposed stapled hemorrhoidopexy (Longo) is particularly advisable for circular hemorrhoids. Compared to excisional hemorrhoidectomy the Longo-operation is associated with reduced postoperative pain, shorter operation time and hospital stay as well as a faster recovery, with the disadvantage though of a higher recurrence rate. Data from Hemorrhoidal Artery Ligation (HAL)-, if appropriate in combination with a Recto-Anal Repair (HAL/RAR)-, demonstrates a similar trend towards a better tolerance of the procedure at the expense of a higher recurrence rate. These relatively "new" procedures equally qualify for the treatment of grade III and IV hemorrhoids, and, in the case of stapled hemorrhoidopexy, may even be employed in the emergency situation of an acute anal prolapse. While under certain circumstances different treatment options are equivalent, there is a clear specificity with respect to the application of those procedures in other situations. The respective pros and cons need to be discussed separately with every patient. According to their own requirements a treatment strategy has to be defined according to their individual requirements.Das Hämorrhoidalleiden ist eine häufige Krankheit an der bis zu einem Drittel der Bevölkerung leidet. Handelt es sich nicht um eine Notfallsituation mit akutem Hämorrhoidalprolaps oder Thrombose, so sollte wegen der minimalen Morbidität primär konservativ behandelt werden. Eine Stuhlregulation mit faserreicher Ernährung und/oder Quellmitteln ist dabei der erste Behandlungspfeiler, wird aber auch perioperativ empfohlen und dient der Langzeitprophylaxe. Gegebenenfalls kann zusätzlich vorübergehend mit Salben oder Suppositorien und/oder Flavonoiden behandelt werden. Die meisten Patienten werden dadurch beschwerdefrei, so dass von einem interventionellen oder invasiven Eingriff abgesehen werden kann. Erst bei persistierenden Symptomen kommen, bei Grad I–II Hämorrhoiden zunächst interventionelle, und bei höhergradigen bzw. therapierefraktären Hämorrhoiden, operative Therapien zum Einsatz. Interventionell konnte sich die Gummibandligatur als Therapie der Wahl etablieren. Ein vergleichbarer Effekt der Sklerosierungs- und Infrarottherapie wurde bisher nicht gezeigt. Wir können die Methoden daher nicht empfehlen. Die Selbstbehandlung mit analer Bougierung zeigt insbesondere bei Vorliegen eines erhöhten Sphinkterdruckes Erfolge und kann, relativ risikolos versucht werden. Gewisse chirurgische Verfahren wie die anale Dilatation, die Sphinkterotomie, die Kryochirurgie, die bipolare Diathermie, die galvanische Elektrotherapie und die Hitzebehandlung können aufgrund schlechter Resultate oder fehlender Daten nicht mehr empfohlen und müssen als obsolet betrachtet werden. Lange Zeit galt die klassische Hämorrhoidektomie bei der Behandlung des höhergradigen Hämorrhoidalleidens als operativer Goldstandard. Dabei ist die geschlossene Variante nach Ferguson bezüglich postoperativen Schmerzen und Wundheilung der offenen Variante nach Milligan-Morgan eher überlegen. Die in jüngerer Zeit vorgeschlagene, alternative Technik der Stapler-Hemorrhoidopexie nach Longo hat sich, insbesondere bei zirkulären Befunden, durchsetzen können. Die Longo-Operation ist der klassischen Methode in punkto postoperativer Schmerzen, Wiedererlangen der Arbeitsfähigkeit, Hospitalisationsdauer und Operationszeit überlegen, zeigt aber mehr Rezidive. Daten zur Hämorrhoiden-Arterien-Ligatur (HAL), allenfalls in Kombination mit rekto-analem-repair (HAL/RAR) zeigen einen ähnlichen Trend: bessere Verträglichkeit, mehr Rezidive. Diese „neueren“ Verfahren eignen sich auch für die Behandlung von höhergradigen Hämorrhoiden (Grad III und IV nach Parks) und können im Falle der Stapler-Hämorrhoidopexie auch bei Notfallsituationen wie dem akuten Hämorrhoidalprolaps erfolgreich zur Anwendung kommen. Unter bestimmten Bedingungen können gewisse Methoden äquivalent eingesetzt werden, während für andere Situationen klare Spezifitäten bezüglich Anwendung der einzelnen Behandlungen bestehen. Diese Vor- und Nachteile sollen dem Patienten dargelegt werden, so dass ein auf seine Bedürfnisse zugeschnittener Behandlungsplan entwickelt werden kann