L’échographie endoanale dans le bilan préopératoire des fistules anales

Purpose

The aim of this study is to assess the efficacy of endoanal ultrasound in the pre-operative evaluation of anal fistulas.

Equipment and methods

A consecutive series of 67 patients with anal fistulas received a pre-operative endoanal ultrasound, either with or without the use of hydrogen peroxide. The position of the internal opening, the type of fistula and the presence of secondary channels were all recorded. The consistency between the surgical data and that of the endoanal ultrasound was assessed.

Results

The average age of patients was 40.5 years and they were predominantly male (4M/1F). In 26 cases (38.8%), the anal fistula was upper transsphincteric (UTAF) and for 22 patients (32.8%) it was lower transsphincteric (LTAF). It was intersphincteric in 13 cases (19.4%), suprasphincteric in 3 cases (4.4%) and a horseshoe shape for 3 patients (4.4%). The results of the EAU were consistent with those from surgery in 74.6% of cases (50/67). This consistency decreased proportionally with the height of the fistula. The internal opening was accurately predicted in 94% of cases (63/67).

Conclusion

Endoanal ultrasound is a highly accurate method of predicting the position of an internal opening. It can also be used to assess the type and the height of the anal fistula. The information is useful pre-operatively in making relevant surgical decisions.     

Traitement endoscopique des complications biliaires du kyste hydatique du foie

Objective

To evaluate the contribution of endoscopic retrograde cholangiopancreatography (ERCP) in diagnostic and especially therapeutic biliary complications of a liver hydatid cyst (LHC).

Patients and Methods

We included 20 patients received for endoscopic management of biliary complications of LHC over 8 years. The mean age was 47 years with male predominance at 64%.

Results

The prevalence of biliary complications of LHC is 3.4% in our series. ERCP allowed the objectifying of a kysto-biliary fistula in 43% of the cases, and incomplete images in the bile duct in 85.7% of the cases related to hydatid material. Endoscopic sphincterotomy was performed in all patients, allowing the extraction of hydatid material with cuff or basket extraction, and a bile duct dilatation by candle. The evolution was marked by the disappearance of jaundice after an average of 5 to 12 days after the endoscopic procedure and the depletion of the external biliary fistula after 10 to 12 days.

Conclusion

The endoscopic treatment of biliary complications of a liver hydatid cyst is an effective method with acceptable mortality and morbidity.     

Application of high-intensity focused ultrasound for fetal therapy: experimental study using an animal model of lower urinary tract obstruction

Objective

The purpose of this study is to investigate whether high-intensity focused ultrasound (HIFU) exposure is able to produce a fistula between the bladder and abdominal wall of a fetus with lower urinary tract obstruction (LUTO).

Materials and methods

We constructed a prototype HIFU transducer in combination with an imaging probe. HIFU was applied to the lower abdomen of a rabbit neonate that was complicated by LUTO as an experimental model to produce a fistula; HIFU was applied in a tank filled with degassed water. Exposed lesions were assessed by histological analysis at necropsy.

Results

When HIFU was applied at 5.5 kW/cm² of spatial-peak temporal average intensity (SPTA), a fistula was created between the lower abdominal wall and the urinary bladder; urine gushed out from the bladder through the fistula within 60 s after HIFU exposure.

Conclusion

The findings suggest that fetal diseases such as LUTO can be non-invasively treated using HIFU exposure from even outside the maternal body, though this study was performed in a water tank.     

Association between hope and burden reported by family caregivers of patients with advanced cancer

Purpose

The aim of this study, in a sample of family caregivers (FCs) of patients with advanced cancer, was to describe the level of FC burden using the Caregiver Reaction Assessment (CRA). In addition, the effects of select FC and patient characteristics on each of the CRA subscales were evaluated.

Methods

FCs and patients (n?=?112) completed a demographic questionnaire, and Herth Hope Index, and the Hospital Anxiety and Depression Scale. FCs completed the CRA. Data were analyzed using multiple linear regression analyses.

Results

For three of the five CRA subscales (i.e., “impact on finances”, “impact on daily schedule”, and “impact on health”), the mean scores were comparable to a Norwegian sample of FCs caring for patients in the late palliative phase. The variance in each of the CRA subscales was explained by different factors. Total explained variance ranged from 5.5 % (“lack of family support”) to 31.8 % (“impact on daily schedule”). FC characteristics, such as being female and lower educational level, distress regarding the patient’s pain, anxiety, depression, and level of hope, as well as the patients’ number of comorbidities, depression, and hope contributed to an increase in various domains of FC burden. FCs’ level of hope was a significant predictor for three of the CRA subscales (i.e., “self-esteem”, “lack of family support”, and “impact on health”).

Conclusions

Findings suggest that FCs’ and patients’ level of hope are important determinants of caregiver burden and that FCs with lower levels of hope represent a high-risk group for higher levels of caregiver burden.     

H?usliche Behandlung von Tumorschmerzpatienten mit patientenkontrollierter Analgesie (PCA)

Background

Only limited data and experience with patient-controlled analgesia (PCA) in outpatients for palliative home care, related to organization, effectiveness and costs are available.

Patients and methods

In our retrospective study we analyzed the effectiveness, care intensity and pain reduction of 108 palliative cancer pain patients with PCA, included in a palliative home care system.

Results

After equivalent conversion of the opioid doses from oral/transcutaneus to parenteral administration a dose increase was necessary in 12.9% of the patients. The pain therapy was effective until death for an average of 38.9 days (median 21 days). During 3,889 days of PCA therapy there were 76 unscheduled visits based on technical problems.

Conclusion

In cases of cancer pain patients with failed oral or transcutaneous opioid medication, sufficient pain reduction can be achieved with parenteral drug administration by PCA. Domestic PCA requires a lot of human and financial resources, with trained nursing services and regular house visits by physicians experienced in palliative medicine but this method is sufficient and safe to use.     

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas

Purpose

The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy–esophagojejunostomy (EJ) operations.

Materials and methods

Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality–morbidity, and mortality related with factors other than the procedure were noted.

Results

Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months).

Conclusion

From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure.     

Pre-embolization evaluation of high-flow priapism: magnetic resonance angiography of the penis

Purpose

High-flow priapism is often a sequela of perineal trauma resulting in an arteriocavernosal fistula (ACF) between a cavernosal artery and lacunar spaces of the penis. We report our experience utilizing magnetic resonance angiography (MRA) in addition to color Doppler Sonography (CDS) in the workup and treatment planning of 4 patients with high-flow priapism.

Methods

All patients had suspected high-flow priapism diagnosed by clinical exam and CDS and underwent MRA of the penis prior to sub-selective arterial embolization (SSAE) of the feeding vessel(s).

Results

While CDS is valuable in diagnosing and lateralizing high-flow priapism, it does not provide clear anatomic delineation of the number and origin of feeding vessels. MRA provided demonstration of the fistula, demonstrated bilateral ACF supply in 2 patients, and afforded three-dimensional display of the feeding vessels which facilitated pre-embolization planning.

Conclusions

In all four cases, MRA was an effective tool for displaying arterial and venous anatomy, localizing the ACF, and planning subsequent SSAE. MRA influenced management in two out of 4 patients by demonstrating bilateral feeding vessels to their ACFs that required bilateral SSAE.     

Radioactive seed immobilization techniques for interstitial brachytherapy

Purpose

In prostate brachytherapy, seeds can detach from their deposited sites and move locally in the pelvis or migrate to distant sites including the pulmonary and cardiac regions. Undesirable consequences of seed migration include inadequate dose coverage of the prostate and tissue irradiation effects at the site of migration. Thus, it is clinically important to develop seed immobilization techniques.

Methods

We first analyze the possible causes for seed movement, and propose three potential techniques for seed immobilization: (1) surgical glue, (2) laser coagulation and (3) diathermy coagulation. The feasibility of each method is explored. Experiments were carried out using fresh bovine livers to investigate the efficacy of seed immobilization using surgical glue.

Results

Results have shown that the surgical glue can effectively immobilize the seeds. Evaluation of the radiation dose distribution revealed that the non-immobilized seed movement would change the planned isodose distribution considerably; while by using surgical glue method to immobilize the seeds, the changes were negligible.

Conclusions

Prostate brachytherapy seed immobilization is necessary and three alternative mechanisms are promising for addressing this issue. Experiments for exploring the efficacy of the other two proposed methods are ongoing. Devices compatible with the brachytherapy procedure will be designed in future.     

Traitement par dilatation instrumentale de la st��nose oesophagienne au cours du syndrome de Plummer-Vinson : �� propos de 14 cas

Aim

To analyze the results of dilation in upper oesophageal web of Plummer-Vinson syndrome.

Patients and methods

This prospective study has 14 patients treated during 9 years. 14 patients treated during 9 years. The mean age was 35 years ± 13.6 (16?C62 years). The male/female sex ratio was 0.07. The patients were treated with oesophageal bougienage and iron supplementation.

Results

The webs were easily disrupted without complications. The total number of dilations was 31. The average number of dilations was 2 ± 2.2 (range 1?C4). The patients?? dysphagia resolved after the treatment and the anaemia improved. The patients were examined periodically and found to be in good condition, with no recurrence during the 2-year follow-up in 12 patients. A relapse of dysphagia was noted in two cases.

Conclusion

Plummer-Vinson syndrome is rare nowadays; it mainly affects middle-aged white women. This study indicates that endoscopic bougienage is safe, effective, and relatively easy to perform in these patients.     

Modifiable factors associated with caregiver burden among family caregivers of terminally ill Korean cancer patients

Purpose

Higher caregiver burden is associated with poor quality of life among family caregivers. However, in Korea, very few studies have examined factors associated with caregiver burden. The present study investigated factors associated with caregiver burden among family caregivers of terminally ill Korean cancer patients, particularly modifiable factors as a potential target of intervention strategies.

Methods

A cross-sectional study using self-administered questionnaires was performed. Sixty-four family caregivers of terminally ill cancer patients who were admitted to the hospice-palliative care unit of a university hospital in South Korea were included. To identify caregiver burden, the Caregiver Reaction Assessment scale (CRA) was used in this study. Time spent in providing care per day, number of visits per week from other family members, family functioning, and a positive subscale, self-esteem, of the CRA were deemed as modifiable factors. Other sociodemographic, caregiving characteristics of the subjects were non-modifiable factors.

Results

Longer time spent providing care per day, fewer weekly visits from other family members, poor family functioning, and low self-esteem were considered as modifiable factors associated with caregiver burden. Low monthly income and the spouse being the family caregiver were non-modifiable factors.

Conclusions

Our study has practical significance in that it identifies modifiable factors that can be used to devise intervention strategies. Developing and applying such intervention strategies for alleviating the factors associated with high caregiver burden could be important for improving the quality of life of both patients and their families.