Innovative management of anal fistula by the use of the anal fistula plug: hype or help?

Impressed by the initial success rates of 80% of the anal fistula plug for the closure of cryptoglandular and Crohn's associated anorectal fistulas, preliminary results from centers world-wide showed a healing rates between 24% and 88%. When compared to traditional flap repair for closing high anorectal fistulas, impairement of continence may be decreased using the plug procedure. Analyzing the different experiences of the plug procedure ranging from promising to disappointing results, a variety of issues such as bowel preparation, treatment of fistula tract, closure of the internal opening, and postoperative management have to be considered. Furthermore, the 'ideal' indication has still to be defined. At the moment, all results which have been published only provide short-term results, and the question whether the plug procedure is appropriate and effective in Crohn's disease cannot be answered definitely. Finally, the question how to proceed in patients with plug dislodgement or failure remains unclear. In general, the introduction of the plug has accelerated a 'new' discussion on the optimal treatment of complex fistulas. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques.     

State laws on insurance coverage for bariatric surgery: help or a hindrance?

BACKGROUND: The purpose of this study was to determine which states have proposed or passed laws regarding insurance coverage for bariatric surgery and to obtain feedback from bariatric surgeons/programs regarding the effectiveness of these laws. METHODS: The Departments of Insurance in all 50 states and the District of Columbia in the United States and all members of the American Society for Bariatric Surgery were surveyed. RESULTS: Responses were obtained from all states and the District of Columbia, and 16 responses were received from the bariatric surgeons/programs. Michigan law requires all Health Maintenance Organizations to pay for all medically necessary treatments or procedures in general, such that if bariatric surgery can be shown to be medically necessary, it should be covered. Four states (Louisiana, Ohio, South Carolina, and Tennessee) have proposed state laws regarding bariatric surgery coverage, and four states (Georgia, Indiana, Maryland, and Virginia) have such laws in effect. However, none of the state laws that were passed "mandate" coverage, but rather "recommend" coverage or mandate that the insurer offer the coverage, for which the insurer can charge additional premiums. Although the numbers of responses from bariatric surgeons/programs were few, all of their responses were in agreement that the state laws have not increased insurance approvals for bariatric surgery and, in some cases, has made it more difficult to obtain approval. CONCLUSION: So far, the laws that have been passed have not adequately addressed the problems with decreasing coverage of bariatric surgery. Recommendations for future legislation are discussed.     

Discrepancies in office and ambulatory blood pressure in adolescents: help or hindrance?

The goal of this commentary is to review the most relevant topics concerning the clinical utility of ambulatory blood pressure (BP) monitoring, such as the state of the art “reference BP values”, the importance of the discrepant situations between office and ambulatory BP (white-coat and masked hypertension) and those of the recommended clinical indications to now. From a small number of studies, operational thresholds to define hypertension have been established. They are useful tools even though more studies are necessary to create strong reference values. Ambulatory BP measurement is increasingly recognized as being indispensable to the diagnosis and management of hypertension, and it has contributed significantly to our understanding of hypertension by revealing or “unmasking” BP phenomena that were not readily apparent using traditional techniques of measurement in clinical practice. Ambulatory BP monitoring should be performed in adolescents with either office mild essential hypertension before starting antihypertensive drug treatment or a strong family history of hypertension or an early cardiovascular event. Obese children with normal office BP values will also benefit from ambulatory BP monitoring. Other indications are the assessment of refractory hypertension or drug-induced hypotension. Finally, additional BP information in chronic renal failure, diabetes, and autonomic neuropathy can be obtained by using ambulatory BP monitoring None of the authors has a conflict of interest to declare. The corresponding author had final responsibility for the decision to submit for publication.     

Surgical treatment of complicated traumatic aneurysm and arteriovenous fistula

Objective: To evaluate the surgical methods and the outcome of management for traumatic arterial aneurysm(TAA) and traumatic arteriovenous fistula (TAVF). Methods : A total of 121 patients with TAA or TAVF were treated by surgery. Clinical, operative and postoperative data were collected and analyzed retrospectively. Results : The surgical techniques included aneurysmectomy and arterial end-to-end anastomosis or vascular grafting or artery ligation, aneurysm ligation and bypass, vascular repair, fistula excision and vascular ligation or vascular grafting or repair and so on. One patient died (0.83%). The follow-up rates of TAA and TAVF were 65.7% and 60% respectively. Conclusions: Complicated TAA and TAVF in different sites should be treated with different methods.     

Diagnosis and treatment of post—traumatic biliary leakage

Objective To improve the quality ofmanagement in biliary leakage following liveror bile tract injury. Methods All patients with liver and/orbile duct injuries from October 1987 to Februa-ry 1998 inclusive were studied retrospectivelyin respects of their age,sex,type and mecha-nism of injury,the grade of liver trauma,treatment and subsequent complications. Results In 271 patients with hepatobili-     

Retrospective analysis of traumatic bladder injury: does suprapubic catheterization alter outcome of healing?

The role of suprapubic catheters in traumatic bladder injuries is not well defined. Current literature suggests that suprapubic catheters are only necessary with large intraperitoneal bladder ruptures. The purpose of this study is to show that all bladder injuries can be managed with transurethral catheterization alone with a similar leak rate, morbidity, and healing time. Retrospective analysis was done of all patients with traumatic bladder injuries at a level I urban trauma center from June 1992 through June 2003. Medical records were reviewed and data analyzed according to type of bladder catheterization (i.e., transurethral or suprapubic). All patients with urethral injuries were excluded. Fifty-six patients met inclusion criteria. Twenty-seven patients suffered penetrating bladder injuries, and 29 bladder injuries were secondary to blunt trauma. Forty-seven patients were treated with transurethral catheter drainage, two were treated with suprapubic catheters, and seven were treated with both transurethral and suprapubic catheters. Forty patients had follow-up cystograms prior to catheter removal. Of the 47 patients treated with transurethral drainage alone, 3 (6%) developed urinary leaks. Of the 9 patients with suprapubic catheters, 2 (22%) developed urinary leaks. The mean time to removal of transurethral catheters was 15 days. The mean time to removal of suprapubic tubes was also 15 days. All study patients successfully healed their bladder injuries regardless of catheterization method. Suprapubic catheter drainage may increase morbidity without improving healing time. These results effectively support the decision to use transurethral catheter drainage alone in all patients with traumatic bladder injuries.     

Does traumatic brain injury result in accelerated fracture healing?

In patients who have sustained a traumatic brain injury with an associated extremity fracture there is often a clinical perception that the rate of new bone formation around the fracture site is increased. Whether this rapidly forming new bone is fracture callus or a variant of heterotopic ossification, a common complication of traumatic brain injury, is the subject of some debate. This review will provide a comprehensive analysis on this topic and will discuss clinical and physiological evidence as well as potential areas for future research in this field.     

Pyelovenous backflow or veno-caliceal valve fistula?

A 70-year-old male with urinary bladder carcinoma was admitted for follow-up. Retrograde pyelography demonstrated transfer of contrast medium into the left renal vein in two independent sessions. The absence of hematuria and a negative CT scan ruled out a classical veno-caliceal fistula. The presence of a veno-caliceal valve fistula into the left renal vein was hypothesized.     

Surgical treatment of post—traumatic pseudoaneurysms and arteriovenous fistulas

Objective:To report the experience in the diagnosis and treatment of post-traumatic pseudoaneurysms and arteriovenous fistulas.Methods:A series of 30 patients(11 women and 19 men) with posttraumatic pseudoaneurysms were reviewed retrospectively.Among them 7 patients (5 women and 2 men) were associated with arteriovenous fistula.Results:The causes included sharp penetration trauma(18 cases),blunt trauma (6 cases) and iatrogenic arterial injury (6 cases).The main clinical manifestations consisted of local pulsatile mass (26 cases),vascular bruits (19 cases),thrill (13 cases),ischemia of distal limb (9 cases),neuropathy (5 cases) and pseudoaneurysm rupture (2 cases).All patients underwent surgery.The operations included:ligation of the vessels (12 cases),surgical resection and primary suture repain of the vascular defect or anastomosis (11 cases),vascular reconstruction with autogenous saphenous vein (3 cases) and synthetic vascular graft (4 cases).Conclusions:Because of the imminent clinical course,early operation is usually indicated.The operative treatment is effective and safe for most of the patients with post-traumatic pseudoaneurysms and arteriovenous fistulas.     

Ureteral metal stents: a tale or a tool?

There are four types of ureteral metal stents: self expandable, balloon expandable, covered, and thermoexpandable shape-memory. Insertion of metal stents requires expertise with transurethral and percutaneous techniques. The stricture is traversed with the aid of a guidewire via a percutaneous nephrostomy, and the stenotic segment is dilated using a high-pressure balloon catheter. The stent is then inserted over the guidewire, such that the upper end bypasses the obstruction by at least 3 to 4 cm, while the lower end extends intravesically for 0.5 to 1 cm from the ureteral orifice. If necessary, two or more stents are placed in sequence, overlapping by at least 2 to 3 cm. Metal stents were initially used for the relief of end-stage malignant disease, and their role in the treatment of benign ureteral strictures is still undefined. Patients often complain of abdominal discomfort and mild pain after stent insertion, which soon resolve spontaneously. Hematuria usually stops after a few days and does not necessitate any treatment. Mild urothelial hyperplasia in the stent lumen is common but usually regresses after 4 to 6 weeks. Many authors suggest the use of a double-pigtail catheter for the first 4 to 6 weeks to avoid narrowing of the ureteral lumen. The influence of stents on ureteral peristalsis is a major but poorly documented issue. Encrustation is a significant problem that needs to be addressed. The characteristics of both the patient and the stent influence its likelihood. Migration of coated metal stents was seen in 81% of patients at our center. Virtual endoscopy has recently been introduced as a tool for the follow-up of patients with stented ureters. Further design development is necessary to obtain the ideal ureteral metal stent. In a recent study in female pigs, paclitaxel-eluting metal stents engendered less inflammation and hyperplasia of the surrounding tissues.     

Research progress in mechanism of traumatic brain injury affecting speed of fracture healing

In patients who have sustained traumatic brain injury with associated extremity fracture, there is often a clinical perception that the rate of new bone formation around the fracture site increases. 1 An overgrowth of callus is observed and ectopic ossification even occurs in the muscle,2 but the mechanism remains unclear. Whether this rapidly-formed new bone is fracture callus or a variant of heterotopic ossification, a common complication of traumatic brain injury, is the subject of some debates. 3 It is generally believed that the process of fracture healing is a recapitulation of normal embryonic osteogenesis,4 i.e. , a series of changes in the intracellular and extracellular matrix, which start from the injury of cells, blood vessels and bone matrix to a complete reconstruction of the bone. s It is a complex process influenced by multilevel and multi-route regulations of the general and local environments in the body, and many growth factors participate in this process, which is the base of bone healing;6 whatever methods are used to promote bone healing, they are based on accelerating the changes of growth factors. 7 So it is worth making a thorough study on the mechanism, by which traumatic brain injury influences the expression levels of growth factors and consequently affects the speed of bone healing.[第一段]