Biofeedback in colorectal practice

PURPOSE: Biofeedback treatment is often offered to patients in colorectal centers; however, standards of treatment are still lacking. A dedicated team approach is desirable but difficult to coordinate. We present our three-year experience of electromyographic-based biofeedback treatment offered within a multicenter, statewide organization. METHODS: Between October 1992 and October 1995, 188 patients completed a biofeedback treatment program in one of five coordinated centers within a 200-mile radius. A unified common database was established and continuously updated. A colorectal surgeon served as statewide director, and dedicated teams were established at each location. Each local team included the medical director and a certified biofeedback therapist and had access to a dietitian and a nurse data coordinator. Electromyographic-based biofeedback sessions were given weekly, and a home trainer program was established. RESULTS: A total of 116 patients with chronic constipation had a mean of eight (range, 2–14) weekly sessions. A total of 72 patients with fecal incontinence had a mean of seven (range, 2–11) weekly sessions. A total of 84 percent of the constipated and 85 percent of the incontinent patients had significant improvement with biofeedback treatment. Patient compliance and satisfaction were high. Constipated patients increased the mean number of weekly unassisted bowel movements from 0.8 to 6.5. Incontinent patients decreased the mean number of weekly gross incontinence episodes from 11.8 to 2. CONCLUSIONS: Biofeedback treatment can be extremely successful in both incontinent and constipated patients. A large geographic area can be covered with coordinated centers in which each dedicated team uses a unified treatment protocol, and a common database is established.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Suitability and durability of multiple internal thoracic artery coronary artery bypasses.

OBJECTIVE: The authors evaluate operative and extended outcomes of coronary artery bypass surgery using the bilateral internal thoracic arteries (ITAs) as bypass grafts. The authors conclude that the procedure is viable and of long-term benefit to most patients. SUMMARY BACKGROUND DATA: Multiple ITA grafting was met with early enthusiasm by the surgical profession, but skepticism and controversy arose with reports of increased operative morbidity, insufficient graft blood flow, a high incidence of failure of the right ITA, and uncertainty about durability and long-term benefits. METHODS: To assess the actual incidence and impact of these complications and long-term results, the authors prospectively studied 500 consecutive patients with multiple ITA bypasses, constituting the closely observed and carefully documented experience of one surgeon over an 11-year period. RESULTS: Operative mortality in the series of 500 patients was 1.8%, perioperative myocardial infarction (new Q wave) rate was 0.6%, and deep sternal wound infection occurred in 1%. Six patients (1.2%) had strokes, and nine patients (1.8%) were returned to the operating room to control bleeding. One hundred ninety-eight patients who had abnormal stress test results before surgery were retested within 3 months of surgery. Ninety-four percent of these were normal, 3% were nondiagnostic, and 3% were abnormal. After a mean follow-up of 7.1 years (mode, 7.2 years), 87.5% of patients in the sample were alive, and 93.2% of this group have experienced continuing good clinical results (New York Heart Association class I or II). Eighty-nine patients who underwent an angiogram had 90.8% patency rates of ITA bypasses and 84.5% patency of vein grafts. Only two patients required repeat operations. CONCLUSIONS: The operative results did not support the contention that the coronary artery bypass using ITA procedure produces higher than acceptable mortality and morbidity rates. Multiple ITA bypasses can be performed without excessive morbidity, with low reoperation rates and long-term outcomes that should encourage skeptics to reconsider the procedure's clinical value.     

Histologic Classification of Endoscopically Removed Flat Colorectal Polyps: A Multicentric Study

A total of 594 flat colorectal polyps, removed at endoscopy, were histologically classified into non-neoplastic (n=49) and neoplastic (n=545) polyps. Non-neoplastic polyps were subdivided into metaplastic (n=45) and hyperplastic (n=4), whereas neoplastic polyps were subdivided into adenomas (n=481), intramucosal carcinomas (n=28) and invasive adenocarcinomas (n=36). Several adenoma phenotypes were discerned: tubular (n=375), serrated (n=59), villous (n=39), mixed (n=7) and fenestrated (n=1). Intramucosal carcinomas were subdivided into tubular (n=26) and serrated (n=2), and invasive adenocarcinomas into tubular (n=32), serrated (n=3) and fenestrated (n=1). The microscopic characteristics of each histologic phenotype described in this communication are defined and illustrated.     

Surgery for left ventricular free wall rupture: patch glue repair without extracorporeal circulation.

Left ventricular free wall rupture is a dramatic complication after myocardial infarction. We present our experience with the simple, expedient technique of patch glue repair without extracorporeal circulation. Access is obtained via median sternotomy. Evacuation of blood and haematoma is undertaken and a Goretex patch exceeding the size of infarct is fashioned. The patch is applied to the epicardium using enbrucrilate surgical glue instilled with gentle pressure against the beating heart. We performed this technique on 17 patients from 1993 to 2001, with a operative (30-day) mortality of 23.5% with a post-discharge survival of 85% at 2.2 years.     

Successful management of laryngotracheosophageal cleft through an anterior approach

Laryngotracheoesophageal cleft is an uncommon disease that is difficult to diagnose and treat. Repair of the cleft depends on length and localization of the defect as well as the associated anomalies. A successful repair of a type II cleft is reported in this paper. An anterior split of the larynx and trachea was used and provided excellent exposure and safe repair without injury to the neurovascular structures. This is the best approach and should be used to correct all type II defects.     

Drug conditioning induced by intrastriatal apomorphine administration

The present study examined (1) whether the neostriatum is involved in a drug-induced conditioned locomotor response and; (2) whether this structure participates in the development of behavioral sensitization. Moreover, the present study addressed the question whether the development of behavioral sensitization is necessary for the induction of conditioning. Rats received injections of either apomorphine (2 μg) or vehicle (solution of 0.1% ascorbate/saline) into the dorsal neostriatum daily for 7 days. These treatments were performed immediately prior to (apomorphine-paired group and vehicle group) or 30 min following (apomorphine-unpaired group) 10-min placement in an open field which served as the test environment. After a 3-day drug withdrawal period, the animals were given a 10-min non-drug vehicle test trial in the test environment. Three days later, a drug test with apomorphine was administered to the animals of the paired and unpaired treatment groups; the vehicle group again received an injection of vehicle. The analysis of locomotor activity in the open field (measured as the distance traversed) revealed that locomotor activity in the apomorphine-paired group was higher than in the other groups. There were no indications for behavioral sensitization to intrastriatal apomorphine, since the locomotor response in the apomorphine-paired group did not increase, but rather decreased with daily repeated injections of apomorphine. Furthermore, only the apomorphine-paired animals showed a higher locomotor response when tested after an intrastriatal injection of vehicle in the previously apomorphine-paired environment, which is indicative of a conditioned drug effect. These results suggest that the neostriatum is directly involved in the development of drug-induced conditioning of locomotor behavior but not in the establishment of behavioral sensitization.     

Untersuchung zur Morbidität der indigenen Volksgruppen der Chiquitanos im südlichen Amazonasgebiet

The Chiquitano-tribe lives in the southern Amazonas region in Bolivia, remote from larger towns. A study (n=1514) on morbidity over an one year period (April 1995 till March 1996) and its relation to general and social medicine is given. Most frequently, childreh under 15 years and women in parity age (15–45 years) sought consultation (34,1 %, 42,7 %). Gastrointestinal, respiratoral and gynecological-obstetric diseases were predominant (22,4 %, 16,2 % and 15,7 %). In the dry season, common colds and respiratoral infections represented the major health problem. In the rainy season, infectious diarrhea diseases caused by polluted water as a consequence of extended floods were most frequent. Typical tropical diseases (malaria, Dengue fever, Chagas’ disease, leprosy a.o.) and socially caused diseases (AIDS, dependencies on drugs and alcohol, consequencies of crime) were rarely seen. With respect to severity, 55,8 % of the patients showed mild disorders. More serious diseases were observed in 39, 8 %. 4,6 % of the patients were diagnosed severly ill and needed hospitalization. Epidemiological data on general and social medicine of minorities in developing countries and their actual degree of medical care are important in a shrinking world. The data are useful to estimate medical needs and plan improvements to the health care system especially in rural areas.