Anton Stift

The prevalence of hemorrhoids in adults

IntroductionExact data on the prevalence of hemorrhoids are rare. Therefore, we designed a study to investigate the prevalence of hemorrhoids and associated risk factors in an adult general population.MethodsBetween 2008 and 2009, consecutive patients were included in a prospective study. They attended the Austrian national wide health care program for colorectal cancer screening at four medical institutions. A flexible colonoscopy and detailed examination were conducted in all patients. Hemorrhoids were defined according to a standardized grading system. Independent variables included baseline characteristics, sociodemographic data, and health status. Potential risk factors were calculated by univariate and multivariate analysis.ResultsOf 976 participants, 380 patients (38.93%) suffered from hemorrhoids. In 277 patients (72.89%), hemorrhoids were classified as grade I, in 70 patients (18.42%) as grade II, in 31 patients (8.16%) as grade III, and in 2 patients (0.53%) as grade IV. One hundred seventy patients (44.74%) complained about symptoms associated with hemorrhoids, whereas 210 patients (55.26%) reported no symptoms. In the univariate and multivariate analysis, body mass index (BMI) had a significant effect on the occurrence of hemorrhoids with p = 0.0391 and p = 0.0282, respectively. Even when correcting for other potential risk factors, an increase in the BMI of one increased the risk of hemorrhoids by 3.5%.ConclusionHemorrhoids occur frequently in the adult general population. Notably, a considerable number of people with hemorrhoids do not complain about symptoms. In addition, a high BMI can be regarded as an independent risk factor for hemorrhoids.

Endorectal Advancement Flaps in the Treatment of High Anal Fistula of Cryptoglandular Origin: Full-Thickness vs. Mucosal-Rectum Flaps

PurposeThe treatment of high anal fistula using endorectal advancement flaps represents an important technique to attain cure of fistulation and preserve anal continence. The creation of the advancement flap may comprise the rectal mucosa only or involve the full transection of the rectal wall. A comparison between full-thickness flaps and mucosal (partial-thickness) flaps was made to analyze the defining elements of successful fistula treatment: recurrence rates and anal continence.MethodsA retrospective review of 54 consecutive patients with high anal fistula of cryptoglandular origin was undertaken. Patient risk was categorized according to previous anal surgery. Continence was assessed according to the Vaizey score. Recurrence rates were recorded in a long-term, complete follow-up.ResultsThirty-four patients underwent surgery using a partial-thickness flap; in 20 patients the full-thickness flap was used. There were no major intraoperative or postoperative complications. Continence scores revealed significant incontinence in 11.1 percent of all patients. Full transection of the rectal wall for flap creation did not pose a threat to continence. Twenty-four percent of all patients suffered from a recurrence. Patients with four or more previous anal surgeries were at highest risk for failure. A single patient in the full-thickness flap group (5 percent) as opposed to 12 patients (35.3 percent) in the partial-thickness group suffered from recurrence.ConclusionThe comparison of partial-thickness to full-thickness endorectal advancement flaps suggests an improvement of recurrence rates without higher incontinence rates when a full mobilization of the rectal wall is performed.

Dendritic cell vaccination in medullary thyroid carcinoma.

Purpose: Prognosis and treatment effectiveness for medullary thyroid carcinoma (MTC) are strictly related to tumor stage. Palliative treatment options show no significant benefit. A promising treatment approach for human cancer is based on the vaccination of autologous dendritic cells (DCs). Experimental Design: The objective of this study was to evaluate the effectiveness of DC vaccines in MTC patients. Therefore, we generated autologous tumor lysate-pulsed DCs from 10 patients suffering from advanced MTC for repeated vaccination. Mature DCs were derived from peripheral blood monocytes by using CD14 magnetic bead selection and subsequent culture in the presence of granulocyte macrophage colony-stimulating factor, interleukin 4, and tumor necrosis factor α with or without addition of IFN-γ. DCs were loaded with tumor lysate and further injected into a groin lymph node. Toxicity, tumor marker profile, immune response, and clinical response were determined. Results: Vaccination was well tolerated and induced a positive immunological response in all of the tested patients as evaluated by in vivo delayed-type hypersensitivity reactivity or in vitro intracytoplasmic IFN-γ detection assay. Three patients had a partial response, 1 patient presented a minor response, and 2 patients showed stable disease. The remaining 4 patients had progressive disease. Conclusions: These data provide strong evidence that vaccination with tumor-lysate pulsed DCs results in the induction of a specific immune response in patients suffering from MTC. Objective clinical responses could be observed even for far-advanced disease. Therefore, we suggest that MTC is particularly suited for DC-based immunotherapy.

Endo‐sponge assisted treatment of anastomotic leakage following colorectal surgery

Aim  Endo‐sponge assisted treatment (endo‐sponge) represents a novel approach to treat patients with anastomotic dehiscence following anterior resection for rectal cancer. Yet, limited data are available to predict success, compatibility with radiotherapy and/or chemotherapy as well as acceptance by the patients.

Repeat intestinal resections increase the risk of recurrence of Crohn's disease.

BACKGROUND: Which factors predict recurrence in patients with Crohn’s disease in the era of immunosuppressive medications is still under debate. OBJECTIVE: The current study was conducted to assess long-term outcome after ileocolic resection for Crohn’s disease and to define predictive factors for surgical relapse. DESIGN: This is a retrospective study. SETTINGS: The study was conducted in a tertiary referral center. PATIENTS: A consecutive cohort of patients (n = 203) with Crohn’s disease who underwent ileocolic resection between 1997 and 2006 were analyzed. The mean follow-up time was 8.4 (±2.4) years. MAIN OUTCOME MEASURES: The cumulative probability for repeated intestinal resection for recurrent Crohn’s disease was described by Kaplan-Meier curves. Predictors of surgical recurrence were analyzed by univariate tests. RESULTS: One hundred five patients (51.7%) were exposed to azathioprine/6-mercaptopurine, and 28 patients (13.8%) were exposed to tumor necrosis factor-&agr; blockers after operation. During the follow-up period, 32 patients (15.8%) were reoperated on for disease recurrence. At 5 and 10 years after index surgery, 95.5% and 81.3% of the patients had reoperation-free survival. Previous resections for Crohn’s disease (HR, 2.981; 95% CI, 1.411–6.29; p = 0.003) and urgent indication for surgery (HR, 2.729; 95% CI, 1.047–7.116; p = 0.03) were significant risk factors for reoperation. In addition, patients with postoperative complications following ileocolonic resection were more likely to require reoperation (HR, 1.712; 95% CI, 041–2.817; p = 0.03). In a multiple Cox regression model, previous intestinal resection for Crohns disease remained significant (p = 0.0114) with a HR of 2.654 (95% CI, 1.246–5.654). LIMITATIONS: The limitation is the retrospective design of the study, with its potential selection bias. CONCLUSION: In the present analysis, previous intestinal resection for Crohns disease was found to be an independent risk factor for surgical recurrence. Consequently, shorter surveillance intervals in this group of patients should be considered.

Peritoneal metastases from colorectal cancer: Patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment modality for patients with pseudomyxoma peritonei. The majority of patients with pseudomyxoma who have complete tumour removal and HIPEC are cured. Over the last decade CRS for peritoneal metastasis of colorectal origin has emerged as an effective treatment strategy in carefully selected patients. Although convincing evidence is limited, available data shows promising results. The key to a successful outcome is appropriate selection of patients. In patients with extensive peritoneal disease, where complete cytoreduction is not achieved, surgical treatment may not be beneficial and might impair quality of life. In this paper we discuss the challenges of selecting patients with colorectal peritoneal metastases who are likely to benefit from CRS with HIPEC.

Intermediate Monocytes but Not TIE2-Expressing Monocytes Are a Sensitive Diagnostic Indicator for Colorectal Cancer

We have conducted the first study to determine the diagnostic potential of the CD14++CD16+ intermediate monocytes as compared to the pro-angiogenic subset of CD14++CD16+TIE2+ TIE2-expressing monocytes (TEMs) in cancer. These monocyte populations were investigated by flow cytometry in healthy volunteers (N = 32) and in colorectal carcinoma patients with localized (N = 24) or metastatic (N = 37) disease. We further determined blood levels of cytokines associated with monocyte regulation. The results revealed the intermediate monocyte subset to be significantly elevated in colorectal cancer patients and to show the highest frequencies in localized disease. Multivariate regression analysis identified intermediate monocytes as a significant independent variable in cancer prediction. With a cut-off value at 0.37% (intermediate monocytes of total leukocytes) the diagnostic sensitivity and specificity ranged at 69% and 81%, respectively. In contrast, TEM levels were elevated in localized cancer but did not differ significantly between groups and none of the cytokines correlated with monocyte subpopulations. Of interest, in vitro analyses supported the observation that intermediate monocytes were more potently induced by primary as opposed to metastatic cancer cells which may relate to the immunosuppressive milieu established in the advanced stage of metastatic disease. In conclusion, intermediate monocytes as compared to TIE2-expressing monocytes are a more sensitive diagnostic indicator of colorectal cancer.

Interleukin-8 predicts 60-day mortality in premature infants with necrotizing enterocolitis

OBJECTIVE The purpose of this study was to evaluate the predictiveness of circulating interleukin (IL)-8 for 60-day mortality in premature infants with necrotizing enterocolitis (NEC). BACKGROUND NEC affects up to 5% of premature infants and remains a leading cause of mortality among neonates. METHODS A total of 113 infants with surgically (n=50) or medically (n=63) treated NEC were retrospectively analyzed. Laboratory parameters including serum IL-8 were assessed at the diagnosis of NEC and during the preoperative workup. RESULTS The 60-day mortality was 19% (22/113), 10% (6/63) in medical and 33% (16/50) in surgical NEC. IL-8 levels significantly correlated with 60-day mortality (odds ratio: 1.38; CI 1.14-1.67; p=0.001). Median IL-8 levels at diagnosis were significantly higher in neonates who were later treated surgically (median=2625 pg/ml; range: 27-7500) compared with those treated medically (median=156 pg/ml; range: 5-7500; p<0.001). The AUC to discriminate between medical and surgical NEC was 0.82 (CI, 0.74-0.90), and an exploratory IL-8 cutoff point could be established at 1783 pg/ml (sensitivity of 90.5%; specificity of 59.2%). CONCLUSIONS Our findings that serum IL-8 (i) correlates directly with 60-day mortality and (ii) differs significantly between medically and surgically treated infants may change the process of therapeutic decision making in NEC.

Short‐term complications of wide‐lumen stapled anastomosis after ileocolic resection for Crohn’s disease: who is at risk?

Aim  There is growing evidence that stapled anastomoses are similarly effective compared to hand‐sewn anastomoses in Crohn’s patients. This study was designed to assess safety and limitations of wide‐lumen stapled ileocolic anastomoses.

Postoperative course and long term follow up after colectomy for slow transit constipation--is surgery an appropriate approach?

Objective  Patients with slow transit constipation who do not respond satisfactorily to common medical treatment are considered candidates for colectomy. The present observational long term study was designed to assess outcome after surgery.