University of Southern Indiana. V. Tempeck, MD: "Order cheap Benzac online no RX - Effective Benzac online".
Fifty-seven percent more test group participants W hen evaluating the clinical meaningfulness of the than sham light treated group participants showed a Zerona procedure purchase benzac 20 gr with amex acne after stopping birth control, 61 of the 67 subjects responded to total decrease in combined circumference measure- the satisfaction survey buy benzac 20gr with mastercard acne vulgaris causes. The 79% were able to correctly identify their group assign- comments for test group participants included: ment order benzac 20gr acne nodule, and 78% of sham group members were able to “Feeling slimmer and more lean” ascertain correctly their group 20gr benzac with visa acne whiteheads. Further, an independent “I feel like I’m losing weight” observer was utilized to interpret the visual reduction For sham group participants, no remarks regarding and indicate subject assignment. Tsukihara T, Aoyama H, Yamashita E, Tomizaki T, with an 81% rate when determining individuals belong- Yamaguchi H, Shinzawa-Itoh K, Nakashima R, Yaono R, Yoshikawa S (1996) the whole structure of the 13-subunit ing to the sham group. Science 272(5265): Aesthetic medicine does not deviate from other 1136–1144 medical disciplines in that innovation is the corner- 7. Iwata S, Ostermeirer C, Ludwig B, M ichel H (1995) stone for advancement in medical intervention, and Structure of 2. As a transdermal 660–669 device, the modulation of adipocyte structural integrity 8. Doklady Akad Nauk (M oscow) 342(5): 693–695 improvement that dramatically departs from standard 9. Even though further studies are (2002) Human fbroblast alterations induced by low power warranted to better understand this modality, preced- laser irradiation at the single cell level using confocal ing histological trials and completion of a Level 1 microscopy. J Refract Surg 24(4):S424–S430 trial of its effectiveness for enhancing ease of liposuction 14. Dermatol Ther 20(6):448–451 therapy effectiveness for reducing pain after breast augmen- 16. Lubart R, Eichler M , Lavi R, Friedman H, Shainberg A agulation of osteoid osteomas of the hands and feet. Eur (2005) Low-energy laser irradiation promotes cellular redox Radiol 18(11):2635–2641 activity. Tsukihara T, Aoyama H, Yamashita E, Tomizaki T, Alam M (2005) Low-level laser therapy for wound healing: Yamaguchi H, Shinzawa-Itoh K, Nakashima R, Yaono R, mechanism and effcacy. Dermatol Surg 31(3):334–340 Yoshikawa S (1995) Structures of metal sites of oxidized 18. Neira R, Solarte E, Isaza C, et al (2001) Effects of the cacy of low-power laser therapy on pain and function in electric laser diode beam on in vitro human adipose tissue cervical osteoarthritis. Stelian J, Gil I, Habot B, Rosenthal M , Abramovici I, Kutok Reconstructiva N, Khahil A (1992) Improvement of pain and disability in 29. Niera R, Arroyave J, Solarte E, et al (2001) In vitro culture domized, placebo-controlled trial of low level laser therapy of adipose cells after irradiating them with a low-level for activated Achilles tendinitis with microdialysis measure- laser device. Congreso Bolivariano de Cirugia Plastica ment of peritendinous prostaglandin E2 concentrations. Acupunct Electrother Res 32(1–2):81–86 vention of oral mucositis in patients undergoing hematopoi- 34. Yan C, Lian X, Li Y, Dai Y, W hite A, Qin Y, Li H, Hume reconstruction procedure (double-blind randomized study). Am J Pathol 169(3):916–926 Low power laser irradiation alters gene expression of olfac- 37. M aloney R, Shanks S, Jenney E (2009) the reduction in tory ensheathing cells in vitro. Lasers Surg M ed 37(2): cholesterol and triglyceride serum levels following low-level 161–171 laser irradiation: a non-controlled, non-randomized pilot 26. Lasers Lasers Surg M ed 31(3):216–222 Surg M ed 41(10):799–809 Ultrasound-Assisted Lipoplasty: 40 Basic Physics, Tissue Interactions, and Related Results/Complications William W. Ultrasonic surgery is the use of metal probes Safe and effective use of ultrasonic instrumentation for vibrating at low ultrasonic frequencies (20–60 kHz) to lipoplasty requires an understanding of both the tech- achieve a desired surgical effect in tissues. The probe nology and associated surgical methods that differ design, the frequency of vibration, and the surgical signifcantly in many ways from the basic tools and technique all play a role. This chapter metal tip of the probe interacting with the tissue that is presents the basic physics and tissue interactions for of concern; it is not sonic radiation or some other ultrasound-assisted lipoplasty, the benefts of proper mysterious phenomenon. It is complex, but under- use of this technology, and complications associated standable. First-generation ultrasonic lipoplasty Over the past decade and a half, there have been three devices arrived in the late 1980s and early 1990s, sec- distinct generations of ultrasonic instrumentation ond-generation devices arrived in the mid-1990s, and for lipoplasty introduced to the market. First- passed to a probe that vibrates in resonance with the generation ultrasonic instrumentation is represented handpiece. Vibration frequencies for ultrasonic sys- tems for lipoplasty range from 22 to 36 kHz. There is no signifcant difference in tissue effect across this fre- quency range; it simply alters the lengths of the resonant pieces by changing the wavelength of the vibration. Cimino the ultrasonic probe and handpiece vibrate longitu- power available from ultrasonic devices. This means a very effective medium in which to assess power that standing waves are established in the probe and because it is a consistent and strong coupling agent. The third-generation devices typi- function of the vibration frequency and the amplitude cally delivery 10–15 W of power to the water bath, setting. It is important to understand that the vibration generally 50% of the power of the earlier generation is not “lateral,” i. W hen transverse vibration occurs, as it some- the reduced overall power with much greater effciency times can with smaller diameter or longer probes, it [1]. This measured data is also important to visualize standing waves in the showed that the design of the tip greatly infuences the probe as opposed to a single back and forth motion of effciency of the coupling. A reciprocating powered cannula tion devices possess effciencies in the range of 100– device moves the cannula back and forth as a solid 175 mJ/mm3 in the clinically usable amplitude range unit. Ultrasonic probes vibrate with standing waves whereas the third-generation technology has effcien- and thus achieve the ability to concentrate energy at cies in the range of 175–250 mJ/mm3 in the clinically the tip of the probe. In summary, third-generation technology tudes and probe dimensions for the various frst-, was able to roughly double the effciency while cutting second-, and third-generation ultrasonic devices for the power applied in half. W hat matters is the available 5-mm probe with two aspiration holes and a relatively power at the tip of the device, which does scale with fat front surface. The majority of the frontal surface is amplitude, but is also a function of frequency. Thus, when the probe is pressed lower amplitudes and higher frequencies can achieve into tissues strongly, there is strong coupling of the the same level of power as higher amplitudes and lower ultrasonic energy from the face of the probe. The active area vibration is not a useful indicator of actual power for for this probe is inside the concave recess and will not effecting tissues. Power deposited in tissues is a func- contact tissue unless the tissue is pulled into the recess tion of the generator setting, but also a strong function with suction or unless the probe is pressed strongly of the “coupling” between the tip of the probe and the into a tissue area. A vibrating tip that is pressed strongly into the probe design is actually quite small. The outside ring tissue will couple signifcantly more energy to the tis- around the outside diameter of the probe will act as an sue than the same tip that is gently touching the same ultrasonic knife when vibrating, which will be dis- tissue.
Longitudinal view of the radiocarpal joint demonstrating the distal radius order benzac 20gr overnight delivery acne scar removal, scaphoid buy benzac 20 gr otc acne jeans review, and radiocarpal joint buy cheap benzac 20 gr on line acne-fw13c. Synovial hypertrophy (arrows) of the wrist in a dorsal longitudinal ultrasound scan buy 20gr benzac fast delivery skin care 77054. Longitudinal extended field-of-view image demonstrating diffuse carpal synovitis (arrowheads). Longitudinal ultrasound image demonstrating a joint mouse in the radiolunate joint. Longitudinal ultrasound image demonstrating synovitis and crystal deposition of the lunocapitate joint. A: Photograph shows a lump (arrow) over the dorsal aspect of the wrist that was evident only during palmar flexion. The superior hypoechoic extension could represent the beginnings of a ganglion cyst. Given the potentially disastrous sequela to failing to diagnosis scaphoid fractures, the use of multiple imaging modalities including ultrasound, bone scans, computerized tomography, and magnetic resonance imaging is indicated (Fig. A: Severe degenerative changes of the radiocarpal and midcarpal joint can be seen. B: Ultrasound shows a large fluid effusion located inside the synovial sheath of the flexor carpi radialis tendon. The tenosynovitis is caused by local friction against the palmar osteophytes of the degenerated scaphotrapezium. Transverse ultrasound image demonstrating a giant cell tumor of the tendon sheath of the flexor pollicis longus. Transverse ultrasound image demonstrating extensor tenosynovitis of the fourth extensor department. Longitudinal color Doppler image demonstrating inflammatory destruction of the lunate and scaphoid bones in a patient with severe rheumatoid arthritis. Ultrasound image in a 60-year-old man with a known long-standing scaphoid fracture nonunion sustained in high school. A: Ultrasonography of the right scaphoid bone obtained in long axis shows a marked deformity of the central portion of the scaphoid bone. B: the left scaphoid bone was imaged for comparison purposes and shows normal contour. Intra-articular distribution pattern after ultrasound-guided injections in wrist joints of patients with rheumatoid arthritis. As the median nerve exits the axilla, it passes inferiorly adjacent to the brachial artery (Fig. At the antecubital fossa, the median nerve lies just medial to the brachial artery. Continuing its downward path, the median nerve gives off a number of motor branches to the flexor muscles of the upper arm (Fig. These branches are susceptible to nerve entrapment by aberrant ligaments, muscle hypertrophy, and direct trauma (Fig. As the median nerve approaches the wrist, it overlies the radius where it is susceptible to trauma from radial fractures and lacerations. The nerve lies deep to and between the tendons of the palmaris longus muscle and the flexor carpi radialis muscle at the wrist. Prior to passing through the carpal tunnel, the median nerve gives off the palmar cutaneous branch which travels downward next to the median nerve between the palmaris longus and flexor carpi radialis muscles, giving off sensory branches to the scaphoid and in some patients, the lunate bone. The nerve then moves medially toward the tendon of the flexor carpi radialis muscle and passes through a superficial facial tunnel made up of fibers from the distal antebrachial fascia and occasionally fibers from the flexor retinaculum. The nerve then moves subcutaneously to pass across the base the thenar eminence providing sensory innervation to the proximal palmar triangle and thenar eminence. The palmar cutaneous branch of the median nerve does not pass through the carpal tunnel beneath the flexor retinaculum along with the median nerve (Fig. Arising from fibers from the ventral roots of C5 and C6 of the lateral cord and C8 and T1 of the medial cord of the brachial plexus, the median nerve lies anterior and superior to the axillary artery in the 12:00 to 3:00 o’clock quadrant as it passes through the axilla. As the median nerve exits the axilla, it passes inferiorly adjacent to the brachial artery. A: the ligament of Struthers from an anomalous supracondylar process to the medial epicondyle, which may compress the median nerve. Prior to passing through the carpal tunnel, the median nerve gives off the palmar cutaneous branch, which travels downward next to the median nerve between the palmaris longus and flexor carpi radialis muscles. The palmar cutaneous branch of the median nerve provides sensory innervation to the skin of the thenar eminence and the proximal palm (Fig. As the median nerve passes beneath the flexor retinaculum, which is also known as the transverse ligament, through the carpal tunnel, it is subject to entrapment for a variety of pathologic conditions (Figs. The terminal branches of the median nerve provide sensory innervation to a portion of the palmar surface of the hand as well as the palmar surface of the thumb, index, and middle fingers, and the radial portion of the ring finger (Fig. The median nerve also provides sensory innervation to the distal dorsal surface of the index and middle fingers and the radial portion of the ring finger. Superficial dissection shows the median nerve lies deep to and between the tendons of the palmaris longus muscle and the flexor carpi radialis muscle at the wrist. Carpal tunnel syndrome can be caused by a variety of structural and anatomic abnormalities and is associated with a number of pathologic conditions. While the clinical presentation of carpal tunnel syndrome is consistent, this entrapment neuropathy has many causes and is associated with many pathologic conditions (Table 48. Carpal tunnel syndrome presents as pain and dysesthesias with associated numbness and weakness in the hand and wrist that radiate to the thumb, index finger, middle finger, and radial half of the ring finger. These symptoms may also radiate proximal to the level of nerve entrapment into the distal forearm. Decreased sensation in the distribution of the median 446 nerve of the thumb, index finger, middle finger, and radial half of the ring finger is often present as weakness of thumb opposition. A positive Phalen test is highly suggestive of the diagnosis of carpal tunnel syndrome. Phalen test is performed by having the patient place the wrists in complete unforced flexion for at least 30 seconds (Fig. The test is considered positive if this maneuver elicits dysesthesia, pain, or numbness in the distribution of the median nerve. Wasting of the thenar eminence may be seen in more advanced cases of carpal tunnel (Fig. Patients suffering from carpal tunnel syndrome will exhibit a positive Tinel sign over the superficial median nerve. The Phalen test for carpal tunnel syndrome is performed by having the patient place the wrists in complete unforced flexion for at least 30 seconds. The test is considered positive if this maneuver elicits dysesthesia, pain, or numbness in the distribution of the median nerve. The numbness and dysesthesias of entrapment or compromise of the palmar cutaneous branch of the median nerve are limited to the proximal palm and thenar eminence and motor findings are conspicuously absent (Fig. The overlap of symptoms of carpal tunnel syndrome and entrapment and/or compromise of the palmar 447 cutaneous branch of the median nerve can lead to many clinical misadventures and the use of ultrasonography and electromyography can help solidify the clinical diagnosis. The clinician should entertain a high index of suspicion for iatrogenic damage to the palmar cutaneous branch of the median nerve following carpal tunnel surgery if the patient complains of persistent numbness in the proximal palmar triangle and over the thenar eminence.
Death usually takes place within 1 year IgM paraproteinemia: Occasional cases of IgM myeloma because of infection benzac 20gr low cost acne mask. Patients develop lymphoproliferation with occur and are characterized by infltration of the bone mar- fever cheap 20gr benzac skin care brand owned by procter and gamble, anemia cheap benzac 20gr skincare for men, fatigue buy cheap benzac 20gr acne off, angioimmunoblastic lymphadenopathy, row by plasmacytes, numerous osteolytic lesions, and occa- hepatosplenomegaly, eosinophilic infltrates, leukopenia, lym- sionally bleeding diathesis. There is elevated true Waldenström’s macroglobulinemia, but is rare com- IgG1 in the serum. Plasmacytomas were used extensively egaly, infltration of the bone marrow by vacuolated plasma to generate monoclonal immunoglobulins prior to the devel- cells, and frequently by elevated synthesis of κ light chain. Benign tion in which the serum contains an M component, serum gammopathies occur in amyloidosis and monoclonal gammo- albumin is less than 2 g/dl, and there is no Bence-Jones pro- pathy of undetermined etiology. There are no osteolytic lesions, and plasma often accompanied by benign polyclonal gammopathies. Of include rheumatoid arthritis, lupus erythematosus, tuberculo- these patients, 20 to 40% ultimately develop a monoclonal sis, cirrhosis, and angioimmunoblastic lymphadenopathy. When monoclonal spikes exceed 2 g/dl with other immunoglobulins decreased and no Bence-Jones pro- Hypergammaglobulinemia: Elevated serum γ globulin tein in the urine, the condition is usually malignant. A polyclonal increase in immu- 1 to 2% of myelomas are nonsecretory monoclonal gammo- noglobulins in the serum occurs in any condition where pathies. Waldenström’s macroglobulinemia and a few progressing to Hypergammaglobulinemia may also result from a mono- lymphoma or chronic lymphocytic leukemia. Repeated immunization may also induce to such conditions as multiple myeloma or to the less omi- hypergammaglobulinemia. They include a diverse assemblage of neoplastic diseases characterized by prolif- M component is a spike or defned peak observed on elec- eration of a single cell clone producing an M component, a trophoresis of serum proteins, which suggests monoclonal monoclonal immunoglobulin, or immunoglobulin fragment. The absolute plasma cell number Light-chain disease is a paraproteinemia termed Bence- is more than 2000 per cubic millimeter of blood. Reactive plasmacytosis linked to renal amyloidosis and renal failure as a consequence must be considered in the diagnosis. Light-chain disease patients have Benign monoclonal gammopathy is a paraproteinemia that a worse course than do patients with IgA or IgG myelomas. They have ized by a monoclonal immunoglobulin (M component) in none of the clinical signs and symptoms of multiple myeloma the patient’s serum. Heavy-chain disease is a type of myelomatosis in which aberrant monoclonal immunoglobulin μ chains are present Plasmacytoma is a plasma cell neoplasm. Also termed in the serum but not in the urine, and Bence-Jones proteins myeloma or multiple myeloma. Although very uncommon, this tal plasmacytoma in laboratory mice or rats, paraffn oil is condition may be associated with chronic lymphocytic leu- injected into the peritoneum. These tumors, comprised of neoplastic plasma cells, have been demonstrated in the bone marrow and are very synthesize and secrete monoclonal immunoglobulins, yielding suggestive of the diagnosis of μ heavy-chain disease. Light chains synthe- Africa, the Near East, the Mediterranean area, and some sized by these patients are not incorporated into molecular regions of southern Europe. Rare cases have been reported in IgM; therefore, these individuals demonstrate a distinct fail- the U. The condition may prove fatal, even though remis- ure in assembly of immunoglobulin molecules. Polymeric IgG3 may be associated with cryoglobulinemia in Cryofbrinogenemia is cryofbrinogen in the blood that is which the protein precipitates in those parts of the body exposed either primary or secondary to lymphoproliferative and auto- to cooling. Cryoglobulinemia patients develop embarrassed immune disorders, tumors, acute or chronic infammation. More commonly, patients may manifest Raynaud’s phe- Polyclonal hypergammaglobulinemia is an elevation in the nomenon following exposure of the hands or other parts of the blood plasma of γ globulin which is comprised of increased anatomy to cold. Cryoglobulinemias are divisible into three types: type I monoclo- nal cryoglobulinemia, which is often associated with a malignant Cryoglobulin is a serum protein that precipitates or gels in condition, i. It is an immunoglobulin that gels or precipitates when lymphoma or chronic lymphocytic leukemia, and benign mono- the temperature falls below 37°C. Cryoglobulins are Epstein–Barr and cytomegalovirus inclusion virus, Sjögren’s usually associated with infectious, infammatory, and neo- syndrome, crescentic and membranoproliferative glomerulone- plastic processes. They are found in different body fuids and phritis, subacute bacterial infections, biliary cirrhosis, diabetes they also appear in the urine. Also of IgG, of low immunoglobulin light-chain concentrations called dysimmunoglobulinemia. Immunofxation elec- γ Heavy-chain disease, also called Franklin’s disease, is a trophoresis, employing fuorochrome-labeled antibodies, can very rare syndrome in which the myeloma cells synthesize γ resolve this masking effect. Clinically, this disease affects mostly older individuals who have either a gradual or sudden onset. The α Heavy-chain disease is a rare condition in individuals of patients may be weak, have fever and malaise, and demon- Mediterranean extraction who may develop gastrointestinal strate lymphadenopathy over a period of time. Swelling of the lymphoma and malabsorption with loss of weight and diar- uvula and edema of the palate may be a consequence of lym- rhea. The aberrant plasma cells infltrating the lamina pro- phoid tissue involvement of the nasopharynx and Waldeyer’s pria of the intestinal mucosa and the mesenteric lymph nodes ring. Lymph nodes affected may include those of the axilla, synthesize α chains alone, usually α-1, with no production mediastinum, tracheobronchial tree, and abdomen. Even though the end-terminal sequences are enlargement of the spleen and liver may follow infection of intact, a sequence stretching from the V region through much these patients. Thus, there is no cysteine 5 years and usually leads to death, although remission has been residue to cross-link light chains. The blood serum contains 588 Atlas of Immunology, Third Edition proteins with an electrophoretic peak that correspond in 131 mobility to the homogeneous (Bence-Jones negative) protein 96 present in the urine. There is an elevated sedimentation rate, N mild anemia, thrombocytopenia, leukopenia, and sometimes 161 0 47 eosinophilia. Abnormal plasma cells and lymphocytes may 43 26 appear in the blood and occasionally be manifested as plasma cell leukemia. To confrm the diagnosis of γ heavy-chain dis- 68 ease, one must demonstrate a spike with the electrophoretic 174 mobility of a fast γ or β globulin reactive with antiserum C2 144 against γ heavy chains, but not with κ or λ light chains. There represent the light chains of either the κ or λ variant excreted is total failure in light-chain synthesis in all individuals. Thus, in the urine of patients with a paraproteinemia as a result of γ heavy-chain disease may mimic lymphomas of one type or excess synthesis of such chains or from mutant cells which another (as well as multiple myeloma, toxoplasmosis, and his- make only such chains. The highest frequency of B-J excretion is seen in IgD myeloma; the lowest is seen Essential mixed cryoglobulinemia is a condition that in IgG myeloma. The daily amount excreted parallels the is identifed by purpura (skin hemorrhages), joint pains, severity of the disease. The B-J proteins are secreted mostly impaired circulation in the extremities on exposure to cold as dimers and show unusual heat solubility properties.
The primary Transverse sectioning of the anococcygeal ligament also cryptoglandular complex may be encircled with a seton for provides access to the deep post-anal space order benzac 20 gr fast delivery acne coat. The long-term effect It is important to note that horseshoe abscesses may not upon the sphincter is not precisely known buy discount benzac 20 gr acne fulminans. Moreover benzac 20gr discount acne vacuum, the authors prefer entering the deep post-anal space by the classic bilateral rubor over the ischioanal fossa may a vertical division of the anococcygeal ligament along its represent underlying frank suppuration or merely cellulitis 4 Classification and Treatment of Anorectal Infections 25 emanating from the primary abscess cheap benzac 20gr visa acne 8o. Ueber die analen Divertikel der Rectumsschleim-haut assessment is made from the posterior midline incision. Perianal fistula tract with an indwelling draining seton may then be abscesses and fistulas. Clinical Assessment of Anal Fistulas 5 Herand Abcarian bowel disease are often much less painful, contain very thin Introduction pus and the patient may present with some pain and drainage for weeks without a significant acute illness. Patients with A successful outcome from any type of fistula operation is hematologic disorders such as acute myelogenous leuke- dependent on accurate clinical assessment and classification. This is more likely to the patient gives a history of a prior episode of perianal be seen in hematology–oncology units of major medical cen- swelling and pain (low abscess) or deep rectal pain with ters than in physician/surgeon’s offices. The abscess are encountered, the surgeon must not rush into attempting to either ruptures spontaneously and drainage of pus and blood drain the abscess especially when in the majority of cases is followed by resolution of acute pain or alternately the severe thrombocytopenia is part and parcel of pancytopenia. Intermittent the patient must be told that the infectious process begins swelling and pain followed by drainage and relief of pain are in the anal canal and spreads outward and drainage of the typical symptoms of anal fistulas. It should be noted that abscess alone may not be adequate to eradicate the infection. This typical history can be found in the overwhelming majority of patients with fistula in ano. The patient may be examined on a tilt table in the knee external penetrating injury is much clearer and the clinical chest position, but the same can be carried out in the Sims course easier to follow. The first landmark is often readily visible to the secondary opening of the fistula, is often open and draining or has a telltale granu- H. Abcarian in chronic fistulas with fibrosis and retraction of the external and obscure its ease of identification. Palpation of the be able to find the internal opening at a second or third try soft tissue between the secondary opening and the anal canal and the surgeon should avoid getting frustrated and persist to often feels like a firm cord (much like the extensor tendons the point of causing a false passage. In deeper (higher) fistulas, ing is found after some additional maneuvers, it is best to this cord-like structure can be palpated only to the margin if insert a loose marking seton to allow easy identification of the external sphincter as the tracts dips under the muscle to the fistula tract during a subsequent definitive surgical proce- connect with the anal canal. Other helpful maneuvers in identification of the bilaterally in cases of horseshoe fistulas. Rectal examination with bi-digital palpation may elicit Ordinarily, a fistula being treated for the first time requires induration in the perianal or ischiorectal fossa at the same very little if any additional imaging. This signifies presence of an acute or operations resulting in scarring and distortion of the fistula chronic abscess cavity associated with the fistula. The pri- tract, and in cases where there is more than one fistula mary opening may feel like small grain of rice or lentil. Fistulography, which was popularized in the 1970s and as an indentation above the dentate line in the anorectal ring 1980s but has fallen out of favor with advent of other or lower rectal wall. There were publications pro and con often at the dentate line corresponding to Goodsall’s rule, of fistulography but currently this procedure is rarely uti- unless the patient has had previous surgery or the fistula is lized [4 ]. Endoanal ultrasonography without or with injection of sharp foreign body as mentioned above. Computerized tomography of pelvis and perineum with from the primary opening, which confirms the diagnosis. Magnetic resonance imaging is quite helpful in diagnos- however may judiciously proceed to use a draining seton ing fistula and assessing the closure of the fistula after instead of definite surgical procedure if the fistula is consid- seemingly successful procedures, especially in Crohn’s ered to be too complex or undrained pus is encountered dur- disease. Identification of primary and secondary openings and the lateral traction using a Kocher clamp is often helpful to fistula tract itself which is described above. If the fistula tract is very thin, lacrimal probes may be classification and the thickness of sphincter muscle used instead of the regular fistula probes. This is much harder than simple identification of very narrow, one may have difficulty delineating it even with the tract because it takes experience and judgment to decide lacrimal probes. In such cases slow injection of hydrogen which fistula is easily amenable to fistulotomy and which peroxide alone or with the addition of 1–2 drops of methy- requires sphincter-sparing procedure. As Phillip suggests, lene blue might result in bubbling of the injected material it is more important to know how much sphincter will be through the primary opening. A larger amount of methylene left behind rather how much will be divided during fistu- blue tends to stain the granulation tissue in dark blue color lotomy (see Chap. Reducing this to its simple form, it is 5 Clinical Assessment of Anal Fistulas 29 important for the surgeon to be sure whether the fistula is It is for this reason and medical/legal implications of high or low and if the surgeon is inexperienced, unsure, or treatment-related fecal incontinence that the involve- does not treat anal fistulas on regular basis, it is better to ment of a colon and rectal surgical specialist in the treat- insert a loose marking seton (braided suture or vessel loop) ment of anal fistula is not only desirable, but most often in the tract and refer the patient to a specialist [3]. Role of seton in fistulot- Although fistula in ano is not a life-threatening disease, it is omy of the anus. Cologne , Juan Antonio Villanueva-Herrero , Enrique Montaño-Torres , and Adrian E. Ortega David Henry Goodsall is credited with the first “topo- Introduction graphical” description of anal fistula. Goodsall’s Fistula disease is a frequent consequence of anorectal rule states that fistula having an external orifices situated abscess. Up to 50 % of patients with an anorectal abscess behind (posterior) to a transverse line drawn through the cen- progress to develop a chronic fistula. Cryptoglandular or ter of the anus usually have their internal orifice in the poste- idiopathic origin is the most frequent cause. In a series examining dates back to Hippocrates—the first to describe the use of a the accuracy of this dictum in 216 patients with fistulas, it seton [2]. Hundreds of remedies have been proscribed to appears to be more accurate for posterior fistulas. The difficulty in finding a univer- fistulas less often follow this straight course described, with sally successful treatment speaks to the pleomorphic nature an average of 49 % following the proposed path [4]. Clinical evaluation of fistulas becomes Goodsall’s rule serves as an imperfect guide to identify the critical to determining the appropriate intervention. His initial classification scheme was slightly more elaborate, but included the follow- ing four basic fistula types (with percentages based on his Classification preliminary series of 400 patients): intersphincteric (45 %), transphincteric (29 %), suprasphincteric (20 %) and Several classification schemes have been developed to better extrasphincteric (5 %). They slightly based on larger series to represent the scope of clinical portend implications important both in terms of defining disease as follows: intersphincteric (70 %), transphincteric anatomy and the likelihood of therapeutic success. These involve both the internal and external sphincters and pass into the ischioanal fossa. The length of the fistula is determined by the location of the previous incision and drainage or site of spontaneous decompression. These curvi- linear fistula tracts originate at the level of the dentate line but traverse cephalad above the puborectalis before turning downward through the ischioanal fossa to reach the peri- anal skin. Extrasphincteric fistulas are usually caused by overzeal- ous probing and creation of false fistula tracts. Posterior secondaries passes through the levators rendering them amongst the most follow a curvilinear trajectory into a posterior midline primary. On the right is an uncom- (b) low transphincteric; (c) supralevator; (d) two variations of mon variant of cryptglandular origin extrasphincteric fistula.
