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Ilereditarv posterior m icrophthal­ In adults purchase triamterene online pills arteria vitellina, the nanophthalmic eye is often associated m os with papillom acular fold and high hyperopia generic 75 mg triamterene amex blood pressure medication vision problems. J Med glaucoma purchase triamterene cheap arrhythmia heart disease, cataract surgery, and retinal complications such Genet 1993;30:661-9. Arch Ophthalm ol responds poorly to conventional surgical therapy and has 1952;48:161-2. Ann Ophthalm ol iridectomy and laser gonioplasty appear to have the highest 1981;14:15-9. M acroquistes dc retina, retinos- or subretinal fluid with air injection into the vitreous quisis e hipcrm ctropia elevada. Localization o f a novel gene for con­ Nanophthalmos is a rare developmental eye disorder genital nonsyndrom ic simple m icrophthalm ia to chrom osom e that may be inherited in a sporadic, autosomal dom i­ 2ql 1-14. Arch O phtham ol splicing regulators cause nanophthalm os and autosom al dom inant 1979;97:878-84. N anophthalm os: guidelines for diagnosis and oculodentodigital dysplasia w ithout syndactyly. Retinal degeneration with m utations cause the pleiotropic phenotype o f oculodentodigital nanophthalm os, cystic m acular degeneration, and angle closure dysplasia. H erm ann P Lc syndrom e: m icrophtalm ic-rctinitc pigm entaire- O phthalm ol 1993;16:29-40. Bilateral nanophthalmos, pigmentary findings in autosom al dom inant vilreorctinochoroidopathy: report retinal dystrophy, and angle closure glaucom a-a new syndrome? N anophthalm os w ith uveal effusion: of m icrocornca, rod-cone dystrophy, cataract, and posterior staphy­ clinical and cmbryological considerations. Uveal effusion syndrom e: a new hypothesis concerning bones: transient hypocalcemia in a m other and son. M anagem ent of strabismus type of growth deficiency with tubular stenosis, transient hypopara­ in nanophthalm ic patients: a long-term follow-up report. N anophthalm os associated two sibs born to consanguineous parents: evidence for an autosom al with cryptorchidism. Ophthalm ology 1986,93(4): lary tubular stenosis: a case o f Catfcy-Kenny syndrom e. Anophthalmia may be malformations, we have tried to move away from purely unilateral or bilateral and is often associated with smaller descriptive discussions towards a gene-specific classification. Developmental Because a mechanistic understanding of these conditions mechanisms responsible for anophthalmia may include a requires a working knowledge of ocular development, we failure of early eye patterning, failure of the optic vesicle to will briefly review the relevant embryology here. However, in many cases where patients opment begins at approximately 22 days of gestation with have no clinically apparent ophthalmic tissues, histologic the appearance of bilateral grooves in the neuroectodcrm and/or radiologic screening can reveal ocular tissue remnants of the embryo (optic grooves), the molecular events impor­ (e. The prevalence of anophthalmia may depend on the Around 25 days of gestation, evaginations of the anterior population studied,7and anophthalmia may be grouped in ncuroectoderm appear, becoming the optic vesicles, which some reports with microphthalmia. Estimates of ano­ are connected to the developing diencephalon via their phthalmia prevalence range from 0. The inner layer of the optic cup forms the ably much larger than actual numbers in most countries. This structure, alternatively with clear Mendelian inheritance, ocular pathology may named the optic fissure, the embryonic fissure, or the chor­ be asymmetric or even unilateral. While some patients oidal fissure, allows for the ingress of migrating neural with syndromic forms of anophthalmia/microphthalmia crest cells that form the early vascular (hyaloid) system of often have delayed development and/or mental retardation, the developing eye. This process occurs first in the implants, orbital osteotomies, bone grafts, and/or orbital equatorial portions of the eye and proceeds proximally expanders, may improve the appearance of patients with and distallv. Yamani and colleagues have found that Optic stalk the sclera of nanophthalmic eyes contains irregularly arranged collagen lamellae, an absence of elastic fibers, Inner Lum en of and abnormal glycogen-like deposits. It is likely that this abnormal fissure fluid dynamics in nanophthalmic eyes contributes to their Hyaloid artery increased risk of uveal effusions and choroidal detachment, and vein particularly after surgery. As the optic veiscle invaginates, it for autosomal dominant nanophthalmos to a 14. The inferior part of the invagmating cup or fetal fissure closes around blood vessels that form the retinal and hyaloid circulation. While we follow this distinction here, it is likely that “simple" and “complex" microphthalmia Failure of the optic fissure to close during the fifth week of represent points along a phenotypic continuum in which human gestation results in uveal coloboma. Depending upon which areas of the Л word of caution concerning the word “coloboma” is fissure remain open, uveal coloboma may affect the iris in order. Colobomas may be unilateral or bilateral and around the eye where some piece of tissue is missing. In the left eye the coloboma is extensive and involves the optic nerve head and a major part of the inferior fundus and macula. In the left eye there is a large chorioretinal coloboma involving the optic nerve head and infenor fundus. Ihis chapter will limit itself to those disorders that involve optic fissure closure when using the word “coloboma. Thus, neither all eyes with coloboma are Abnormalities in the ciliary body caused by coloboma microphthalmic, nor do all microphthalmic eyes have may result in an absence of zonules in the alfected area. Cataracts optic fissure interferes with the development of intraocular may develop at a younger age in patients with coloboma," pressure, ergo eye growth. Other iris abnormalities that have a similar configu­ ration but that are displaced in other directions arc likely not due to an abnormality in optic fissure closure and therefore should not be referred to as colobomas. A mild manifesta­ tion of iris coloboma may be iris transillumination limited to the inferior quadrant of the iris (Fig. This has of light sensitivity and may be bothered by the cosmetic resulted In loss of zonules and straightening of the lens equator in the appearance of the displaced pupil and/or iris heterochromia. Postoperative monocular diplopia has been reported and may be managed by pupilloplasty. In general, chorioretinal colobomas appear as areas of well-demarcated bare sclera in the inferior quadrant of the fundus with varying degrees of irregular, surrounding pigment abnormality. Gopal and associates have shown using opti­ cal coherence tomography that the transition from normal retina to the intercalary membrane covering the coloboma derives from the inner retinal layers and may be either gradual or abrupt. Right eye is small and punched forward imaging, they can grow to compress the developing eye by cyst. Although most cases of microphthalmia with cyst are sporadic, familial cases have been reported, with ence of progressive growth. Microphthalmos with cyst should be differentiated from congenital cystic eye that results from failure of invagination of the optic vesicle. Right eye is pushed up under upper Microphthalmia with Malformations of the Hands and Feet lid and cyst results In bulging of lower lid. Zlotogora and colleagues reported five families with autosomal reccssivc coloboma­ Microphthalmia and Intrauterine Insults tous microphthalmia and stated that the gene for this Maternal drug intake: thalidomide, alcohol, isotretinoin, others condition has a high frequency among Iranian Jews.

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The occurrence of such serial complex tensive cerebral and cardiovascular investigation triamterene 75 mg prehypertension examples, the clinician will partial seizures masquerading as dementia is also known as ‘epi- remain uncertain whether the patient’s episodes are cerebral or car- leptic pseudodementia’ and represents a potentially treatable cause diac in origin buy triamterene 75 mg overnight delivery blood pressure medication hydralazine, unless a typical spell is recorded with simultaneous of memory dysfunction buy triamterene 75 mg on line halou arrhythmia. In a study of 94 patients at least 60 years of age (mean aging, is sometimes overestimated. It is commonly stated that epileptiform discharges are non-epileptic episodes had been taking anticonvulsant medications less frequently seen in elderly patients with seizures [38]. Auras may be very non-specifc, for example simply ly misinterpreted as epileptiform. Upon ‘blinded’ cerebrovascular disease is the most common identifable cause of reinterpretation by electroencephalographers at the epilepsy centre, new-onset seizures in the elderly, and this tends to most common- it was found that 46% (21 out of 46) of the patients with wicket ly involve the frontal lobe [34]. Benbadis and Tatum [40] tigations, a frm diagnosis may remain elusive, and in most cases it reported 15 patients who were eventually diagnosed with psycho- is prudent simply to wait and see. Even if events are happening frequently 15 records reviewed, the patterns that were incorrectly considered enough for a therapeutic response to be assessed quickly, a thera- epileptiform were wicket spikes (n = 1), hypnogogic hypersynchro- peutic trial will rarely produce a decisive answer and only add the ny (n = 1) and hyperventilation-induced slowing (n = 1). The range of ‘normal’ sive examination cannot be emphasized enough, routine biochem- increases with age, so that discriminating normal from abnormal ical and haematological testing may yield helpful clues. This par- that 47% became seizure-free on the frst drug, and a total of 67% ticularly holds true for patients with medically refractory partial became seizure-free with the second or third monotherapy agent. A seizures, for whom appropriate surgical treatment results in com- 2013 study analysing data from 122 patients with newly diagnosed plete resolution of seizures in the majority of patients with unilat- epilepsy over the age of 65 reported seizure freedom rates at 6, 12, eral mesial temporal lobe epilepsy [43] or tumours [44], and even 18 and 24 months as 90%, 77%, 74% and 67%, respectively [55]. Elderly people with epilepsy are not a homogeneous group with similar physiological changes that can predictably afect the choice of drug and dosage. A great degree of variability is seen even within normal healthy individuals, and Risk of recurrence even more variability occurs in elderly patients. Factors that contrib- In all patients presenting with a frst unprovoked seizure, the long- ute to pharmacokinetic variability include comorbidities (especially term (at least 2 years’ follow-up) risk of recurrence is about 38%, renal and hepatic), physical frailty, dietary infuences, compliance ranging from 25% to 52% [46,47,48,49]. Factors that clearly increase and drug interactions from multiple comedications [56,57]. Data on risk of recur- A description of pharmacokinetic properties and known age-re- rence afer the frst unprovoked seizure in older patients are minimal. In Absorption selected populations, the recurrence rate may be as high as 80% [50]. Absorption of medications depends upon the dissolution of drug As many newly diagnosed unprovoked seizures in the elderly formulation, largely dependent upon gastric acid secretion, which have an antecedent cause, most ofen cerebrovascular disease, it is ofen declines in the elderly [58]. In addition, gastric emptying may likely that in most patients with newly diagnosed seizures in the slow, intestinal transit time may increase, mesenteric blood fow elderly population that the seizures will recur. In the elderly popu- and the intestinal absorptive surface may decrease, all contributing lation, it is reasonable to begin anticonvulsant medication afer the to variable absorption of diferent drugs. However, useful prospective derly, which can specifcally impair the absorption of phenytoin [59]. In In addition, gabapentin, which is absorbed via a saturable l-amino making the decision to begin pharmacological treatment, seizure acid transmitter system in the small intestine [60], may be particular- severity, the risk of recurrence, personal preference and the need ly susceptible to physiological changes in gastrointestinal absorption. Protein binding Several acute systemic and neurological illnesses can cause a signifcant decline in serum albumin levels. Suboptimal nutrition Treatment of epilepsy in the elderly may also contribute to lower albumin levels. A reduction in se- Although it has been frequently stated that epilepsy is more easi- rum albumin concentrations will cause the free fraction of highly ly controlled in the elderly population [51,52], there is a dearth of protein-bound medications to increase substantially, and may re- large studies specifcally addressing this issue. Data from the two sult in prominent adverse efects despite little or no change in the studies addressing tolerability of anticonvulsants in the elderly total serum level. Although a high rate of medication Hepatic mass and blood fow both decline with age, such that liver withdrawal probably contributed to the relatively low rate of sei- volume is about 25% lower in people aged 65 than in young adults zure freedom, these fndings suggest that seizures are not so easi- [62]. The majority of drugs metabolized in the liver are metabo- ly controlled in this population. Similarly, in the Veterans Afairs lized by the cytochrome P450 system, and with increasing age this Cooperative Study No 428, which randomized elderly patients system declines in efciency, although to a variable, unpredictable with new or recent-onset epilepsy to treatment with gabapentin, degree [63]. Topiramate and val- not substantially diferent from seizure control rates in younger proate are also partially metabolized via this pathway. The hepatic glucuronidation conjugation process is believed to change is highly variable, and about one-third of patients do not ex- decline much less with age. Because muscle mass, the source tion include lamotrigine, valproate, the active metabolite of oxcar- of serum creatinine, declines with age, the serum creatinine level bazepine, retigabine (ezogabine) and eslicarbazepine [64]. Interindividual variation may be considerable in relation to age and other factors. In particular, the transition aData refer to the active metabolite monohydroxycarbazepine. It has been clearly demon- strated that even 1 year of use in monotherapy leads to measurable Pharmacodynamic changes loss of bone density [70]. Although we believe that phenytoin should In addition to the pharmacokinetic efects potentially altering levels no longer be used as a frst-line (or probably second-line) agent in of medication in the serum, it is also likely that pharmacodynamic the elderly, prescribing patterns are not likely to change markedly in alterations in the efects of the drugs at the cellular level are impor- the near future. Reproduced with permission from Wolters Kluwer ilepsy [68,69], several features make them less than ideal choices. Management of Epilepsy in the Elderly 213 should be made in small increments of 30 mg in order to minimize Newer antiepileptic drugs risks of toxicity. We also recommend not changing formulations of Two prospective trials in the elderly have shown that lamotrigine phenytoin (e. In the Veterans Afairs Cooperative Study No 428 Valproate is a potent inhibitor of hepatic enzymes, is highly pro- [14], patients 60 years of age or older with newly diagnosed epilep- tein bound and can be involved in numerous drug interactions. The primary outcome measure of should be considered in any patient on valproate with unexplained the study was early termination, which occurred in 64. In addition, it is not rare for valproate to exacer- tients taking carbamazepine, a rate that was signifcantly higher bate or cause parkinsonism [72]. Fewer Carbamazepine, also widely prescribed, has a less than favoura- patients taking lamotrigine terminated the study because of adverse ble pharmacokinetic profle. As an inducer of hepatic enzymes, nu- reactions than either patients taking carbamazepine (P <0. Tere were no signifcant diferences in commonly in elderly patients taking carbamazepine [73]. More patients out controlling for severity, lamotrigine had the highest 12-month on gabapentin experienced large weight gain (>18 pounds) than on retention rate (78. Fluid reten- the 12-month retention rates seen with carbamazepine, gabapentin, tion was signifcantly more likely with gabapentin than with car- oxcarbazepine, phenytoin and topiramate (Figure 16. Of seven patients were stratifed into non-refractory and refractory patients, relative hospitalized for hypersensitivity reaction, six were in the carbamaz- rates remained comparable. A prospective open-label study of levetiracetam in 491 elderly pa- A similar earlier study by Brodie et al.

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Thrombin which is produced by clotting mechanism acts Functions of Plasmin as an enzyme to activate protein C to its active form cheap 75mg triamterene mastercard blood pressure chart form. The anticlotting mechanism activated by thrombin can also be Functions of plasmin can be broadly divided into two cate- initiated by thrombomodulin cheap triamterene 75 mg without prescription blood pressure medication mood swings, a hormone secreted from gories: Fibrinolytic actions and nonfibrinolytic actions triamterene 75mg low price heart attack ecg. Plasmin initially cleaves α and β chains within the Activated protein C inactivates the inhibitors of plasmin D domain of fibrinogen that releases Aα and Bβ frag- activator. Inhibitors of Fibrinolysis Inhibitors of fibrinolysis can be divided into two categories: Plasminogen plasmin inhibitors and plasminogen-activator inhibitor. Its molecular weight is 92,000 and plasma half-life is Plasmin is inhibited by serpins, a family of serine protease approximately two days. They form an irreversible complex with the containing 560 amino acids and a light chain of 231 amino active site serine of the target protease. This is the most important and rapidly the tissue plasminogen activator and urokinase. It is formed by endothelial cells, mac- tors also results in decreased fibrinolysis. Therefore, in liver Pregnancy is a hypofibrinolytic state: In pregnancy, overall fibrinolytic diseases, clotting time is prolonged. This leads to increased fibrin deposition, as suggested important role in preventing intravascular coagulation by increased D-dimer levels. The hemostatic and fibrinolytic imbalance is increased in preeclampsia and eclampsia. This hepatic clearance of activated clotting factors is accelerated when clotting is spontaneously activated. Role of platelets: In addition to its role in primary Regulation of Blood Coagulation hemostasis, platelets contribute to coagulation in vari- Blood coagulation at the site of injury is a life saving pro- ous ways. Following platelet activation, platelet phospholip- clot (fibrin-platelet plug) is formed, the process of clotting ids (platelet factor 3 and 4) released to their sur- must be terminated to avoid thrombotic occlusion in the face act as cofactors to accelerate the formation of adjacent normal areas of blood vessel. Thus, platelet plays an the balance between coagulation and anticoagulation important role in activation of factor X, which is a is due to play of various regulatory mechanisms, as listed crucial step in blood coagulation. As platelets adhesion and aggregation are localized occurs in vascular stasis, intravascular coagulation at the injured vessel wall, platelets help in restrict- is facilitated. Thus, continuous and dynamic flow of ing clotting reactions to the site of injury. Role of vascular endothelium: Vascular endothelium Anticoagulants prevent blood from clotting. They are plays an important role in restricting coagulation pro- mainly used: cess to the site of injury. For collection of blood sample for laboratory investiga- − Damage to vascular endothelium initiates the clot- tions ting mechanism by exposing its collagen and nega- 2. For anticoagulation therapy − Once adequate hemostasis is achieved, thrombo- modulin, a hormone secreted by endothelial cells Anticoagulants for Blood Collection of blood vessel prevents further blood coagulation by activating protein-C-protein S complex. However, as fluoride is not a strong anticoagu- determination of blood gases and pH, and plasma glu- lant, it is mixed with the oxalate. They form insoluble complexes with cal- monly used and most powerful anticoagulants. As calcium is an important cofactor for blood coag- Heparin is a natural constituent of blood. It is commonly used for osmotic fragility test, blood let fragments are large enough to be counted as nor- gas determination and pH assays. It is also commonly used in anticoagulation therapy and in preventing blood coagulation during animal Sodium Citrate experiments. For coagulation studies like determination of pro- Anticoagulants are used for treatment or prevention of thrombin time or partial thromboplastin time, 9 vol- thrombosis (intravascular clots). They are usually required umes of blood are added to 1 volume of sodium citrate for: solution (9 : 1). Placement of mechanical heart valves as heart valve venous blood are added to 1 volume of the sodium prosthesis is associated with risk of thromboembolism citrate solution (4 : 1). Prevention of thromboembolism in chronic nonrheu- matic atrial fibrillation Double Oxalate 4. Prophylaxis after attacks of cerebral ischemia As this anticoagulant contains ammonium and potassium 5. Peripheral vascular diseases causes shrinkage of red cells whereas ammonium oxa- 7. Hence, double oxalate is also Anticoagulants used in anticoagulation therapy are of called balanced oxalate. The oxalates form an insoluble complex with the cal- cium in the blood, and thereby prevent coagulation. They undergo post-translational γ-carboxylation of approximately 10 glutamic acid residues in the N-terminal Gla- domain (the domain where γ-carboxylation of clotting proteins takes place is called the Gla-domain). The γ-carboxylation of these cofactors is necessary to enable them to bind calcium and to localize enzymatic processes to a phospholipid surface like membrane of activated platelet. Factors 2, 7, 9 and 10 are Vitamin K- γ-carboxylation of about 3 to 10 glutamic acid residues, dependent clotting factors. Inhibitors of Thrombin Hirudin Many low-molecular weight selective inhibitors of throm- Hirudin is a polypeptide containing 65 amino acids. It is bin have been recently identified and are under clinical produced by the salivary glands of Hirudo medicinalis, a trials. It is a naturally occurring most specific inhibitor of Intravenous or Subcutaneous Anticoagulants thrombin. It has been tried in the treatment of acute coronary Heparin is a glycosaminoglycan consisting of chains of syndrome, patients undergoing coronary angioplasty alternating residues of D-glucosamine and iduronic acid. Laboratory investigations of bleeding disorders are carried out for patients who have a history of spontaneous bleed- Assessment of Defects in Definitive ing or excessive bleeding after injury or surgery. Bleeding Hemostatic Plug disorders are primarily due to the defects in formation of either in temporary hemostatic plug or in definitive 1. Prothrombin consumption test tion disorder, tests are performed to detect the deficiency 4. Partial thromboplastin time of clotting factor that has caused the disease and also to 5. Activated partial thromboplastin time assess whether the defect is in intrinsic or extrinsic sys- 6. Petechiae appear in the fore arm of the subject when the blood pressure cuff in the arm is from 5 to 12 minutes. More than 10 petechiae indicate capillary weakness, thrombin remaining in the serum after clot is formed. Increased serum prothrombin results from a quantitative Platelet Aggregation Test or qualitative platelet deficiency. Measurement of platelet aggrega- preparation of rabbit brain emulsion (which contains tis- tion is an essential part of the investigation of any patient sue thromboplastin) is added to plasma in the presence of with suspected platelet dysfunction in a modern laboratory. The percentage difference of the platelet count done which triggers the transformation of fibrinogen to prior to and after passage through the glass bead col- fibrin. The It assesses the clot stability and platelet functions (for platelet substitute in the form of partial thromboplastin detailsof clot retraction time, refer to previous chapter).

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The tie is then whether the operation should be considered a failure rests affixed to the fistula plug so that it will be pulled through the internal orifice out the external discount triamterene generic arrhythmia yahoo answers. Alex Ky Conclusions nonantigenic because it is degraded via a combination of the anal fistula plug was felt to be a reasonable alternative hydrolytic and enzymatic pathways quality triamterene 75mg blood pressure monitor reviews. Members of the Panel were copolymer indicate that the bioabsorption process should be asked to state what they felt to be a reasonable rate of success complete within 6 months [11] cheap 75 mg triamterene otc arteria lienalis. The device consists of a and concluded that 50–60 % should be considered accept- disk 16 mm in diameter, attached to six tubes, each 9 cm in able. The size of the plug can be tailored by changing the concluded that patient selection, avoidance of local infec- number and length of the tubes so that it occupies the fistula tion, and meticulous technique were required. Besides the tract until the bioabsorbable nature of the material allows consideration of cost it was felt that the patient would not be the body to fill the defect with native tissue [12]. In com- adversely affected by insertion of the fistula plug because all parison to the Surgisis plug, the disk was devised to decrease other management options were still available. The plug is depicted in nized, however, that even in patients with apparent healing Fig. Finally it was unanimously agreed that the procedure should be undertaken only by trained surgeons familiar with anorec- tal anatomy and experienced in conventional anal fistula sur- Preparation gery and in the management of its complications. Prepare the patient and surgical site using standard tech- niques appropriate for anal fistula repair. Gore Bio-A Plug Remove the device from its sterile packaging using aseptic technique. Using sharp sterile scissors, trim the disk diameter to a the Gore Bio-A is a synthetic plug as compared to Surgisis, size appropriate for the defect allowing for adequate fixa- which is a biologic plug. Care should be taken porous fibrous structure composed solely of a synthetic to avoid the creation of sharp edges or corners when trim- bioabsorbable polyglycolide–trimethylene carbonate copo- ming the disk. Individual tubes can be removed from the device to accom- the copolymer has been found to be both biocompatible and modate the diameter of the fistula tract. When removing 13 Synthetic Fistula Plug 93 tubes, begin with the center-most tubes, carefully cutting the tube as close to the disk as possible (proximally adja- cent) without compromising tube attachment. To facilitate introduction and deployment of the device in the fistula tract, it is recommended that a suture be used to gather the tubes and pull the device through the fistula tract. A bite depth of approximately 3 mm is recom- mended to ensure adequate suture retention strength. Note: the use of a resorbable suture is recommended to minimize the potential that any permanent material is implanted. However, to facilitate passage of the tubes through the fistula tract, briefly immerse the entire device in sterile saline. Device Placement Use standard techniques to define, clean, and prepare the fistula tract. Alex Ky Insert a fistula probe or other suitable instrument through the fistula tract, entering through the external (secondary) opening and exiting via the internal (primary) opening. Note: Take care to ensure that disk lies flat and is well apposed to the rectal mucosa at the internal (primary) open- ing of the fistula tract. After the device is properly positioned in the fistula tract, one of the following fixation methods should be used to secure the disk at the internal (primary) opening. Alex Ky Fixation Method I – Using a suitable resorbable suture, secure the disk of the contents into the fistula tract. In regard to technique, the button was secured flush with the anal mucosa and secured with two to three 2-0 Vicryl sutures. Of note, patients whose fistula plug was inserted after pretreat- fistula plug [14]. There were a total of 27 plug insertions over ment of the fistula with a draining (loose) seton appeared to a 28-month period in 16 patients. Successful closure (healing) was clinically defined as the the median age was 49 (range, 33–65) years. Patients with absence of any discharge or swelling, with the internal open- known hypersensitivity to materials in the plug, those who ing closed by the time the anoscopy was performed and all had more than three external openings or Crohn’s disease, external openings closed at the perineal examination at the and those who were under 18 years of age or were pregnant 13 Synthetic Fistula Plug 95 Table 13. Healing of the fistula was defined as complete the size of the external opening increased to allow for adequate drain- closure of the internal opening and the external wound and age. In describing the surgical technique, all arms of the plug were pulled tight and the were excluded form the study. The head was then covered with a the absence of any discharge or swelling, with the internal mucosa-submucosa-flap (Vicryl 2-0). Six months all external openings closed at the perineal examination at after surgery the fistula had healed in 20 patients (50. In regard to technique, the disk Three additional fistulas healed after 7, 9, and 12 months. Successful closure was varied significantly amongst the five surgeons with a range observed in only 3 out of 19 patients (15. In patients having only prior drainage of the results from this study were attributed to the learning curve abscess healing occurred in 63. In regard to surgical technique, the submucosal pocket was closed with 3-0 Vicryl Conclusion stitches. The disk was included in the suture to prevent plug migration and the protruding tubes were trimmed 2–3 mm the Gore Bio-A fistula plug is a new and evolving treatment beyond the surface of the perianal skin. All patients were evaluated by physical the data that has been published up to this point. Success was defined to the learning curve of the surgery, patient selection, and the as the absence of drainage, closure of the external opening, small number of patients. One technical aspect that needs to and the absence of perianal swelling or abscess formation. In regard to results, there was no early dislodgement, and It is not clear whether it is optimal to secure the disk on top closure occurred in 8 of 11 patients (72. Intuitively, it Ommer and colleagues recently published the initial seems that covering the disk with a mucosal flap would pro- results from Germany [16]. This plug has also not been extensively patients (30 male, 10 female, age 51±12 years) who studied in Crohn’s patients. There are only four patients in the underwent closure of a high transsphincteric (n= 28) or literature who have been treated with the Gore Bio-A plug. Efficacy of research will more clearly define the proper fixation method anal fistula plug in closure of cryptoglandular fistulas: long-term and surgical indications. Bioprosthetic plugs for complex anal fistulas: an early a new synthetic plug in the treatment of anal fistulas: results of a experience. Long-term results treatment of high anal fistulas—initial results from a German of fibrin glue treatment for cryptogenic perianal fistulas: a multi- multicenter-study. Jensen Introduction Technique Treatment of anal fistula can be a delicate balance between the patient needs no special preparation, although some maximizing the chances of successful healing and avoiding surgeons may prefer enemas to clear the rectum of stool. The patient is placed under either procedures have been used in the treatment of anal fistula, regional or general anesthesia and positioned in the prone with varying success. The buttocks are spread and taped to useful tool in the armamentarium of the surgeon faced with provide exposure.