Colorectal Dis. 2019 Aug 27. doi: 10.1111/codi.14832. [Epub ahead of print]
Binda GA1, Amato A2, Alberton G1, Bruzzone M3, Secondo P2, Lòpez-Borao J4,5, Giudicissi R6, Falato A7, Fucini C6, Bianco F7, Biondo S4,5.
AIM: The optimal surgical treatment of splenic flexure neoplasm is still not well defined. Extended right hemicolectomy (ERH) and left colic resection (LCR) have been proposed but conclusive evidence concerning postoperative morbidity and oncological results is lacking. The aim of this study was to analyse the short-term outcomes after surgery for splenic flexure cancer with regard to surgical procedure and surgeon’s specialty. METHODS: This was a multicentre study on patients who underwent surgery for primary colon cancer of the splenic flexure. RESULTS: From 2004 to 2015, 324 patients fulfilled the criteria for inclusion into the study; 270 (83.4%) had elective surgery while 54 (16.6%) had emergency resection: 158 (48.8%) underwent ERH and 166 (51.2%) LCR; 176 (54.3%) procedures were performed by colorectal surgeons, 148 (46.7%) by general surgeons. In the ERH group a significantly higher rate of emergency operations was carried out (P = 0.005). After elective surgery, no significant differences between ERH and LCR concerning 30-day mortality (3.3% vs 2.0%) and the need for reoperation (10.6% vs 7.4%) were found. Nodal harvesting was significantly higher in the ERH and colorectal surgeon groups in any clinical scenario. At multivariate analysis, age and smoking habit were predictive of the need for reoperation and major morbidity while the general surgeon group showed a higher risk of anastomotic failure (OR = 1.92; P = 0.168). CONCLUSION: We analysed the largest series in literature of curative resections for splenic flexure tumours. The optimal procedure still remains debatable as ERH and LCR appear to achieve comparable short-term outcomes. Surgeon’s specialty seems to positively affect patient’s outcomes.
Quaderno vaccino HPV
Pubblicato il Quaderno Vaccino HPV del Rotary Club Sanremo Hanbury cui la SICCR ha dato il patrocinio e che ha tra gli autori il Dott. Antonio Amato.
Dall’introduzione “Il Quaderno Vaccino HPV vuole essere un mezzo di comunicazione semplice, basata sulla ricerca. Non è un fumetto, non è una rivista scientifica, ma una modalità di comunicazione chiara, ricca di immagini, basata sull’evidenza scientifica e sull’esperienza clinica di chi quotidianamente affronta le patologie HPV-correlate.
L’importanza di un’adeguata informazione è basilare per la responsabilizzazione dei cittadini sulle attività di prevenzione e, in particolare, sulla vaccinazione, uno degli interventi preventivi più efficaci e sicuri, che non comporta soltanto benefici diretti alla persona sottoposta a vaccinazione, ma ha risvolti positivi anche sul resto della comunità. Le immagini digitali ed il web hanno accelerato una diffusione standardizzata (e spesso sbagliata) tanto da far credere che il futuro possa essere già qui con noi senza bisogno che ci si muova da casa propria. Sono sempre più numerose le persone che credono di poter sostituire la figura medica con i consigli del web. In tutto ciò, l’arte aiuta a ritrovare la dimensione dell’osservazione riportandoci alla responsabilità di interrogarci sulla verità e sulla menzogna, sull’immagine della realtà proposta e sull’immagine della realtà reale. La nuova necessità è quella di comprendere la vera natura delle cose scindendole da facili e falsi messaggi, permettendoci di affrontare nel migliore dei modi le sfide organizzative ed economiche a tutela della salute del singolo e della collettività. Il quaderno vaccino anti HPV è un punto di partenza che necessita un continuo aggiornamento, data la dinamica del mondo della ricerca e della comunicazione. Le notizie scientifiche devono essere ben comprese da tutti per trasmettere un corretto messaggio basato sull’esperienza clinica e sulle pubblicazioni scientifiche, frutto del lavoro di professionisti che hanno studiato anni per affrontare le patologie in questione. La struttura del quaderno ripercorre le relazioni che come Rotary club abbiamo fatto e ci accingiamo a fare con gli altri club, con le scuole e con i cittadini. In ogni pagina è riportato il titolo dell’argomento, una finestra blu con un messaggio semplice e comprensibile anche per persone che non lavorano in ambito sanitario, e la relativa diapositiva; a seguire, alcune righe di commento più specifiche per chi volesse approfondire l’argomento. La bibliografia finale, pur non essendo un lavoro scientifico, è a testimoniare tutti i lavori che sono stati presi in considerazione per scrivere questo quaderno che, ribadiamo, ha lo scopo di comunicare in maniera semplice sulla vaccinazione anti HPV, partendo dall’ evidenza scientifica”
Quaderno vaccino HPV *
*la pubblicazione non può essere riprodotta poiché è protetta da copyrigth
Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study).
Binda GA, Bonino MA, Siri G, Di Saverio S, Rossi G, Nascimbeni R, Sorrentino M, Arezzo A, Vettoretto N, Cirocchi R; LLO Study Group.
Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment. METHODS: This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015. RESULTS: A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis. CONCLUSION: Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.
Br J Surg. 2018 Dec;105(13):1835-1843. doi: 10.1002/bjs.10916. Epub 2018 Jul 14.
© 2018 BJS Society Ltd Published by John Wiley & Sons Ltd.
Colorectal Disease Special Issue Colorectal Polyps Recent Advances from Genetics to Management 2nd Genoa Meeting 14 April 2014
We are pleased to present this supplement which contains the proceedings of the Second Genoa Conference on Colorectal Polyps which took place in April 2014, the first of which was held in 2004 in the same beautiful city of Genoa. It reflects the current knowledge acquired during the subsequent ten years of the classification, genetic status and management of this common clinicopathological condition. It contains sections on epidemiology, genetics, histopathological classification, advances in imaging, prevention and treatment all of which have changed tremendously since 2004. The programme includes 24 presentations divided into five sessions. The faculty consists of recognised experts in the field. Each presentation is followed by debate and discussion under the guidance of chairpersons supported by a strong contribution from the floor.
The supplement contains ten chapters which for reasons of space include the 24 contributions assembled in logical sequence. The meeting has been recorded and is available as a video at www.colorectalpolyps.net.
Comparison between magnetic resonance imaging and rigid rectoscopy in the preoperative identification of intra and extraperitoneal rectal cancer
Paparo F, Puppo C, Montale A, Bacigalupo L, Pascariello A, Clavarezza M, Binda C, Rollandi GA, Binda GA.
AIM: Accurate preoperative discrimination between extra- and intraperitoneal rectal cancer has important treatment implications. Our main object was to compare the diagnostic performance of magnetic resonance imaging (MRI) with rigid rectoscopy (RRS) in assessing the location of rectal cancers above or below the peritoneal reflection (PR), using the findings during abdominal surgery for treatment of the cancer as the reference standard. We also compared the accuracy of MRI and RRS in assessing the level of the lower border of the tumour form the anal verge.
METHOD: Patients with rectal carcinoma awaiting surgery underwent MRI and RRS. The MRI images were reviewed by two abdominal radiologists who determined the location of the inferior border of the tumour in relation to the peritoneal reflection. ROC curve analysis was performed to determine the diagnostic performance of RRS at different cut-off values.
RESULTS: The sensitivity and specificity of MRI were 98.15% and 100% and 100% and 76.92% for RRS at a cut-off value <10 cm. The mean level of the lower border of the tumour from the anal verge on RRS and MRI was 68±44.3 mm and 73.5±42.4 mm (p=0.25), with a trend towards overestimation with MRI.
CONCLUSION: Rigid rectoscopy is still the main means of assessing the level of a rectal tumour from the anal verge, but MRI has value in determining the level of the tumour in relation to the peritoneal reflection, which cannot be seen on endoscopy.
Italian consensus conference for colonic diverticulosis and diverticular disease
R. Cuomo, G. Barbara, F. Pace, V. Annese, G. Bassotti, G. A . Binda, T. Casetti, A. Colecchia, D. Festi, R. Fiocca, A. Laghi, G. Maconi, R. Nascimbeni, C. Scarpignato, V. Villanacci, and B. Annibale
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
Clinical and molecular features of attenuated adenomatous polyposis in northern Italy
de Leon MP, Urso ED, Pucciarelli S, Agostini M, Nitti D, Roncucci L, Benatti P, Pedroni M, Kaleci S, Balsamo A, Laudi C, Di Gregorio C, Viel A, Rossi G, Venesio T.
Dipartimento di Medicina Interna, Università di Modena e Reggio Emilia, Modena, Italy.
BACKGROUND: Attenuated familial adenomatous polyposis (AFAP) is characterized by the presence of 10-99 colorectal adenomas. The disease may be associated with mutations in either APC or MUTYH genes. We purposed to evaluate the contribution of adenomatous polyposis coli (APC) and MutY homologue (MUTYH) germline alterations to the AFAP phenotype and to identify genotype/phenotype correlations.
METHOD: During counselling for familial adenomatous polyposis (FAP), 91 probands (and 107 affected individuals) who met the criteria of AFAP were identified. Eighty-two families were screened for constitutional mutations of the APC and MUTYH genes.
RESULTS: MUTYH mutations were detected in 21 families (25.6 % of the 82 tested), and APC mutations in 7 (8.5 %). Overall, constitutional alterations were found in 34.1 % of the probands. Patients with APC mutations were younger at cancer onset and had a higher mean number of polyps (48.5 ± 33.0 in APC+ individuals vs. 35.7 ± 24.9 in MUTYH+ individuals, and 33.2 ± 18.4 in the “no mutation” group). Clinical features rendered the “no mutation” group closer to MUTYH+ than to the APC+ group. Colorectal cancer at diagnosis was detected in 40 % of AFAP individuals.
CONCLUSION: AFAP is a new clinical entity with its frequency in the general population still undefined. The number of adenomas varies greatly, with an average of 30-40 lesions. The molecular basis of AFAP can be established in approximately 1/3 of the patients. Both MUTYH and APC genes are implicated in AFAP, though the role of MUTYH is of considerably greater relevance.
Telomerase is an independent prognostic marker of overall survival in patients with colorectal cancer
Bertorelle R, Briarava M, Rampazzo E, Biasini L, Agostini M, Maretto I, Lonardi S, Friso ML, Mescoli C, Zagonel V, Nitti D, De Rossi A, Pucciarelli S.
Immunology and Molecular Oncology Unit, Istituto Oncologico Veneto, IRCCS, Via Gattamelata 64, 35128 Padova, Italy
BACKGROUND: Colorectal cancer (CRC) is an important cause of cancer-related death. Prediction of recurrence is an important issue in the treatment of disease, particularly for stage II patients. The level of telomere-specific reverse transcriptase (hTERT), the catalytic component of the telomerase complex, increases along with CRC progression, but its prognostic value is still unclear.
METHOD: One hundred and thirty-seven CRC patients were studied for hTERT expression in tumour cells by real-time PCR. hTERT level was evaluated as a prognostic factor of overall survival (OS) in all patients and of disease recurrence in a subgroup of 50 stage II patients.
RESULTS: The median hTERT level was 93.8 copies (interquartile range 48-254). Patients with high hTERT levels (above the median) showed a significantly worse survival than those with low hTERT levels (below the median; log-rank test P<0.0001; hazard ratio (HR)=3.30 (95% confidence interval (CI) 1.98-5.52); P<0.0001). The negative prognostic value of high hTERT level is independent of the pathological stage and microsatellite instability (HR=2.09 (95% CI 1.20-3.64), P=0.009). Moreover, in stage II CRC, high hTERT levels identified patients with a higher risk of disease recurrence (HR=3.06 (95% CI 1.03-9.04), P=0.043) and death (HR=3.24 (95% CI 1.37-7.71), P=0.008).
CONCLUSION: hTERT level is an independent prognostic marker of OS in CRC patients. In addition, assessment of hTERT level could improve stratification of stage II CRC patients for the risk of disease recurrence.
Neoadjuvant FOLFIRI+bevacizumab in patients with resectable liver metastases from colorectal cancer: a phase 2 trial
Nasti G, Piccirillo MC, Izzo F, Ottaiano A, Albino V, Delrio P, Romano C, Giordano P, Lastoria S, Caracò C, de Lutio di Castelguidone E, Palaia R, Daniele G, Aloj L, Romano G, Iaffaioli RV..
Medical Oncology, Abdominal Department, National Cancer Institute G. Pascale Foundation, Via Mariano Semmola, 80131 Napoli, Italy.
BACKGROUND: Preoperative treatment of resectable liver metastases from colorectal cancer (CRC) is a matter of debate. The aim of this study was to assess the feasibility and activity of bevacizumab plus FOLFIRI in this setting.
METHOD: Patients aged 18-75 years, PS 0-1, with resectable liver-confined metastases from CRC were eligible. They received bevacizumab 5 mg kg(-1) followed by irinotecan 180 mg m(-)(2), leucovorin 200 mg m(-)(2), 5-fluorouracil 400 mg m(-)(2) bolus and 5-fluorouracil 2400 mg m(-)(2) 46-h infusion, biweekly, for 7 cycles. Bevacizumab was stopped at cycle 6. A single-stage, single-arm phase 2 study design was applied with 1-year progression-free rate as the primary end point, and 39 patients required.
RESULTS: From October 2007 to December 2009, 39 patients were enrolled in a single institution. Objective response rate was 66.7% (95% exact CI: 49.8-80.9). Of these, 37 patients (94.9%) underwent surgery, with a R0 rate of 84.6%. Five patients had a pathological complete remission (14%). Out of 37 patients, 16 (43.2%) had at least one surgical complication (most frequently biloma). At 1 year of follow-up, 24 patients were alive and free from disease progression (61.6%, 95% CI: 44.6-76.6). Median PFS and OS were 14 (95% CI: 11-24) and 38 (95% CI: 28-NA) months, respectively.
CONCLUSION: Preoperative treatment of patients with resectable liver metastases from CRC with bevacizumab plus FOLFIRI is feasible, but further studies are needed to define its clinical relevance.
Laparoscopic low ventral rectocolpopexy (LLVR) for rectal and rectogenital prolapse: surgical technique and functional results
Lauretta A, Bellomo RE, Galanti F, Tonizzo CA, Infantino A.
Department of Surgery, Santa Maria dei Battuti Hospital, Via Savorgnano, 2, 33079, San Vito al Tagliamento, PN, Italy.
BACKGROUND: Laparoscopic ventral rectopexy limits the risk of autonomic nerve damage, and the colpopexy allows correction of a concomitant prolapse of the middle compartment. The aim of this study is to describe a modified laparoscopic ventral rectocolpopexy procedure with a low approach to the sacral hollow (laparoscopic low ventral rectocolpopexy: LLVR). We propose this technique to manage combined rectogenital prolapse.
METHOD: Between November 2006 and June 2009, all patients with symptomatic rectal prolapse associated with genital prolapse and/or enterocele underwent LLVR. Demographics, results of imaging studies, mortality, morbidity, and functional outcome were retrospectively analyzed.
RESULTS: Thirty patients underwent LLVR: two patients suffered from a full-thickness rectal prolapse while 28 had symptomatic recto-anal intussusception. The mean operating time was 94 ± 39 minutes. Conversion to laparotomy was never needed. Hospital stay ranged between 2 and 14 days (mean of 5 ± 2.5 days). No mortality was recorded and only two complications occurred (6.6%): one trocar site incisional hernia and one vaginal suture erosion in a patient who had concomitant hysterectomy. After a mean follow-up of 13.9 months, constipation was completely resolved or improved in 92.8% patients. Significant reduction in the mean Altomare obstructed defecation score (14.7-5.6; p < 0.05) was recorded. Preoperative incontinence improved after the procedure in all patients affected. No new cases of postoperative constipation or fecal incontinence were registered. Only one case of recurrence in a patient with recto-anal intussusception was recorded (3.4%), after 19 months.
CONCLUSION: Laparoscopic low ventral rectocolpopexy is safe and associated with very low morbidity. In the medium term, it provides good result for prolapse and associated symptoms.
Emerging technologies in coloproctology: results of the Italian Society of Colorectal Surgery Logbook of Adverse Events
Basso L, Pescatori M, La Torre F, Destefano I, Pulvirenti D’Urso A, Infantino A, Amato A; AECO Group. Italian Society of Colorectal Surgery or Società Italiana di Chirurgia Colorettale), Rome, Italy
Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy.
BACKGROUND: The aim of this paper is to present the results of the Italian Society of Colorectal Surgery [or Società Italiana di Chirurgia Colorettale (SICCR)] Logbook of adverse events (AE) occurring in relation to emerging technologies in coloproctology (ETCs), over a 3-year period.
METHOD: A total of 245 AE were reported (patients age: mean = 49.6 years, range = 20-75 years; gender: 155 = F, 90 = M). The “observations” originated from the same institution of the AEs in 44 cases (18.0%), while 201 patients (82.0%) had been operated on somewhere else.
RESULTS: The three most reported ETCs were: Procedure for prolapsed haemorrhoids (PPH) (n = 120-48.9%), stapled transanal rectal resection (STARR (n = 96-39.2%), and transanal haemorrhoidal dearterialization (THD) (n = 11-4.5%). PPH, STARR, and THD together accounted for n = 227 (92.6%) observations. For the three main reported ETCs, the various AEs are listed. Chronic pain after PPH was 46/120 (38.3%), and after STARR of 21/96 (21.9%). The overall re-operation rate was n = 135 (55.1%) versus n = 110 (44.9%) no reoperation. In particular, for the three main reported ETCs, n = 68/120 (56.7%) following an AE after PPH, n = 47/94 (50.0%) following an AE after STARR, and n = 6/11 (54.5) following an AE post-THD. The various types of treatment to solve AE after each of the three most observed ETCs are reported in the text.
CONCLUSION: Our results do not allow us to draw statistical conclusions; however, this was not the aim of our survey. ETCs are important, yet they are not without major risks. Manufacturers should help colorectal surgeons to convey the right message to patients.
Transrectal sentinel lymph node biopsy for early rectal cancer during transanal endoscopic microsurgery
Arezzo A, Arolfo S, Mistrangelo M, Mussa B, Cassoni P, Morino M.
Department of Surgical Sciences, University of Torino , Torino , Italy.
Abstract Background: Local excision of invasive cancer by transanal endoscopic microsurgery (TEM) entails the risk of lymphnode metastases that obliges to radical surgery. A determination of metastatic lymph-nodes would avoid major surgery in the vast majority of cases. We applied the concept of sentinel lymphnode (SLN) biopsy to suspected invasive rectal cancers treated by TEM. Methods: Indocyanine green (ICG) is injected in the submucosa underneath the lesion. The tumor is dissected full-thickness until the perirectal fat. A near infra-red (NIR) optic provides a map of mesorectal lymphatics, on which guide the perirectal fat is dissected and lymph-nodes are excised. Results:The technique was tested in three patients. In all cases the pathologist confirmed presence of lymphnodes in the excised tissue, no case showed metastasis. In all cases final pathology of the rectal neoplasm did not indicate radical surgery. Conclusion: In suspected invasive cancers, SLN mapping could be a useful technique to identify the first lymph node receiving drainage from the tumour, whose accurate pathological examination could predict the status of the remaining nodes and indicate further radical surgery. An ongoing study on a prospective case series will assess sensitivity and negative predictive value of SLN biopsy.
Collagen matrix injection combined with flap repair for complex anal fistula
Sileri P, Boehm G, Franceschilli L, Giorgi F, Perrone F, Stolfi C, Monteleone G, Gaspari AL.
Department of Surgery, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy.
Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non-cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two-staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two-stage approach seems to be safe and effective.
Exhaled volatile organic compounds identify patients with colorectal cancer
Altomare DF, Di Lena M, Porcelli F, Trizio L, Travaglio E, Tutino M, Dragonieri S, Memeo V, de Gennaro G.
Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy.
BACKGROUND: An effective screening tool for colorectal cancer is still lacking. Analysis of the volatile organic compounds (VOCs) linked to cancer is a new frontier in cancer screening, as tumour growth involves several metabolic changes leading to the production of specific compounds that can be detected in exhaled breath. This study investigated whether patients with colorectal cancer have a specific VOC pattern compared with the healthy population.
METHOD: Exhaled breath was collected in an inert bag (Tedlar(®) ) from patients with colorectal cancer and healthy controls (negative at colonoscopy), and processed offline by thermal-desorber gas chromatography-mass spectrometry to evaluate the VOC profile. During the trial phase VOCs of interest were identified and selected, and VOC patterns able to discriminate patients from controls were set up; in the validation phase their discriminant performance was tested on blinded samples. A probabilistic neural network (PNN) validated by the leave-one-out method was used to identify the pattern of VOCs that better discriminated between the two groups.
RESULTS: Some 37 patients and 41 controls were included in the trial phase. Application of a PNN to a pattern of 15 compounds showed a discriminant performance with a sensitivity of 86 per cent, a specificity of 83 per cent and an accuracy of 85 per cent (area under the receiver operating characteristic (ROC) curve 0•852). The accuracy of PNN analysis was confirmed in the validation phase on a further 25 subjects; the model correctly assigned 19 patients, giving an overall accuracy of 76 per cent.
CONCLUSION: The pattern of VOCs in patients with colorectal cancer was different from that in healthy controls. The PNN in this study was able to discriminate patients with colorectal cancer with an accuracy of over 75 per cent. Breath VOC analysis appears to have potential clinical application in colorectal cancer screening, although further studies are required to confirm its reliability in heterogeneous clinical settings.
Strangulated ileal trans-coloanal-anastomotic hernia: a complication of Altemeier's procedure previously never reported
Di Lena M, Angarano E, Giannini I, Guglielmi A, Altomare DF.
Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy.
A postoperative complication after Altemeier operation, so far never reported, is described in a 42 years old mentally disabled patient with external full thickness rectal prolapse who usually had prolonged straining at defecation. After 6 d from perineal rectosigmoidectomy, the patient, was discharged free of complications. Four days later he was readmitted in emergency for strangulated perineal trans-anastomotic ileal hernia that occurred at home during efforts to defecate. The clinical feature required an emergency operation for repositioning the ileal loops into the abdomen, resection of the necrotic ileum, and end colostomy. The outcome of the second operation was free of complication and the patient was discharged on the 6(th) postoperative day. In conclusion, after Altemeier operation prolonged straining at defecation should be carefully avoided.
Conservative and surgical treatment of haemorrhoids
Altomare DF, Giuratrabocchetta S.
Department of Emergency and Organ Transplantation, Policlinico Universitario Bari, Piazza G. Cesare, 11-70124 Bari, Italy
The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients’ postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.
A novel biomarker-based analysis reliably predicts nodal metastases in anal carcinoma: preliminary evidence of therapeutic impact
Mistrangelo M, Senetta R, Racca P, Castellano I, Chiusa L, Bellò M, Ricardi U, Morino M, Cassoni P
Digestive and Colorectal Surgery, Centre of Minimal Invasive Surgery, University of Turin, Molinette Hospital, Italy
AIM: Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers METHOD: Clinicohistopathological data from fifty pretreatment anal carcinomas biopsies were collected. Immunohistochemical analysis with antibodies against Ki67, p53, Epidermal Growth Factor Receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinical-pathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients RESULTS: All patients had undergone synchronous radio-chemotherapy; Tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumor expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) of patients presenting with a YKL-40/EGFR negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease free survival. Tumour grade significantly correlated with DFS only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome CONCLUSION: YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy. This article is protected by copyright. All rights reserved.
Faecal soiling: pathophysiology of post-defaecatory incontinence
Department of Surgery and Translational Medicine, University of Florence, Italy
AIM: Passive post-defecatory incontinence is poorly understood and yet is an important clinical problem. The aim of this study was to characterize the pathophysiology of post-defecatory incontinence in patients affected by faecal soiling.
METHOD: Seventy-two patients [30 women; age range, 49-79 years; 42 men; age range, 53-75 years] affected by faecal passive incontinence with faecal soiling were included in the study. Two patient groups were identified: Group 1 comprised 42 patients with post-defecatory incontinence and Group 2 had 30 patients without incontinence after bowel movements. After a preliminary clinical evaluation, including the Faecal Incontinence Severity Index (FISI) score and the Obstructed Defecation Syndrome (ODS) score, all patients of Groups 1 and 2 were studied by means of endoanal ultrasound (EU) and anorectal manometry (AM). The results were compared with those from 20 healthy control subjects.
RESULTS: A significantly higher ODS score was found in Group 1 (P < 0.001). EU revealed a significantly diffuse thinning of the internal anal sphincter (IAS) in Group 2 (P < 0.02) with a linear relationship between signs of internal anal sphincter (IAS) atrophy and the FISI score (ps : 0.78; p< 0.03). Anal resting pressure (Pmax and Pm ) was significantly lower in Group 2 (p < 0.04). The straining test was considered positive in 30 (71.4%) patients in Group 1 significantly greater compared with Group 2 (p < 0.01). A significantly higher conscious rectal sensitivity threshold (CRST) was found in Group 1 patients (p < 0.01).
CONCLUSION: The ODS score, a positive straining test, and high CRST values suggest that post-defaecatory incontinence is secondary to impaired daefecation. This article is protected by copyright. All rights reserved.