Anna Crocco

Severe acute pancreatitis: advances and insights in assessment of severity and management.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity

AIM To study the effect of botulinum toxin in patients with chronic anal fissure after biliopancreatic diversion (BPD) for severe obesity. METHODS Fifty-nine symptomatic adults with chronic anal fissure developed after BPD were enrolled in an open label study. The outcome was evaluated clinically and by comparing the pressure of the anal sphincters before and after treatment. All data were analyzed in univariate and multivariate analysis. RESULTS Two months after treatment, 65.4% of the patients had a healing scar. Only one patient had mild incontinence to flatus that lasted 3 wk after treatment, but this disappeared spontaneously. In the multivariate analysis of the data, two registered months after the treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate. CONCLUSION Botulinum toxin, despite worse results than in non-obese individuals, appears the best alternative to surgery for this group of patients with a high risk of incontinence.

Extended or limited lymph node dissection? A gastric cancer surgical dilemma

W e read with great interest the article by Memon and coworkers1 reporting the outcome of a meta-analysis of randomized controlled trial evaluating the efficacy and drawbacks of limited (D1) versus extended (D2) lymphadenectomy for proven gastric carcinoma. This is a very excellent article; the basic organization of this report is clear and convincing, and the associated conclusions and recommendations are based on a review by investigators with long-standing interest in gastric disorders.2–4 Worldwide, gastric cancer is one of the top-3 leading causes of cancer mortality, but their incidence and presentation vary geographically. Currently, surgery is the only possible cure. Nodal status is an important prognostic indicator for gastric cancer, and despite results of randomized controlled trials, debate continues over the importance of aggressive lymphadenectomy. On the basis of the results of the meta-analysis, the authors conclude that D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complication rate, and reoperation rate, decreased length of hospital stay, and 30-day mortality rate. Finally, the 5-year survival in patients who underwent D1 gastrectomy was similar to the D2 cohort.1 Similar results have been founded in recent meta-analysis.5 Overall, 14 randomized controlled trials (3432 patients) were included in the meta-analysis. Of the D1 and D2 surgery groups, the operative mortality and postoperative morbidity were higher in the D2 group than in the D1 group, but the 3and 5-year survival rates were not statistically different. Also, the operative time was shorter in the D1 group than in the D2 group. In the D2 versus D3 surgical group, the operative mortality, percentage of postoperative complications, operative time, and hospital stay were not significantly different. The results suggest that D2 and D3 surgical

Anastomotic leak and local recurrence in colorectal cancer

W e read with interest the systematic review and meta-analysis by Mirnezami et al.1 The aim of the study is to investigate the long-term oncological influence of anastomotic leak (AL) after restorative surgery for colorectal cancer (CRC) using meta-analysis methods. Principal outcomes evaluated were local recurrence, distant recurrence, and longterm survival. We agree with the authors that the study is subject to a number of limitations. Adjuvant therapy may have a confusing effect on the results of the paper, and also fewer patients with advanced CRC who develop an AL receive adjuvant therapy, when compared with stage-matched groups of patients without an AL.2 It seems conceivable that failure to receive adjuvant treatment, or delays to the start of therapy due to development of an AL, may facilitate recurrence of CRC. Therefore, we agree with the authors that caution must also be exerted in overinterpretation of the reported findings; a statistical association between AL and increased local recurrence and reduced cancer specific survival does not imply a causative association. The impact of AL on the immediate postoperative morbidity and mortality is well known.3–5 However, it is controversial whether the AL itself is a prognostic factor for local recurrence and/or survival of patients with CRC. Although some investigators report that AL is an independent prognostic factor associated with local recurrence or survival, others do not support this point of view.5 One problem with this type of analysis is that usually the proportion of patients with AL is so small that it is difficult to identify it as a factor in long-term survival.3 Meta-analysis uses statistical methods to obtain a quantitative estimate of the effect of a particular intervention from the effects reported in many studies. Compared with traditional reviews and expert opinion, meta-analysis provides a more objective and quantitative summary of the evidence that is

Treating Benign Prostatic Hyperplasia with Botulinum Neurotoxin

Botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several disorders; the use of this agent has extended to a plethora of conditions including focal dystonia, spasticity, inappropriate contraction in most gastrointestinal sphincters, eye movement disorders, hyperhidrosis, genitourinary disorders and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of pain, and for the management of tension or migraine headaches and myofascial pain syndrome. Benign prostatic hyperplasia (BPH) is a common condition in ageing men; the goal of therapy is to reduce the lower urinary tract symptoms (LUTS) associated with BPH and to improve the quality of life. However, medical treatment, including drugs that relax smooth muscle within the prostate and drugs that shrink the gland are not totally effective or without complications. The standard surgical treatment for BPH is progressively changing to minimally invasive therapies, but none of them has provided clear results. The use of BoNT-A to inhibit the autonomic efferent effects on prostate growth and contraction, and inhibit the abnormal afferent effects on prostate sensation, might be an alternative treatment for BPH. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease; systemic pharmacologic effects are rare, permanent destruction of tissue does not occur, and graded degrees of relaxation may be achieved by varying the dose injected. In this paper, clinical experience over the last years with BoNT in BPH impaired patients will be illustrated.

Classification of the severity of acute pancreatitis: how much is really needed for a new classification?

To the Editor: W e read with great interest the article by Dellinger and coworkers,1 reporting a new international classification of acute pancreatitis (AP) severity, and the editorial by Bradley.2 These are very excellent articles, and the associated conclusions and recommendations are based on a review by investigators with long-standing interest in AP diagnosis and treatment.3 A global Webbased survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. Furthermore, the authors state that, in an attempt to buttress justification for areas of the proposal lacking sufficient clinical evidence, expert opinion was solicited. According to Bradley,2 we believe that the definition of an expert coworker seems rather lenient in that the inclusion criterion was the publication of a single article on AP in the most recent period. Because of the extreme diversity of potential clinical courses in patients with AP, and because of the wide range of organs and tissues that may become involved, few other diseases require the degree of flexibility in management as that required from those clinicians who undertake the care of patients with AP. We believe that there are important reasons to define and stratify the severity of AP.4 First, on admission, it is important to identify patients with potentially severe AP who require aggressive treatment.5,6 Second, in a secondary care setting, clinicians need to identify such patients for possible transfer to specialist care. Third, for specialists who receive such referrals, there are advantages to stratifying these patients into subgroups based on the presence of persistent organ failure (OF) and local and/or systemic complications.

Type A botulinum toxin treatment for chronic anal fissure

Dear Editor: We read with great interest the systematic review on efficacy and safety of botulinum toxin treatment in patients with anal fissure by E. Yiannakopoulou. The manuscript is well written, complete and exhaustive. The review of the literature data is careful and rigorous. This systematic review aimed to answer several primary questions. The intention to give an answer to all these questions makes the paper even more interesting. We agree with the author that botulinum toxin consists of an alternative effective therapeutic modality for the treatment of anal fissure. Although probably not more effective than the gold standard lateral internal sphincterotomy, this therapeutic option is minimally invasive, and if it is not successful, repeated botulinum toxin injections can be applied or surgical treatment can be performed. The drawback of lateral internal sphincterotomy is the high frequency of anal incontinence. The main scope of the research efforts focused on less invasive techniques should be the establishment of a technique with minimal frequency of anal incontinence. In recent years, there has been recognition of incontinence after anorectal surgery. Lateral internal sphincterotomy has been considered the most effective treatment for anal fissure, although up to 10% of patients have a recurrence. Furthermore, as many as two thirds may experience incontinence. Any disturbed continence following lateral internal sphincterotomy is of concern. A number of factors affect outcome and morbidity after lateral internal sphincterotomy, including previous anorectal surgery, additional procedures, surgical technique, length of sphincterotomy and obstetric history. The poorly defined risk of incontinence following surgical sphincterotomy has sparked interest in pharmacological sphincterotomy approaches to produce reversible reduction of sphincter pressure and to obtain fissure healing, minimizing the risk of incontinence. A recent study was designed to assess the efficacy of botulinum toxin in healing recurrent anal fissure following lateral internal sphincterotomy. Thus, 80 patients were included in the study, all of whom reported a history of previous lateral internal sphincterotomy for chronic anal fissure and complained of severe postdefaecatory pain. Injections of botulinum toxin were performed easily in all patients. One month after the treatment, eight patients (10%) had mild incontinence of flatus that lasted for a few weeks and then resolved spontaneously. At 2 months, 59 patients (74%) had a healing scar, and no patient complained of incontinence to flatus. At the 1-month follow-up, both resting anal pressure (P<0.001) and maximum voluntary squeeze pressure (P00.01) were significantly lower than baseline values. At 2 months, maximum voluntary squeeze pressure did not differ significantly from baseline (P0 0.058), whereas resting anal pressure was significantly lower than the pretreatment value (P<0.001). In the study, injection of botulinum toxin was used not only as a therapeutic tool but also as a diagnostic test to identify patients who would not be suitable for further surgical sphincterotomy if they developed temporary incontinence after toxin injection. Furthermore, we agree with the author that future research efforts should focus on comparison of lateral internal G. Brisinda : S. Vanella :A. Crocco :G. Maria Department of Surgery, Catholic University Hospital Agostino Gemelli, Rome, Italy