Claudio Fucini

Follow-up of colorectal cancer resected for cure

Sixty-four consecutive patients who had undergone curative resection for colorectal carcinoma were studied prospectively to evaluate the roles of sequential CEA determinations and independent instrumental follow-up in the early detection of resectable recurrences. Fifty-two of these patients also were submitted to sequential determinations of other tumor antigens: TPA (tissue polypeptide antigen) and Ca 19-9 (colon cancer antigen detected with a monoclonal antibody), for a retrospective evaluation of their utility as markers of recurrent tumors. Twenty-two recurrences were detected in a period ranging from 12 to 72 months (median, 47 months). CEA was the best predictor of recurrence (sensitivity, 90 percent) when compared with the other two markers (TPA sensitivity, 60 percent; Ca 19-9 sensitivity, 20 percent). When compared with the instrumental or biochemical examinations of the follow-up. CEA was still the most sensitive indicator of relapse although the specificity was quite low (78 percent) if minimal significative increases were considered. History and physical examination were more useful than CEA in detecting local recurrences in rectal cancer where the preoperative CEA level was low. A few second-look explorations based solely on small CEA increases failed to demonstrate recurrence or revealed peritoneal carcinomatosis. Selected second-look surgery based on demonstrated recurrences resulted in a resectability rate of 57 percent. A follow-up program based on frequent CEA assays, history, and physical examinations, including rectal, vaginal, and perineal exploration, is proposed. Extensive instrumental investigations should follow when a minimal significative CEA rise is observed, or when history and physical examinations suggest a possible recurrence. Second look surgery should be evaluated after confirmed or highly suspected diagnosis of recurrence, on the basis of instrumental or clinical examinations.

Electromyography of the pelvic floor musculature in the assessment of obstructed defectation symptoms

PURPOSE: The purpose of this study was to use electromyography to examine the behavior of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation in patients with symptoms of obstructed defecation and in normal subjects to highlight differences of clinical significance. METHODS: A total of 35 patients (31 females) aged 20 to 80 (mean, 53.7±13.3) years with unprepared bowel who had normal colon transit time and obstructed defecation symptoms and 12 voluntary control subjects (7 females) aged 23 to 68 (mean, 48±11.5) years underwent an electromyography evaluation of the activity of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation. The patients were also examined in separate sessions with defecography and anal manometry. RESULTS: During attempted defecation, puborectalis muscle and external sphincter always reacted in the same manner. When evaluated with pubococcygeus muscle, three main patterns of activity were observed either in patients or in controls: 1) coordinated activation pattern; 2) coordinated inhibition pattern; and 3) uncoordinated or equivocal pattern: activation of pubococcygeus muscle with inhibition of puborectalis muscle/external sphincter, activation followed by inhibition of the three muscles, and activation followed by inhibition of pubococcygeus muscle and no change in the others. We never observed activation of puborectalis muscle/external sphincter concomitant with inhibition of pubococcygeus muscle. The inhibitory coordinated pattern occurred significantly (P = 0.01) more frequently in controls than in patients. These subjects also presented a significantly (P = 0.01) lower frequency of pubococcygeus muscle inhibition. CONCLUSIONS: Either activation or inhibition appears as a physiological behavior, possibly adopted in different circumstances, of the pelvic floor muscles during attempted defecation. The higher prevalence of coordinated inhibitory patterns in normal subjects and the lower frequency of pubococcygeus muscle inhibition in patients with symptoms of obstructed defecation, however, suggests that a loss of inhibition capacity progressing from pubococcygeus muscle to puborectalis muscle/external sphincter muscles could determine the insurgence of obstructed defecation symptoms in some subjects, who should therefore benefit from biofeedback retraining aimed at reacquisition of the inhibition capacity of all muscles of the pelvic floor during defecation.

Excision of the levator muscles with external sphincter preservation in the treatment of selected low T4 rectal cancers

AbstractPURPOSE: The existence of an anatomic and functional separation between the puborectalis muscle and external anal sphincter permits the performance of an abdominoendoanal excision, instead of an abdominoperineal excision, of the rectum and levator muscles, with preservation of a functioning external sphincter, in selected patients with very low rectal cancer and limited infiltration of the levator muscles. METHODS: Seven patients (4 females; age, 48–69; mean, 60.7 ± 7.8 years) with low posterior or posterolateral localized rectal cancers with infiltration of the puborectalis muscle (T4) were submitted to preoperative chemoradiation and excision of the rectum with the levator muscles, while the external sphincter and its innervation were preserved. A coloanal anastomosis was performed at the dentate line. RESULTS: At a median follow-up of 58 (range, 42–102) months, 6 patients (86 percent) were alive and disease free. No local recurrence was observed. Anorectal function, at three years from surgery was no worse than that of six patients of the same age and gender who had undergone more conventional coloanal anastomoses with preservation of the levator muscles. CONCLUSION: Selected patients with very low rectal cancers infiltrating the levator muscles (T4) and responding to preoperative chemoradiation therapy can still be treated with an advanced sphinctersparing procedure, instead of an abdominoperineal excision. Oncologic and functional results seem to be satisfactory.

Anatomic plane of separation between external anal sphincter and puborectalis muscle

PURPOSE: The possible existence of an anatomic and functional separation between the external sphincter and the puborectalis muscle has been reported in the medical literature. In this article we confirm, by means of anatomic and clinical observations, the presence of such a separation, focusing on its importance in understanding the pathway of diffusion for some suppurative anal lesions and to plan advanced sphincter-sparing procedures. METHODS: Twenty adult anatomic specimens of the anal region (12 from women) were cut in the sagittal, coronal, and paracoronal planes, stained with hematoxylin and eosin, and examined. The pelvic floor musculature was examined in three patients undergoing postanal repair operations. Thirty primary posterior and posterolateral anal fistulas, preoperatively classified as transsphincteric (22) or suprasphincteric (8) were carefully traced during and after staged fistulotomy in 30 (11 female) patients, and their relationship with puborectalis muscle and external sphincter was evaluated. An attempt was made peranally to separate the external sphincter from the puborectalis muscle in four patients (3 females) aged 56 to 65 years with rectal cancers 4 to 5 cm from the anal verge so as to perform a sphincter-sparing procedure. RESULTS: A connective plane of separation between puborectalis muscle and external sphincter was clearly identified in 14 (70 percent) anatomic specimens. In three (21 percent) cases the two muscles presented a pronounced overlapping arrangement. An anatomicofunctional separation between puborectalis muscle and external sphincter was easily demonstrated during postanal repair operations. All fistulous tracks ran between the external sphincter and puborectalis muscle, despite the pronounced upward direction of the ones preoperatively classified as suprasphincteric. A plane of separation between puborectalis muscle and external sphincter was identified and developed in four patients with very low rectal cancers. An abdominoperanal rectolevatorial excision was performed. A coloanal anastomosis was performed on the residual lower anal canal. CONCLUSION: An anatomic plane of separation is present between the puborectalis muscle and the external sphincter. The presence of this plane is important to help understand the diffusion of some suppurative anal lesions and to plan advanced sphincter-sparing procedures.

Limitations of CEA monitoring as a guide to second-look surgery in colorectal cancer follow-up.

Forty-two patients with localized colorectal cancer (Dukes’ A, B, C stages) were treated with potentially curative surgery and controlled with a follow-up program, which included CEA monitoring, for a period ranging from 12 to 48 months (median 33 months). During this period, we observed recurrent neoplastic disease in 14 patients. A retrospective analysis of the results showed that: 1. patients with a preoperative CEA value > 20 ng/ml have a significantly higher risk of recurrence than the patients with CEA < 20 ng/ml; 2. sensitivity of the CEA test was good for metastatic recurrent disease, fairly good for residual neoplastic disease, but insufficient for local recurrence; 3. test-specificity was poor, as demonstrated by the negative results of four exploratory laparotomies performed exclusively on the basis of increased CEA levels. Since the principal aim of a second-look operation is the cure of local recurrence, this type of surgery cannot be proposed only on the basis of increased CEA levels.

Apoptotic proteins as prognostic markers and indicators of radiochemosensitivity in stage II/III rectal cancers

Aim  The expression of pro‐apoptotic (Bax) and anti‐apoptotic (mutated p53, Bcl‐2, Bclxl) proteins was determined retrospectively using immunohistochemistry in pre‐treatment biopsy samples from patients with rectal cancer treated with or without preoperative chemoradiation to investigate their role as prognostic markers and indicators of radiochemosensitivity.

A simple device for prolapsing loop colostomies

A simple device, applied to a conventional stomal appliance, prevents loop colostomy prolapse.

Ruthenium red selectively antagonizes capsaicin-induced release of vasoactive intestinal polypeptide (VIP) from the human colon

Ruthenium red (RR) is an inorganic dye that has shown to block the actions of capsaicin on primary sensory neurons in different animal models. The aim of this study was to assess whether RR is able to antagonize the release of vasoactive intestinal polypeptide (VIP) evoked by capsaicin in the human colon. Samples of descending colon were collected from patients undergoing colectomy for carcinoma of the colon. Tissue slices from the muscle of human colon were exposed to either 10 microM capsaicin or an isotonic high K+ medium (KCl 80 mM), in the absence or presence of 10 microM RR. Either capsaicin or high K+ produced a prompt release of VIP. RR (10 microM) completely antagonized the capsaicin-induced release of VIP from muscle of human colon. This effect was elective, since VIP release evoked by high K+ was unaffected by the presence of RR. These findings indicate that RR acts as a selective antagonist of capsaicin in human tissue and that the mechanism underlying peptide release by capsaicin is preserved across species. Multiple mechanisms leading to VIP release exist in the human colon.

The double contrast barium enema in the identification of proximal colonic adenomas and carcinomas beyond the limits of fiberoptic sigmoidoscopy.

Eight hundred and twenty patients were examined by fiberoptic sigmoidoscopy (SIG) and double contrast barium enema (DCBE) to detect colonic cancers or adenomas. Cancer or adenoma in the bowel tract proximal to the upper limit of SIG insertion was detected in 4-patients and in 12 on DCBE. The DCBE detection rate of proximal colonic lesions varied according to the hemoccult (HO) outcome. This was 1.16 % for cancer and 2.03 % for adenoma in HO+ patients and null for cancer and 1.23 % for adenoma in HO–- patients. The detection rate of proximal adenomas was higher in patients who presented adenomas on endoscopy in the distal bowel (SIG+), 2.46 % as compared to 0.48 % in SIG- patients,. independent of the HO reports. Routine DCBE is practically useless in HO-SIG- patients and questionable in HO-SIG+ patients since improvement of the detection rate is null for cancer and moderate for adenoma. It is recommended for HO+ patients because it increases the colonic cancer detection rate (10.5 % in this study).