Domenico Mascagni

Stapled Transanal Rectal Resection for Outlet Obstruction: A Prospective, Multicenter Trial

PURPOSE:This prospective, multicenter trial was designed to assess the safety and effectiveness of a novel technique in the treatment of outlet obstruction caused by the combination of intussusception and rectocele by using a double-transanal, 33-mm circular stapler.METHODS:From January to October 2001, 90 patients with outlet obstruction were operated on and followed (mean, 16.3 ± 2.9 months) by the validated Constipation Scoring and Continence Grading Systems, clinical examination, defecography, and anorectal manometry. Anal ultrasound also was performed in 58 multiparous patients.RESULTS:Operative time and hospital stay were short (mean, 43.3 ± 8.7 minutes and 2.1 ± 0.8 days, respectively), and postoperative pain was minimal. The mean time to resume normal activity was 10.2 ± 4.5 days. Complications were 17.8 percent fecal urgency, 8.9 percent incontinence to flatus, 5.5 percent urinary retention, 4.4 percent bleeding, 3.3 percent anastomotic stenosis, and 1.1 percent pneumonia. All constipation symptoms significantly improved (P < 0.001) without worsening of anal continence. No patient complained of dyspareunia. At postoperative defecography, all patients had a double incisure of the lower rectal outline in the site of anastomosis, with the disappearance of both intussusception and rectocele. Anal pressure was not significantly modified, whereas rectal compliance was restored (P < 0.05). No lesions of anal sphincters caused by the operation were found in multiparous patients. The outcome at one year was excellent in 48 of 90 patients, good in 33, fairly good in 5, and poor in 4.CONCLUSIONS:This novel technique seems to be safe and effective in the treatment of outlet obstruction caused by the combination of intussusception and rectocele. Randomized trials are required to confirm these findings.

Hiding Intersphincteric and Transphincteric Sepsis in a Novel Pathological Approach to Chronic Anal Fissure

Aim. The purpose of this study was to investigate whether endoanal ultrasonographic findings could better characterize chronic anal fissures, mostly in those patients with persistent and recurrent disease after medical treatment. Methods. Between January 2004 and April 2010, patients referred to our departments suspected for anal fissure were considered in a database. Physical examination and anoscopy confirmed the diagnosis of anal fissure in 543 patients. Chronicity was defined on the basis of morphological features of the fissure and mainly on its persistence or recurrence after medical therapy. Moreover, 172 out of 543 patients were selected with respect to the inclusion criteria and submitted to endoanal ultrasonography. Results. Seventeen out of 172 were anterior fissures (9.8%) and 155 posterior (90.2%). In 112 (65.1%) out of 172 patients submitted to endoanal ultrasonography, an associated chronic abscess was demonstrated, with expression of 91 intersphincteric and 21 low transphincteric fistulas, respectively. According to clinical data as well as comorbidities and previous surgery, there were no significant differences between patients with associated abscess and those with only chronic anal fissure. Conclusion. The authors assume that chronic fissures may persist because of hiding sepsis in the anal canal and that chronic anal fissure might be the clinical and pathological expression of a coexisting intersphincteric or low transphincteric fistula, and the ultrasonographic findings strongly support this theory.

GIANT ABDOMINOPELVIC EPITHELIOID ANGIOMYOLIPOMA ASSOCIATED WITH TUBEROUS SCLEROSIS: REPORT OF A CASE

Tuberous sclerosis is a hereditary autosomal-dominant disease characterized by hamartomas that can develop in any organ. We report herein the case of a 34-year-old female with tuberous sclerosis and a huge abdominopelvic mass that started growing quickly 2 years after its diagnosis. The patient had undergone several previous operations for hydrocephalus and cerebral tubers, and a nephrectomy for right renal angiomyolipoma. On admission, she was in poor general health with renal failure, severe anemia, and weight loss. A laparotomy revealed that the tumor occupied the pelvis, the lower and part of the upper abdomen, and was hypervascularized, with an extremely irregular surface covered in nodules, vegetations, and areas of hemorrhagic necrosis. The development of the mass and the impossibility of recognizing the internal genital organs led us to assume that the formation had originated from these. Frozen-section examination indicated an undifferentiated tumor that had not been completely resected. Her postoperative course was complicated by bronchopneumonia and progressive renal failure. The patient died 10 days after surgery due to cardio-respiratory failure. A histological diagnosis of epithelioid angiomyolipoma was confirmed. Although it is presently impossible to determine whether angiomyolipoma with predominant epithelioid cells is more aggressive than typical angiomyolipoma, it definitively demonstrated local aggressive behavior in this patient.

Evaluation of anal function after surgery for rectal cancer

Sphincter‐saving surgical procedures for rectal cancer have been legitimized if executed respecting the criteria of oncological radicalness. Our objective was to evaluate anal sphincteric continence after rectal cancer surgery.

Advances in rectal cancer surgery

PURPOSE: We discuss our experience in radical rectal cancer surgery and critically review the results of the current literature. In particular, the importance of distal clearance, total excision of the mesorectum, and pelvic lymphadenectomy is stressed. METHODS AND RESULTS: The rationale for determining a pelvic lymphadenectomy is identified in the high percentage (20 percent) of lateral endopelvic metastatic nodes demonstrated in cases of extraperitoneal rectal cancers. The results after pelvic lymphadenectomy and the eventual complications are observed. The autonomic nerve-sparing procedure is described and the preliminary results, with a decreased rate of urinary and sexual sequelae, are discussed. CONCLUSIONS: It was concluded that, in cases of an advanced rectal cancer, radical surgery, if associated with the nervesparing technique, can improve survival without affecting the incidence of major complications.

Prevention of complications during reoperative thyroid surgery.

BACKGROUND Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Expression and prognostic value of the cell polarity PAR complex members in thyroid cancer

Establishment and maintenance of the apical-basal cell polarity, required for proper replication, migration, specialized functions and tissue morphogenesis, relies on three evolutionary conserved complexes: PAR, CRUMBS and SCRIBBLE. Loss of cell polarity/cohesiveness (LOP/C) is implicated in cancer progression, and members of the polarity complex have been described as either oncogenes or oncosuppressors. However, no information on their role in thyroid cancer (TC) progression is available. In the present study, we evaluated the gene expression of the PAR complex members aPKCι, PARD3α/β and PARD6α/β/γ in 95 papillary TC (PTC), compared to their normal matched tissues and in 12 anaplastic TC (ATC). The mRNA and protein levels of investigated genes were altered in the majority of PTC and ATC tissues. In PTC, univariate analysis showed that reduced expression of aPKCι, PARD3β and PARD6γ mRNAs is associated with increased tumor size, and the reduced expression of PARD3β mRNA is associated also with recurrences. Multivariate analysis demonstrated that the presence of lymph node metastasis at diagnosis and the reduced expression of PARD3β are independent risk factors for recurrences, with hazard ratio, respectively, of 8.21 (p=0.006) and 3.04 (p=0.029). The latter result was confirmed by the Kaplan-Meier analysis, which evidenced the association between decreased PARD3β mRNA levels and shorter disease-free interval. In conclusion, we demonstrated that the expression of PAR complex components is deregulated in the majority of PTC and there is a general trend towards their reduction in ATC tissues. Moreover, a prognostic value for the PARD3β gene in PTCs is suggested.