Donato F. Altomare

Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty

PURPOSE: This study assessed the efficacy of anterior overlapping sphincteroplasty and parameters predictive of a successful outcome. METHODS: Clinical findings and physiologic investigations of female patients who underwent anterior overlapping sphincteroplasty for fecal incontinence between 1988 and 1996 were reviewed. The extent of sphincter damage was assessed at needle electromyography as the number of quadrants exhibiting decreased motor unit potentials. Prolonged pudendal nerve terminal motor latencies were those of greater than 2.2 ms. The size of the endoanal ultrasound defect was assessed as degrees circumference of the external sphincter in which viable muscle was absent. Patients were reviewed by telephone questionnaire and were asked to grade the outcome of their surgery as excellent or good (success) or fair or poor (failure). Incontinence was graded using a scoring system of 0 (perfect continence) to 20 (complete incontinence). RESULTS: There were 100 patients who had an overlapping sphincteroplasty; complete follow-up information was obtained for 77 patients at a median of 24 (range, 2–96) months. The median age was 47 (range, 25–80) years and they had a median duration of incontinence of four (range, 0.1–39) years. Prior sphincteroplasty had been performed in 30 patients with a median of one (range, 1–7) operations. Investigations performed included electromyography (n=49), pudendal nerve terminal motor latency (n=71), endoanal ultrasound (n=49), and manometry (n=67). Sixty percent of patients had improved continence and 42 (55 percent) considered their surgery to have been successful as attested to by a significant decrease in their incontinence score (from 15.1±4.5 to 4.3±4.2;P<0.0001). Neither patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of electromyography damage, size of the endoanal ultrasound defect, nor any manometric parameter correlated with outcome. However, 62 percent of 59 patients with bilaterally normal pudendal nerve terminal motor latencies had a successful outcome compared with only 16.7 percent of 12 patients with unilateral or bilateral prolonged pudendal nerve terminal motor latencies (P<0.01). CONCLUSION: Bilateral normal pudendal nerve terminal motor latencies are the only factors predictive of long-term success after overlapping sphincteroplasty.

Treatment of external anorectal mucosal prolapse with circular stapler: an easy and effective new surgical technique.

PURPOSE: The aim of this study was to demonstrate the feasibility, effectiveness, and reliability of a new technique for treating overt rectal mucosal prolapse using a stapler device. METHODS: Eighteen consecutive patients with overt rectal mucosal prolapse were selected for the study. Preoperative anal manometry and cinedefecography demonstrated no anal incontinence and the absence of full-thickness rectal prolapse. One or two purse strings were prepared 3 to 4 cm distally to the dentate line and tied on a 33 mm circular stapler introduced through the anus and then fired. RESULTS: The operation lasted an average of 15 minutes, and no local complications were recorded. Supplementary hemostatic sutures (2 to 6 stitches) were sometimes necessary. Seven patients did not require postoperative analgesia, whereas eight patients received one or two administrations of analgesics. Longer-lasting analgesic treatment (4 days) was necessary in only three patients. Sixteen patients were discharged after 48 hours, and only 1 after four days because of pulmonary infection. Patients resumed normal activities after a median period of three days. Median follow-up was 20 months. The prolapse was eliminated in all cases. No stricture was found at anal exploration, and no episodes of anal incontinence or bleeding were recorded. Postoperative manometry did not show significant changes compared with preoperative findings. CONCLUSIONS: This new surgical technique is safe, effective, and rapid, causing minimum or no postoperative pain and could be proposed to replace traditional surgery for this common condition.

Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique.

AbstractPURPOSE: The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler. METHODS: Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH 01 system™), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned. RESULTS: One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P < 0.04). CONCLUSION: Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.

New strategies for colorectal cancer screening.

Colorectal cancer (CRC) is still one of the leading causes of cancer-related death in Western countries, despite major improvements in its treatment. The dramatically high social and economic impact of CRC on human health makes the identification of a reliable screening tool of paramount importance. Current screening methods, such as the fecal occult blood test and colonoscopy do not adequately meet the ideal requisites of a screening test because, even if they are effective, they are limited first by too low specificity and sensitivity, or second by high invasiveness, costs and risk. Nowadays extended efforts are made by researchers to look for more reliable and effective screening tests based on a systems biology approach, using biological samples easily available, such as urine, breath, serum and feces. The effectiveness and reliability of several new attempts to screen these patients by non-invasive analysis of their biological samples using genomic (genetic and epigenetic alteration), transcriptomic (miRNA), proteomic (cancer-related antigens, new antibodies against tumor-associated antigens, mutated proteins) and metabolomic (volatile organic metabolites) methods are discussed in this review. Among the most interesting new screening tools, fecal fluorescent long-DNA, fecal miRNA and metabolomic evaluation in breath and/or serum seem to be most promising.

No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial.

BACKGROUND: No randomized controlled trial has compared no rectopexy with rectopexy for external full-thickness rectal prolapse. OBJECTIVE: This study was performed to test the hypothesis that recurrence rates following no rectopexy are not inferior to those following rectopexy for full-thickness rectal prolapse. DESIGN: This was a multicenter randomized controlled trial. Eligible patients were randomly assigned to no rectopexy or rectopexy. The end point was recurrence rates defined as the presence of external full-thickness rectal prolapse after surgery. A prerandomized controlled trial meta-analysis suggested a sample size of 251 patients based on a 15% expected difference in the 5-year cumulative recurrence rate. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. Data were presented as median (range). SETTING: This study was conducted in 41 tertiary centers in 21 countries. PATIENTS: Patients with prior surgery for rectal prolapse or pelvic floor descent were not included. INTERVENTIONS: The no-rectopexy arm was defined as abdominal surgery with rectal mobilization only. The rectopexy arm was defined as abdominal surgery with mobilization and rectopexy. Sigmoid resection was not randomized and was added in the presence of constipation. MAIN OUTCOME MEASURES: Two hundred fifty-two patients with external full-thickness rectal prolapse were randomly assigned to undergo no rectopexy or rectopexy in 41 centers. All patients but one underwent the allocated intervention. One hundred sixteen no-rectopexy patients were comparable to 136 rectopexy patients for age (P = .21), body mass index (P = .61), ASA grade (P = .29), and previous abdominal surgery (P = .935), but not for sex (P = .013) and external full-thickness rectal prolapse length (8 (1-25) cm vs 5 (1-20) cm, P = .026). Sigmoid resection was performed more frequently in the no-rectopexy arm (P < .001). There was no significant difference in complication rates (11% vs 17.9%; P = .139). The mortality rate was 0.8%. The loss of patients to 5-year follow-up was 10.3%. Actuarial analysis demonstrated a significant difference in 5-year recurrence rates between study arms (8.6% vs 1.5%) (log-rank, P = .003). LIMITATIONS: Limitations were the high proportion of male patients, randomization timing, the lack of standardization for rectopexy technique, and the 10% loss to follow-up. CONCLUSIONS: Recurrence rates following no rectopexy are inferior to those following rectopexy for external full-thickness rectal prolapse.

Functional Outcome of Sacral Nerve Stimulation in Patients With Severe Constipation

BACKGROUND:Sacral nerve stimulation has been reported as an effective treatment for constipation. OBJECTIVE:This study aimed to evaluate the therapeutic efficacy of permanent sacral nerve stimulation on the treatment of idiopathic constipation resistant to medical and behavioral management over a median follow-up period of 25.6 (range, 6–96) months. DESIGN:A retrospective review of a prospectively maintained institutional review board-approved database was performed. SETTING:The study was performed at 2 tertiary-care European institutions with expertise in sacral nerve stimulation. PATIENTS:Patients were considered eligible if they had had symptoms for at least 1 year and if conservative treatment had failed. INTERVENTION:Patients were tested by percutaneous nerve evaluation before the procedure. If this evaluation was successful, patients underwent sacral nerve therapy with an implanted device. MAIN OUTCOME MEASURE:Patients were evaluated by means of a bowel function diary and the Wexner constipation score. RESULTS:A total of 48 consecutive patients (39 females, median age 50.0 years (range, 17–79 years) entered the study. Twenty-three patients were implanted with a permanent stimulator. On an intention-to-treat basis, only 14 of 48 patients (29.2%) met the definition of a successful outcome at the latest follow-up period (median, 25.6 (range, 6–96) months). The mean Wexner score decreased from 20.2 (SD 3.6) at baseline to 5.8 (SD 4.1) at the latest follow-up examination (p < 0.001). However, 6 of 14 patients (42.8%) were still using laxatives and/or enemas at the last follow-up. LIMITATIONS:The study was limited by the pragmatic approach necessary to evaluate the results in routine clinical practice. CONCLUSIONS:This study shows that sacral nerve stimulation has limited efficacy on an intention-to-treat basis as a routinely recommended therapy for intractable idiopathic constipation.

Pharmacological treatment of hemorrhoids: a narrative review.

Introduction: Hemorrhoid disease is the cause of most proctologic complaints and hundreds of medical and surgical therapies have been proposed to relieve symptoms. However, the role and the correct indication of medical treatments are still controversial. Further, the utility of conservative measures are rarely scientifically supported by adequate trials. Areas covered: This narrative review is based on the search and analysis of full papers in English language selected from PubMed in the past 30 years using the following MeSH Editing: hemorrhoids, conservative treatment, medical treatment and hemorrhoids, pregnancy and hemorrhoids, thrombosed hemorrhoids, randomized trials and hemorrhoids, postoperative pain and hemorrhoids. Expert opinion: Early stages (I/II degrees) of this disease could be effectively managed conservatively with several approaches as lifestyle changes, fiber supplement, topical ointments and phlebotonic drugs. The more advanced hemorrhoid stages (III/IV degrees) need some type of surgery, but medical therapy is still useful to minimize anal symptoms as a bridge-to-surgery treatment. Further, post-hemorrhoidectomy pain, hemorrhoidal crisis even in pregnancy could benefit from the adjunct of local and systemic medical treatment. This expert opinion, based also on long-lasting clinical practice, also supports the use of medical treatment in symptoms relief in patients with hemorrhoid disease.

Erratum to: Flavonoids mixture (diosmin, troxerutin, hesperidin) in the treatment of acute hemorrhoidal disease: a prospective, randomized, triple-blind, controlled trial

Background The role of a mixture of phlebotonics in the treatment of acute hemorrhoid crisis is investigated to test their efficacy.

Is Pyloric Function Preserved in Pylorus-preserving Pancreaticoduodenectomy?

OBJECTIVE To assess the function of the pylorus after pylorus-preserving pancreaticoduodenectomy (PPPD) done for periampullary or pancreatic cancer. DESIGN Prospective, observational controlled clinical study. SETTING Teaching hospital, Italy. SUBJECTS 17 patients who had undergone PPPD, and 15 healthy control subjects. INVESTIGATIONS Endoscopy to check for gastritis and marginal ulcers and 24 h-pH monitoring and 99mTc HIDA scintigraphy to detect jejunogastric reflux. Scintigraphy was also used to evaluate gastric and jejunal transit after a solid meal labelled with 99mTc colloid sulphur. MAIN OUTCOME MEASURES Signs of delayed gastric emptying, jejunogastric reflux and gastric outlet obstruction in the short and long term. RESULTS In the early postoperative period only 1 patient had delayed gastric emptying. In the long term, two patients had symptoms of dyspepsia and 8/11 showed alkaline reflux with persistent gastric pH more than 4 for more than 12 hours; 3 had histological signs of gastritis. There was no difference in gastric emptying compared with controls, but three patients had prolonged emptying time (T1/2 more than 85 minutes). Endoscopy findings correlated with pH monitoring results. CONCLUSIONS After PPPD, most patients have abnormal pyloric function, but it is clinically evident in only a small proportion.

The ProTect device in the treatment of severe fecal incontinence: preliminary results of a multicenter trial

BackgroundPatients suffering from severe fecal incontinence (FI) in whom surgical treatment has either failed or is inappropriate due to high operative risks and those who refuse to undergo surgery are condemned to living with their embarrassing symptoms, often responsible for progressive social isolation. ProTect is a new, relatively simple, medical device intended for selected patients suffering from severe FI. It consists of a pliable, silicone catheter with an inflatable balloon that seals the rectum at the anorectal junction, acting like an anal plug. The proximal part of the catheter incorporates two contacts that monitor the rectum for the presence of feces. The patient is alerted to an imminent bowel movement and, hence, a potential fecal accident, through a beeper.MethodsA multicenter trial has been set up to assess the reliability of the device in preventing episodes of FI and to evaluate its impact on quality of life. Patients with significant FI (CCF>10) were prospectively entered into this 14-day study. Two quality of life questionnaires and a daily log of bowel activity and incontinent episodes were completed before and during the study.ResultsCurrently, the study enrolled 17 patients and 11 patients (9 women, 2 men) with a mean age of 66 years (range, 46–85) completed the trial. In these 11 subjects, there was an overall significant improvement in the quality of life (p<0.05) and a significant reduction in incontinence scores (p<0.001) while using ProTect compared to baseline.ConclusionsThe ProTect is a safe non-surgical device that is able to prevent episodes of FI. It is unique because it can be used according to a patient’s needs without interfering with activities of daily living.