Filippo Pucciani

Long-term ambulatory enterogastric reflux monitoring. Validation of a new fiberoptic technique.

A new technique for the long-term ambulatory detection of enterogastric and nonacid gastroesophageal reflux has been conceived, developed, and validated. It is based on the use of a fiberoptic sensor that utilizes the optical properties of bile.In vitro studies have shown good precision, good stability, sensitivity of 2.5 μmol/liter bilirubin concentration, as well as a useful working range of 2.5–100 μmol/liter bilirubin concentration.In vivo studies have been performed in 29 subjects. Simultaneous gastric aspirations have allowed a comparison of fiberoptic system measurements both with spectrophotometric analysis and bile acid concentrations of corresponding gastric juice samples. Linear correlations were shown between fiberoptic assessment and both spectrophotometric and bile acid concentration findings (P<0.01). Simultaneous assessment of reflux with the fiberoptic system and cholescintigraphy has shown a 92.9% concordance as regards the presence or absence of reflux. Present results imply that the fiberoptic system is an important tool for the understanding of the clinical relevance of enterogastric and nonacid gastroesophageal reflux.

Lymph node recovery from colorectal tumor specimens: recommendation for a minimum number of lymph nodes to be examined.

Lymph node involvement is the mostimportant prognostic factor for patients who have undergone radicalsurgery for colorectal carcinoma. An accurate examination of thesurgical specimens is mandatory for the correct assessment of the lymphnode status of the tumor. The risk of understaging is particularly highfor patients with tumors classified as Dukes B (TNM stage II). The aimof this study was to determine if a specified minimum number of lymphnodes examined per surgical specimen could have any effect on theprognosis of patients who had undergone radical surgery for Dukes Bcolorectal cancer. Between 1988 and 1995 a total of 140 patientsunderwent radical resection of Dukes B colorectal cancer by the samesurgeon (C.C.). The relation between clinicopathologic variables andsurvival was estimated using the Kaplan-Meier method. The Coxproportional hazard regression model was used to identify the variablesthat can independently influence survival. A median of 12 lymph nodes(range 3–38) was examined per tumor specimen. The 5-year survival rateof Dukes B patients who had had eight or fewer lymph nodes examinedafter surgery was 54.9%, whereas the survival rate for those who hadhad nine or more lymph nodes examined was 79.9% (p < 0.001). Cox regression analysis identified the number of lymph nodes asthe only independent prognostic factor (p = 0.01).Seventy patients with one to four metastatic lymph nodes (Dukes Cpatients) who had been operated on during the same period were includedin the survival analysis for comparison. The 5-year survival rate ofthe Dukes B patients with eight or fewer lymph nodes examined wassimilar to that of the 70 Dukes C patients (54.9% and 51.8%,respectively). Examination of eight or fewer lymph nodes in Dukes Bcolorectal patients may be considered a high risk factor for missingpositive lymph nodes in the surgical specimens. Our results suggestthat harvesting and examining a minimum of nine lymph nodes persurgical specimen may be sufficient for reliable staging of lymphnode-negative tumors.

Rehabilitation of Fecal Incontinence After Sphincter-Saving Surgery for Rectal Cancer: Encouraging Results

PurposeSome patients, having undergone sphincter-saving operations for rectal cancer, may suffer from fecal incontinence. This study was designed to evaluate the results of rehabilitative treatment in patients with fecal incontinence after sphincter-saving operations and to identify the negative factors that influence therapeutic success.MethodsBetween January 2000 and June 2007, 88 incontinent patients (54 women; age range, 47–73 years; 69 had received a low anterior rectal resection; 19 a straight coloanal anastomosis) were included in the study. After a preliminary clinical evaluation, including the Wexner Incontinence Scale score, anorectal manometry was performed. All 88 patients underwent rehabilitative treatment according to the “multimodal rehabilitative program” for fecal incontinence. At the end of program, all 88 patients were reassessed by means of a clinical evaluation and anorectal manometry; their results were compared with the clinical and manometric data from ten healthy control subjects. Postrehabilitative Wexner Incontinence Scale scores were used for an arbitrary schedule of patients divided into three classes: Class I, good (score ≤3); Class II, fair (score >3 to ≤6); Class III, poor (score >6).ResultsAfter rehabilitation, there was a significant improvement in the overall mean Wexner Incontinence Scale score (P < 0.03) for both surgical operation types (low anterior rectal resection: P < 0.05; coloanal anastomosis: P < 0.02). Only 21 patients (23.8 percent) were symptom-free, and 37 (42 percent) were considered Class III. A significant postrehabilitative direct correlation was found between: 1) Wexner Incontinence Scale score and degree of genital relaxation (rρs 0.78; P < 0.001); 2) Wexner Incontinence Scale score and irradiation (rρs 0.72; P < 0.01); and 3) Wexner Incontinence Scale score and pelvic (rρs 0.65; P < 0.01) or anal surgery (rρs 0.68; P < 0.01). No significant differences were found between prerehabilitative and postrehabilitative anal pressures in low anterior rectal resection and coloanal anastomosis patients.ConclusionsAfter rehabilitation, some patients become symptom-free, many patients show an improvement in the Wexner Incontinence Scale score, and others exhibit the highest grades of fecal incontinence. Genital relaxation, radiotherapy, and previous pelvic, and/or anal surgery are impeding factors to rehabilitative success.

Tumor angiogenesis in lymph node-negative rectal cancer: correlation with clinicopathological parameters and prognosis.

AbstractBackground: Intratumoral microvessel density (MVD) could be used as a prognostic factor in colorectal cancer. We retrospectively analyzed the value of microvessel count in predicting the clinical outcome of stage I and II (Dukes A and B) rectal cancer patients. Methods: Eighty-four patients who had undergone curative resection of lymph node-negative rectal cancer were included. Tumor type and differentiation, the depth of local invasion, venous invasion, the character of the invasive margin, and the degree of lymphocytic infiltration were evaluated for each tumor specimen. Immunohistochemical staining for the CD31 endothelial antigen was performed to highlight the microvessels. Results: The median value of MVD was 45 microvessels. Low MVD (microvessels ≤45) was observed in 41 patients (48.8%), and high MVD (>45) was found in 43 (51.2%). The presence of conspicuous lymphocytic infiltration was significantly associated with increased vessel density. With uni- and multivariate survival analysis MVD did not show any prognostic significance. The character of the invasive margin was the only parameter with independent prognostic value. Conclusions: MVD does not seem to provide any additional prognostic information when compared with standard histopathological parameters in lymph node-negative rectal cancer. It is likely that the strong association between MVD and the presence of conspicuous lymphocytic infiltration may interfere with its predictive value.

Multimodal rehabilitation for faecal incontinence: experience of an Italian centre devoted to faecal disorder rehabilitation

Abstract.Background:Sphincter exercises and biofeedback therapy have been used to treat faecal incontinence but results have been unpredictable and standards of treatment have not yet been established. The aim of this study was to retrospectively evaluate the effects of a new multimodal rehabilitation model on faecal incontinence.Methods:All of the rehabilitative procedures are guided by manometric data. Primary study outcome criteria were the determination of changes or deterioration in incontinence, failure to achieve full continence and/or presence of faecal urgency. The clinical outcome was designed according to the Jorge-Wexner incontinence score.Results:Between 1997 and 2001, one hundred forty-nine incontinent patients (85 F and 64 M; age range, 41–73 years; mean age, 60.6 years) underwent multimodal rehabilitation at our outpatient unit. The overall mean incontinence score had significantly improved after treatment (p<0.001), and 58 patients (38.9%) were symptom free. No patient reported any deterioration in incontinence. Faecal urgency persisted in 23 patients (15.4%).Conclusion:In conclusion, multimodal rehabilitation, using manometric study, can modify the incontinence score.

In vivo optical-fibre pH sensor for gastro-oesophageal measurements

Abstract The present work is concerned with the development of an optical-fibre sensor for monitoring pH in the foregut in the extended range 1.0–8.0. Controlled pore glasses (CPGs), with covalently bound chromophore, are fixed at the end of plastic optical fibres using a proprietary process. A good sensitivity, fast response time, the small dimensions of the probe and the biocompatibility of the materials utilized make the sensor suitable for in vivo measurements.

Character of the invasive margin in colorectal cancer

PURPOSE: The clinical significance and prognostic value of the histopathologic parameters used in both the Dukes and Jass classifications were evaluated to select those with an independent effect on survival after radical surgery for colorectal cancer. METHODS: The depth of local spread (limited to the bowel wall or extended beyond it), the number of metastatic lymph nodes (none, 1–4, more than 4), the character of the invasive margin (pushing or infiltrating), and the presence or absence of conspicuous peritumoral lymphocytic infiltration were assessed in 235 patients who had undergone radical resection for colorectal cancer. The influence of these variables on survival was studied by univariate and multivariate analysis. RESULTS: No significant difference in survival was found between patients with conspicuous peritumoral infiltrate and those without it; moreover, multivariate analysis failed to show any independent prognostic value for either lymphocytic infiltration or depth of local invasion. However, the character of the invasive margin and the number of metastatic lymph nodes were identified as the only variables with any independent importance on survival. Based on these data, a new prognostic model may be proposed; it uses the character of the infiltrative margin as a discriminating factor among patients within the lymph node-negative (Dukes A and B stages) and lymph node-positive (Dukes C1 and C2 subsets) groups. A good prognosis for Dukes A, B, and C1 patients was associated with pushing tumors; C1 and C2 patients with infiltrating tumors had a poor prognosis. On the whole, the new prognostic model has allowed for the placement of 59.6 percent of our patients into groups that provide a confident prognosis. The clinical outcome of Dukes A and B patients with infiltrating tumors is still uncertain. CONCLUSIONS: The character of the invasive margin is an important prognostic factor in colorectal cancer. The association of this parameter with the traditional Dukes classification may provide additional useful prognostic information and aid in the selection of those patients who could most benefit from adjuvant therapy.

Controlled-Pore Glasses Embedded in Plastic Optical Fibers for Gastric pH Sensing Purposes

The present work is concerned with the development of an optical-fiber pH sensor for gastric monitoring. Bromophenol blue is used as a chromophore, which is immobilized on controlled-pore glasses (CPGs) by means of a silylation process. As far as the optoelectronic unit is concerned, light-emitting diodes as sources and an appropriate electronic circuit as detection system are utilized. Treated CPGs are fixed at the end of two plastic optical fibers (core diameter = 500 μm) by means of a proprietary process; a reflector made of Teflon®, anchored to the distal end of the fibers, ensures good fibers/probe coupling efficiency. The behavior of the realized probe is carefully investigated, with particular attention devoted to the presence of hysteresis, to ionic strength and temperature effect, and to its lifetime. The fast response time, thanks to the absence of a mechanical envelope, the small dimensions of the probe, and the biocompatibility of the utilized materials make this sensor suitable for in vivo measurements.

Evidence for oesophageal and anorectal involvement in very early systemic sclerosis (VEDOSS): report from a single VEDOSS/EUSTAR centre

BACKGROUND The oesophagus is the first gastrointestinal (GI) tract involved in systemic sclerosis (SSc), followed by the anorectum. OBJECTIVE Evaluation of oesophageal and anorectal involvement and their correlations in patients with very early diagnosis of SSc (VEDOSS). PATIENTS AND METHODS 59 patients with VEDOSS, evaluated with oesophageal and anorectal manometry and investigated with lung function tests and chest HRCT. Demographic data, oesophageal and anorectal symptoms, Raynauds phenomenon, autoantibodies, videocapillaroscopy patterns, puffy fingers and digital ulcers were recorded for all patients. RESULTS In 4 patients oesophageal manometry and in 17 patients anorectal manometry was not performed because of scarce tolerance. Oesophageal peristalsis was absent in 14 patients; its pressure and speed were significantly lower in 41 patients (p<0.001 and p=0.005, respectively). The maximum pressure and mean pressure (Pmax and Pm) of lower oesophageal sphincter were significantly lower (p=0.012 and p=0.024, respectively). Patients with a diffusing capacity of the lung for carbon monoxide<80% presented a hypotonic lower oesophageal sphincter (p=0.008) and an abnormal peristalsis (p<0.001); patients with a diffusing capacity of the lung for carbon monoxide>80% showed only an abnormal peristalsis (<0.001). The anal resting pressure (ARP) at 4.3 cm and 2 cm from anal edge and the anal canal Pm were significantly decreased (p<0.001 and p=0.010, respectively). The maximum voluntary contraction was significantly abnormal in its Pmax and Pm (p=0.017 and p=0.005) and in its duration (p=0.001). In patients with a positive HRCT, the ARP and the canal Pmax and Pm were significantly lower; patients with negative HRCT presented only an abnormal ARP. CONCLUSIONS In patients with VEDOSS, oesophageal and anorectal disorders are frequently detected, showing that very early SSc is characterised by GI involvement.

Descending Perineum Syndrome: Are Abdominal Hysterectomy and Bowel Habits Linked?

PURPOSEThis retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome.METHODSEighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography.RESULTSDyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05).CONCLUSIONSClinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.