Jacopo Martellucci

Treatment of slow-transit constipation with sacral nerve modulation

Aim  Constipation is common and a selection of the best treatment is difficult, especially for slow‐transit constipation (STC). The aim of the study was to assess the effect of sacral nerve modulation (SNM) on STC.

Early complications after stapled transanal rectal resection performed using the Contour® Transtar™ device

Aim  This study evaluated the early results (with particular reference to complications) of stapled transanal rectal resection (STARR) carried out using the CCS‐30 Contour® Transtar™ device. The procedure was performed in a single centre on patients with obstucted defecation caused by rectocele or rectal intussusception.

Clinical relevance of transperineal ultrasound compared with evacuation proctography for the evaluation of patients with obstructed defaecation.

Aim  Dynamic evacuation proctography (DEP) is still considered the gold standard diagnostic procedure for posterior compartment pelvic disorders. The study aimed to assess the value of dynamic transperineal ultrasound (DTPU) compared with DEP in patients with obstructed defaecation syndrome (ODS).

Is simple mucosal resection really possible? Considerations about histological findings after stapled hemorrhoidopexy

IntroductionThe common removal of smooth muscle during stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. The purpose of the study is to confirm the high frequency of the involvement of smooth muscle fibers in stapled hemorrhoidectomy and to determine its association with postoperative findings.MethodsThis retrospective study evaluated 241 cases of stapled hemorrhoidopexy treated from 2003 to 2006. Data include the most common postoperative complications such as bleeding, anal pain, and recurrence. Histological doughnuts were examined, and the presence of muscle fibers was evaluated.ResultsEarly complications occurred in 27/241 patients (11.2%) including bleeding (14), anal pain (eight), incontinence (two), abscess (two), hematoma (one). Recurrence was observed in 11 cases (4.5%). Muscularis propria fibers were identified in 217 of 241 (90%) pathologic specimens. Five complications occurred in the group in which muscle fibers were not identified (4/24). The frequency of complications in the group with and without smooth muscle tissue in the resected specimens was 9.6% and 25%, respectively.ConclusionsThe presence of muscle fibers is not an occasional finding in the histological specimens, even if the presence of smooth muscle does not seems to influence the outcome of stapled hemorrhoidopexy. The idea of a simple mucosal resection needs to be revised.

Accuracy of endoanal ultrasound in the follow-up assessment for squamous cell carcinoma of the anal canal treated with radiochemotherapy

BackgroundRadiochemotherapy has largely replaced surgery in the treatment for squamous cell cancer of the anal canal. Transanal ultrasonography is well documented as an important investigation method in the management of anal carcinoma. This study aimed to evaluate the accuracy of endoanal ultrasound in the study of the postradiation findings and to distinguish between postradiation fibrosis, residual tumor, and local recurrence.MethodsThe study enrolled 16 consecutive patients with biopsy-proven squamous carcinoma of the anal canal between 2003 and 2006. All the patients underwent a pretreatment and at least four posttreatment endosonographies, according to the follow-up period. All the patients were treated with the same radiochemotherapy protocol.ResultsNine patients had stage uT2 disease; none had uT3 disease; and seven had uT4 disease. There was no evidence of residual tumor in the T2 group after treatment. In the T4 patients after treatment, ultrasound demonstrated tumor regression or abnormalities considered to be radiation-induced changes rather than residual diseases. Only for three patients was a posttreatment biopsy performed to evaluate recurrence (two uT2 and one uT4). Surgical treatment of recurrence was performed for two uT4 patients.ConclusionsEndoanal ultrasound is a safe and effective method for evaluating and following anal cancer before and after treatment. Experience and evaluation during the period of the ultrasonographic abnormalities could give a clear idea concerning the evolution of the anal tumors treated with radiochemotherapy.

Role of enterocele in the obstructed defecation syndrome (ODS): a new radiological point of view.

Aim  The aim of this study was to understand the role of enterocele in the pathogenesis of the obstructed defecation syndrome (ODS) a new defecographic classification based on function.

Low Anterior Resection Syndrome: A Treatment Algorithm.

79 Diseases of the Colon & ReCtum Volume 59: 1 (2016) for almost 100 years abdominoperineal excision has been the standard treatment of choice for rectal cancer. however, as miles said, “the operation is a severe one. i do not think that it should be performed on those over 60 years of age; of 10 such cases all died. With regard to the remainder, of whom there were 36, 8 died from the effects of the operation, 4 have had recurrence, 2 died of intercurrent disease, while 22 are alive and well after periods varying from six months to six years.” the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing an operation with a sphincterpreserving technique has meant that, over the past 20 years, the anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, with the exception of those cancers very close to the anal sphincter. to date, also thanks to the multimodal treatment of rectal cancer, sphincter-preserving surgery with the restoration of bowel continuity to avoid a permanent colostomy is feasible in up to 80% of these patients. however, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from stoma patients and the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision/hartmann operation has yet to be answered. in fact, up to 80% of patients undergoing a low or very low anterior resection will experience postoperatively a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation, emptying difficulties and incontinence, increased gas, collectively referred to as the low anterior resection syndrome (laRs). even if most of the functional impairments are clinically recovered by 6 to 12 months after the operation, longterm studies are now reporting the presence of adverse symptoms up to 15 years after resection. these long-term results suggest that after about 12 months, the symptoms of anterior resection syndrome are the result of permanent changes rather than short-lived neorectal irritability in the postoperative period.2 Bowel dysfunction is a major problem with an immense impact on quality of life following sphincter-preserving resection, and the quality of life of patients who have had rectal cancer is closely associated with the severity of the laRs. impaired bowel function is usually provoked by the variable association of colonic dysmotility, neorectal reservoir dysfunction, and anal sphincter or pelvic nerves damage. there are currently no specific treatments for anterior resection syndrome. management is empirical and symptom based, using existing therapies for fecal incontinence, fecal urgency, and rectal evacuatory disorders. moreover, rectal cancer specialists do not have a very thorough understanding of which bowel dysfunction symptoms truly matter to the patient after sphincter-preserving treatment, or how these symptoms affect the patient’s quality of life, despite laRs being a prevalent and troublesome syndrome. Physicians tend to overestimate the impact of incontinence for liquid stool and frequent bowel movements, while underestimating the impact of urgency and clustering. the aim of the present article is to suggest an operative algorithm for the management of laRs.

Short-term effects of neoadjuvant chemoradiotherapy on internal anal sphincter function: a human in vitro study.

BACKGROUND: Neoadjuvant chemoradiotherapy is recommended in the treatment of locally advanced rectal cancer. Studies have suggested that chemoradiotherapy adversely affects anorectal function. However, the functional implication and the underlying neuromyogenic changes involved in radiation-induced damage are poorly understood. OBJECTIVE: This study evaluated the functional changes following chemoradiotherapy on the internal anal sphincter. DESIGN AND PATIENTS: This article describes an in vitro study on the internal anal sphincter collected from patients undergoing abdominoperineal resection or proctectomy. Five patients were treated by surgery alone (control group), and 6 received preoperative chemoradiotherapy (treatment group). Sphincter strips were mounted in organ bath, and the responses to electrical field stimulation and drugs were monitored. SETTINGS: The study was performed at the University of Oxford. MAIN OUTCOME MEASURES: The end points of this study were to investigate whether chemoradiotherapy has any significant effects on internal anal sphincter function and, subsequently, to establish the type of injury induced. RESULTS: Chemoradiotherapy strips developed similar tone, but significantly lower spontaneous activity (p = 0.001) than controls. Electrical field stimulation induced relaxation, followed by contraction. At 50 Hz, electrical field stimulation produced 25.6 ± 4.9% (mean ± SE) of maximum relaxation followed by a contraction of 5.5 ± 0.9% of basal tone in chemoradiotherapy strips i9n comparison with 47.0 ± 6.2% (p = 0.009) and 17.7 ± 4.0% (p = 0.007) in controls. Relaxation was significantly attenuated by N&ohgr;-nitro-L-arginine. Significant differences were found in responses to carbachol (p = 0.018) and phenylephrine (p = 0.022), but not to sodium nitroprusside. LIMITATIONS: This work was limited by the relatively small number of patients enrolled, because of the difficulty of finding human tissue for laboratory studies, and the lack of long-term results. CONCLUSIONS: Chemoradiotherapy significantly impairs internal anal sphincter function and intrinsic nerves seem more susceptible than smooth muscle. The exclusion of anal canal from the radiation field is recommended, when oncologically safe.

Resected specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up after STARR procedures

AIM To investigate stapled transanal rectal resection (STARR) procedures as surgical techniques for obstructed defecation syndrome (ODS) by analyzing specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up. METHODS From January to December 2007, we have treated 30 patients. Fifteen treated with double PPH-01 staplers and 15 treated using new CCS 30 contour. Resected specimen were measured with respect to average surface and volume. All patients have been evaluated at 24 mo with clinical examination, anorectal manometry and endoanal ultrasonography. RESULTS Average surface in the CCS 30 group was 54.5 cm² statistically different when compared to the STARR group (36.92 cm²). The average volume in the CCS 30 group was 29.8 cc, while in the PPH-01 it was 23.8 cc and difference was statistically significant. The mean hospital stay in the CCS 30 group was 3.1 d, while in the PPH-01 group the median hospital stay was 3.4 d. As regards the long-term follow-up, an overall satisfactory rate of 83.3% (25/30) was achieved. Endoanal ultrasonography performed 1 year following surgery was considered normal in both of the studied groups. Mean resting pressure was higher than the preoperative value (67.2 mmHg in the STARR group and 65.7 mmHg in the CCS30 group vs 54.7 mmHg and 55.3 mmHg, respectively). Resting and squeezing pressures were lower in those patients not satisfied, but data are not statistically significant. CONCLUSION The STARR procedure with two PPH-01 is a safe surgical procedure to correct ODS. The new Contour CCS 30 could help to increase the amount of the resected tissue without differences in early complications, post-operative pain and in hospital stay compared to the STARR with two PPH-01 technique.

A multi-center study on the surgical management of metastatic disease to adrenal glands†

In the management of adrenal lesions in oncological patients, many issues are still controversial: morphological signs of suspected malignancy, accuracy of imaging examinations, use of fine needle aspiration (FNA), and the role of laparoscopy. The present study attempts to address these questions through the evaluation of the management of adrenal metastases (AM) in a wide cohort of patients included in the Italian Register of Endoscopic Adrenal Surgery.