Michele De Fazio

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.

Reliability of electrophysiologic anal tests in predicting the outcome of sacral nerve modulation for fecal incontinence

INTRODUCTION:Sacral nerve modulation has been demonstrated to be a new efficacious treatment for fecal incontinence. The effectiveness of the procedure is preliminarily tested by means of a peripheral nerve evaluation. Integrity of the sacral neural pathway is generally believed to be a necessary condition for a good response, but no data are available to confirm whether electrophysiologic anal tests are predictive of the clinical outcome of the peripheral nerve evaluation.METHODS:Eighty-two incontinent patients underwent the peripheral nerve evaluation after full evaluation of the anorectal physiology. Univariate analysis was performed, and the positive predictive value, sensitivity, and specificity were calculated for each of the tests.RESULTS:Forty-six patients had successful results to the peripheral nerve evaluation and were subjected to permanent implant of a sacral electrostimulator. Anal sphincter electromyography had been performed in 60 patients, whereas pudendal nerve terminal motor latency had been assessed in 68 and evoked sacral potentials in 29 patients. Anal electromyography was statistically related to the outcome of the peripheral nerve evaluation (P = 0.0004) with a positive predictive value of 81 percent, a sensitivity of 44 percent, and a specificity of 81 percent. Pudendal nerve terminal motor latency on the right side did not correlate with the outcome, but left pudendal nerve terminal motor latency was weakly correlated (P = 0.02), although both tests had a low positive predicting value and sensitivity vs. good specificity. Evoked sacral potentials did not correlate with the outcome and had a low positive predictive value, sensitivity, and specificity.CONCLUSIONS:Simple anal sphincter electromyography can predict the outcome of the peripheral nerve evaluation with good positive predictive value and specificity in patients with fecal incontinence. Other, more expensive, electrophysiologic anal tests do not add further prognostic information.

Differences in Gene Expression and Cytokine Release Profiles Highlight the Heterogeneity of Distinct Subsets of Adipose Tissue-Derived Stem Cells in the Subcutaneous and Visceral Adipose Tissue in Humans

Differences in the inherent properties of adipose tissue-derived stem cells (ASC) may contribute to the biological specificity of the subcutaneous (Sc) and visceral (V) adipose tissue depots. In this study, three distinct subpopulations of ASC, i.e. ASCSVF, ASCBottom, and ASCCeiling, were isolated from Sc and V fat biopsies of non-obese subjects, and their gene expression and functional characteristics were investigated. Genome-wide mRNA expression profiles of ASCSVF, ASCBottom and ASCCeiling from Sc fat were significantly different as compared to their homologous subsets of V-ASCs. Furthermore, ASCSVF, ASCCeiling and ASCBottom from the same fat depot were also distinct from each other. In this respect, both principal component analysis and hierarchical clusters analysis showed that ASCCeiling and ASCSVF shared a similar pattern of closely related genes, which was highly different when compared to that of ASCBottom. However, larger variations in gene expression were found in inter-depot than in intra-depot comparisons. The analysis of connectivity of genes differently expressed in each ASC subset demonstrated that, although there was some overlap, there was also a clear distinction between each Sc-ASC and their corresponding V-ASC subsets, and among ASCSVF, ASCBottom, and ASCCeiling of Sc or V fat depots in regard to networks associated with regulation of cell cycle, cell organization and development, inflammation and metabolic responses. Finally, the release of several cytokines and growth factors in the ASC cultured medium also showed both inter- and intra-depot differences. Thus, ASCCeiling and ASCBottom can be identified as two genetically and functionally heterogeneous ASC populations in addition to the ASCSVF, with ASCBottom showing the highest degree of unmatched gene expression. On the other hand, inter-depot seem to prevail over intra-depot differences in the ASC gene expression assets and network functions, contributing to the high degree of specificity of Sc and V adipose tissue in humans.

Solid papillary neoplasm of the pancreas: a case report.

Solid pseudopapillary neoplasm of the pancreas, solid and cystic, is a rare disease compared to ductal adenocarcinoma. The tumor most often affects women of African race aged in their twenties or thirties. We report the case of a 48-year-old man affected by solid pseudopapillary neoplasm of the pancreas treated by distal splenopancreasec-tomy. The patient was discharged on the 10th postoperative day in good general condition, feeling normal and with blood chemistry values within normal limits. The main characteristic differentiating papillary tumors of the pancreas from ductal adenocarcinoma is that in the latter case surgical eradication is a definitive solution and no other treatment is required, as confirmed by our case and those reported in the literature.

Sacral Nerve Modulation for Fecal Incontinence

Sacral nerve stimulation is an innovative, mininvasive approach to fecal incontinence and other pelvic floor dysfunctions based on the delivery of electrical stimuli to the pelvic nerves through an electrode percutaneously positioned through the sacral foramen (usually S3) and connected to an implantable pulse generator. This technique has the unique advantages to affect continence without performing operations on the anal sphincter and to have the possibility to pretesting the outcome of the definitive implant with a low-cost temporary stimulation. Its reliability and effectiveness is nowadays recognized by the FDA [1], by the NICE [2], and by the main Coloproctological scientific societies (ASCRS, ESCP, ICS) and systematic reviews [3].

Mediastinal Mass Following Successful Chemotherapy for Ovary Dysgerminoma: Benign Process or Disease Relapse? A Case Report

BACKGROUND Ovarian dysgerminoma is a rare tumor that affects adolescent girls and young women. Due to its high radio-chemosensitivity, prognosis is normally excellent. Relapses occur in less than 20% of early stage disease, but are more frequent in advanced disease. It is known that some benign mediastinal processes may mimic tumor relapse, particularly in young patients. This is the case of physiologic thymic hyperplasia, which occurs as a rebound phenomenon after chemotherapy in young women with ovarian dysgerminoma. Until now, no cases of dysgerminoma with benign mediastinal mass have been published. CASE A young woman with bulky ovarian dysgerminoma, who obtained complete disease remission after chemotherapy, subsequently developed a mediastinal mass which was initially confused with a mediastinal relapse. CT scan features (close thymic location, homogeneous hypodensity, absence of infiltration of mediastinal structures) and subsequent PET/CT scan (homogeneous glucose uptake and a typical inverted V morphology) supported the diagnosis of thymic hyperplasia. No further invasive procedures were performed. 34 months from the diagnosis the patient is in good physical condition with no signs of relapse. CONCLUSIONS Our case underlines the importance of knowing the age- and treatment-related incidence of physiologic thymic hyperplasia in young women with ovarian dysgerminoma in order to reduce the potential pitfalls and to avoid unnecessary invasive diagnostic procedures.

The unexpected conundrum of endometrioid carcinoma in deep rectal endometriosis arising 11 years after total hysterectomy bilateral salpingo-oophorectomy

Dear Editor: Endometriosis largely affects women, particularly during the fertile age, causing dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility in about 30 % of patients [1]. Its occurrence is estimated to be about 10 % in women in reproductive age, while postmenopausal endometriosis is much less frequent, affecting up to 2–4 % of women, usually in patients with a history of premenopausal disease. Pelvic deep endometriosis infiltrating the rectum and surrounding tissues usually causes severe symptoms, especially pain and obstruction, and its treatment is challenging, because of risk of injury of the pelvic organs and because of the high recurrence rate. Furthermore, even if endometriosis is a benign condition, it has the potential for malignant transformation [2], which occurs in 0.7–1 %, particularly in the ovaries [3]. The endometrial heterotopic tissue is functionally capable of responding to exogenous, endogenous, or local hormonal stimuli, and this estrogen dependence is considered central to its development and progression. For this reason, endometriosis is widely viewed as a disease of the premenopausal age, which normally regresses after menopause because of the lower production of estrogens, even if rare occurrence of endometriosis has been reported in postmenopausal period. In that case, the adipose tissue is supposed to become the main site of endogenous estrogen production even if unopposed hormonal replacement therapy is usually prescribed. However, the onset of deep endometriosis in postmenopausal women submitted to hysterectomy and bilateral oophorectomy for fibromatosis and without hormonal therapy is very rare and represents a conundrum with difficult interpretation. A 54-year-old woman was admitted to our hospital with severe pelvic and anal pain, constipation, and oliguria. Her body mass index was 29. Her personal history included menarche at age 12, with irregular menstrual cycles and dysmenorrhea. She had been pregnant three times, with two spontaneous abortions and one successful pregnancy with cesarean delivery. At the age of 43, she underwent laparotomic hysterectomy and bilateral salpingo-oophorectomy for leiomyomatosis of the uterus. Hormone replacement therapy was not prescribed after surgery. Histologic examination of the resected specimen showed multiple intramural leiomyoma of the uterus, minute borderline cystadenoma, and cyst of the right ovary. At the time of hospitalization, she denied any history of urinary symptoms, and rectal digital examination revealed a palpable, painful, hard, and fixed mass of the pelvis infiltrating the rectal wall. The serum concentrations of carbohydrate antigen 125 (CA 125) and carbohydrate antigen 15.3 (CA 15.3) were 134.4 and 44 .3 U/ml , respec t ive ly. Carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) levels were normal. Endoscopic examination revealed the presence of a pelvic mass compressing the walls of the rectum without mucosa infiltration at 8 cm from the anal verge and a large (>5 cm) villous polypoid lesion of the posterior wall of the rectum. Histology on the rectal biopsies from the polyp documented a villous V. Andriola :M. Battaglia : P. Ditonno :M. G. Fiore :M. De Fazio : R. Memeo :D. F. Altomare Department of Emergency and Organ Transplantation, University BAldo Moro^ of Bari, Bari, Italy