Paola De Nardi

Comparison of Glycerine Trinitrate and Botulinum Toxin-A for the Treatment of Chronic Anal Fissure: Long-Term Results

PurposeThis study was designed to compare the efficacy of two different “chemical sphincterotomies” for chronic anal fissure.MethodsFrom January to December 2001, 30 consecutive patients (17 males; mean age, 41.8 years) with chronic posterior anal fissure were enrolled. The patients were randomly assigned to receive 0.2 percent glycerine trinitrate ointment applied three times daily at theanal margin for eight weeks (Group A) or 20 units Botulinum toxin A injection into the internal anal sphincter on each side of the anterior midline (Group B). The patients were reviewed at 15 days, 1, 3, 6, 12, and every other 12 months. Follow-up ranged between 36 and 46 months. Patients in either group who failed to improve were referred for surgical treatment.ResultsTwelve patients in Group A and 11 in Group B had improvement or relief from symptoms at the first visit. The fissure was healed in ten patients in Group A and in eight in Group B within three months (66.7 and 57.1 percent). Recurrence of the fissure occurred in five patients in each group during the follow-up. The healing rate at three years was 40 and 33.3 percent for Group A and B, respectively. No patients in either group reported serious adverse effects; however, three patients in Group A (20 percent) had transient headache. None had fecal incontinence.ConclusionBoth treatments may be considered as first-line treatment even if less effective than surgery.

Feasibility of an Adaptive Strategy in Preoperative Radiochemotherapy for Rectal Cancer With Image-Guided Tomotherapy: Boosting the Dose to the Shrinking Tumor

PURPOSE To investigate the feasibility of preoperative adaptive radiochemotherapy by delivering a concomitant boost to the residual tumor during the last 6 fractions of treatment. METHODS AND MATERIALS Twenty-five patients with T3/T4N0 or N+ rectal cancer were enrolled. Concomitant chemotherapy consisted of oxaliplatin 100 mg/m(2) on days -14, 0, and +14, and 5-fluorouracil 200 mg/m(2)/d from day -14 to the end of radiation therapy (day 0 is the start of radiation therapy). Radiation therapy consisted of 41.4 Gy in 18 fractions (2.3 Gy per fraction) with Tomotherapy to the tumor and regional lymph nodes (planning target volume, PTV) defined on simulation CT and MRI. After 9 fractions simulation CT and MRI were repeated for the planning of the adaptive phase: PTVadapt was generated by adding a 5-mm margin to the residual tumor. In the last 6 fractions a boost of 3.0 Gy per fraction (in total 45.6 Gy in 18 fractions) was delivered to PTVadapt while concomitantly delivering 2.3 Gy per fraction to PTV outside PTVadapt. RESULTS Three patients experienced grade 3 gastrointestinal toxicity; 2 of 3 showed toxicity before the adaptive phase. Full dose of radiation therapy, oxaliplatin, and 5-fluorouracil was delivered in 96%, 96%, and 88% of patients, respectively. Two patients with clinical complete response (cCR) refused surgery and were still cCR at 17 and 29 months. For the remaining 23 resected patients, 15 of 23 (65%) showed tumor regression grade 3 response, and 7 of 23 (30%) had pathologic complete response; 8 (35%) and 12 (52%) tumor regression grade 3 patients had ≤5% and 10% residual viable cells, respectively. CONCLUSIONS An adaptive boost strategy is feasible, with an acceptable grade 3 gastrointestinal toxicity rate and a very encouraging tumor response rate. The results suggest that there should still be room for further dose escalation of the residual tumor with the aim of increasing pathologic complete response and/or cCR rates.

Short and long-term outcomes of laparoscopic colectomy in obese patients

AIM To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases. METHODS A total of 98 obese (body mass index > 30 kg/m(2)) patients who underwent laparoscopic (LPS) right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy. Controls were selected to match for body mass index, site of primary disease, American Society of Anesthesiologists score, and year of surgery (± 3 year). The parameters analyzed included age, gender, comorbid conditions, American Society of Anaesthesiologists class, diagnosis, procedure, and duration of operation, operative blood loss, and amount of homologous blood transfused. Conversion rate, intra and postoperative complications as were as reoperation rate, 30 d and long-term morbidity rate were also analyzed. For continuous variables, the Students t test was used for normally distributed data the Mann-Whitney U test for non-normally distributed data. The Pearsons χ(2) tests, or the Fisher exact test as appropriate, were used for proportions. RESULTS Conversion to open surgery was necessary in 13 of 98 patients (13.3%). In the LPS group, operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy (P = 0.03, P = 0.0001, respectively). Overall morbidity, anastomotic leak and readmission rate did not significantly differ between the two groups. A trend toward a reduction of wound complications was observed in the LPS when compared to open group (P = 0.09). In the LPS group, an earlier recovery of bowel function (P = 0.001) and a shorter length of stay (P = 0.03) were observed. After a median follow-up of 62 (range 12-132) mo 23 patients in the LPS group and 38 in the open group experienced long-term complications (LPS vs open, P = 0.03). Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one (P = 0.03). CONCLUSION Laparoscopic colectomy in obese patients is safe, does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Multidisciplinary treatment of rectal cancer in 2014: where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.

Laparoscopic treatment of deep pelvic endometriosis with rectal involvement.

PURPOSE: Our study aimed to evaluate the feasibility and outcome of laparoscopic excision of deep pelvic endometriosis with extensive rectal involvement causing severe symptoms. METHODS: Ten patients, mean age 32 years (range, 27-43), with deep pelvic endometriosis and rectal wall involvement, requiring surgical resection, were studied since January 2004. Prior to surgery and 6 months postsurgery, patients completed a 100-point rank questionnaire on intensity of intestinal and extraintestinal symptoms. A laparoscopic approach was performed by a team of a gynecologist and colorectal surgeons. RESULTS: At surgery, complete excision of infiltrating endometriosis was achieved, with 7 low rectal resections, 2 rectosigmoid resections, and 1 proctectomy with coloanal anastomosis. Additional procedures were: ureter resections (n = 2) with one reimplantation in the bladder, left ovariectomies (n = 2), ovarian endometrioma resections (n = 4), and laser ablation of superficial peritoneal lesions (n = 4). In four cases, a laparotomic conversion was needed. Mean follow-up was 27.6 months (range, 18-37). Neither intraoperative nor postoperative serious complications were observed. All the patients experienced significant improvement of intestinal and extraintestinal symptoms. CONCLUSIONS: Laparoscopic resection of deep pelvic endometriosis with rectal involvement can be successful in improving digestive and gynecologic symptoms; however, this approach is challenging with a high rate of laparotomic conversion.

New approach to anal cancer： Individualized therapy based on sentinel lymph node biopsy

Oncological treatment is currently directed toward a tailored therapy concept. Squamous cell carcinoma of the anal canal could be considered a suitable platform to test new therapeutic strategies to minimize treatment morbidity. Standard of care for patients with anal canal cancer consists of a combination of radiotherapy and chemotherapy. This treatment has led to a high rate of local control and a 60% cure rate with preservation of the anal sphincter, thus replacing surgical abdominoperineal resection. Lymph node metastases represent a critical independent prognostic factor for local recurrence and survival. Mesorectal and iliac lymph nodes are usually included in the radiation field, whereas the inclusion of inguinal regions still remains controversial because of the subsequent adverse side effects. Sentinel lymph node biopsies could clearly identify inguinal node-positive patients eligible for therapeutic groin irradiation. A sentinel lymph node navigation procedure is reported here to be a feasible and effective method for establishing the true inguinal node status in patients suffering from anal canal cancer. Based on the results of sentinel node biopsies, a selective approach could be proposed where node-positive patients could be selected for inguinal node irradiation while node-negative patients could take advantage of inguinal sparing irradiation, thus avoiding toxic side effects.

Recurrent giant liposarcoma of the spermatic cord.

A giant recurrent retroperitoneal liposarcoma of the spermatic cord was removed in a 40-year-old man. The tumor measured 50 cm and weighed 42 Kilograms. Radiotherapy and chemotherapy have little role in this neoplasm. Despite the huge dimension of the mass surgery was successfully undertaken without relapse at 12 months follow-up.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?: IMA ligation in diverticular disease

The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome.

Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer.

BACKGROUND An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer. AIM The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry. METHODS Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2). RESULTS Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively. CONCLUSIONS CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.

Tu2005 Manometric Evaluation of Anorectal Function in Patients Treated With Pre-Operative Chemo-Radiotherapy and Total Mesorectal Excision for Rectal Cancer

ence was measured using the COREFO questionnaire. Rectoanal manometry was performed prior to and 6 months after treatment to assess anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), rectoanal inhibitory reflex (RAIR), rectal distension-related sensation levels (first sense (FS), first urge (FU), maximum tolerable volume (MTV)) and rectal compliance (RC). Results. Of 26 enrolled patients, 4 were excluded because of unexpected cancer. Of the remaining 22 (EMR/TEM 10/12), 17 were male and mean age was 62.4 ± (standard deviation) 9.4 years. Mean adenoma size was 48 ± 17 mm and median distance from the dentate line was 3 cm (range 0-14). Prior to treatment, incontinence for solid feces, liquid feces, flatus and soiling were reported by 14%, 41%, 68% and 55%, respectively. Mean ARP, SP and SE were 66 ± 18 mmHg, 205 ± 101 mmHg and 21 ± 10 s (SE ≥ 30 s in 8 patients (36%)). RAIR was present in 16 patients (73%). Median levels of FS, FU and MTV were 85 mL (25-300), 120 mL (55-340) and 223 (150-500). In 3 patients, the MTV was not reached. RC was 6.7 ± 2.7 mL/mmHg. Follow-up data were available for 9 patients (EMR/TEM 6/3). Six months after treatment, incontinence for solid, liquid feces, flatus and soiling were reported by 0%, 0%, 67% and 44%, respectively. Mean ARP, SP and SE after 6 months were 55 ± 14 mmHg, 193 ± 56 mmHg and 27 ± 7s (SE ≥ 30 s in 6 patients (67%)). In paired analyses, ARP was significantly lower compared to preoperative values (p=.038). SP was comparable, with longer SE (p=.023). RAIR was present in 7 patients (78%). Median levels of FS, FU and MTV after 6 months were 100 mL (10350), 120 mL (60-350) and 230 (115-350); in 2 patients, FS and FU were not reached, respectively. Distension-related sensation levels were comparable to preoperative values. RC was also comparable to preoperative assessment (5.8 ± 2.7 mL/mmHg, p=.355). Discussion. Rectoanal functional complaints in patients with large rectal adenomas may be caused by increased distension-related sensitivity levels as well as increased rectal mucus production in comparison with healthy adults. Although endoscopic or surgical adenoma resection may cause a decrease in ARP, the short-term effects of EMR and TEM on rectoanal function seem limited.