Pierluigi Lobascio

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.

Factors affecting the outcome of temporary sacral nerve stimulation for faecal incontinence. The value of the new tined lead electrode

Aim  Sacral nerve stimulation (SNS) is an effective but expensive treatment for faecal incontinence. About 50% of the patients are unresponsive for unknown reasons, hence knowledge of any factors predictive of success would be highly desirable. The aim of this study was to analyse the potential factors associated with a successful outcome of the temporary test of electrostimulation.

Overlapping sphincteroplasty and modified lotus petal flap for delayed repair of traumatic cloaca

Traumatic cloaca is a disabling condition characterized by disruption of the perineal body, anterior sphincter tears and loss of the distal rectovaginal septum. Anterior overlapping sphincteroplasty is the method of choice to treat faecal incontinence caused by obstetric injury. However, reconstruction of large perineal body defects may be a challenging task for surgeons. Herein we describe the successful use of a modified lotus petal flap following overlapping sphincteroplasty to repair a traumatic cloaca that had occurred during vaginal delivery 20 years earlier. After 3 months of follow-up and ileostomy closure, the patient had a good aesthetic result and only minor faecal incontinence episodes not requiring pads, fully recovered urinary continence and a significant improvement in her quality of life.

Retrobulbar metastasis from gallbladder carcinoma after laparoscopic cholecystectomy. A case report

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor. The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.

Tachyarrhythmia due to Atrial Fibrillation in an Intragastric Balloon Carrier: Coincidence or Consequence?

A morbidly obese patient is reported who underwent insertion of a BioEnterics® Intragastric Balloon (BIB) as a pre-surgical procedure (ie. prior to restrictive gastric banding). While carrying the BIB, the patient suffered an episode of severe supraventricular tachyarrhythmia (atrial fibrillation). Although such an event is not definitely correlated to the BIB, the episode led us to modify the pre-treatment protocol, introducing dynamic Holter ECG into the work-up investigations and excluding subjects with a pathological cardiac rhythm.

Potential role of the steroid receptor pattern in the response of inoperable intra-abdominal desmoid to toremifene after failure of tamoxifen therapy

Dear Editor: Desmoid tumors are rare, non-metastatic soft tissue tumors caused by an abnormal clonal proliferation of fibroblastlike cells with a huge amount of extracellular matrix. Although they can occur sporadically, particularly in the extremities, they typically develop in about 20% of patients with a family history of adenomatous polyposis, in this case, Gardners syndrome. Desmoid tumors are, in fact, the first cause of death in patients submitted to total proctocolectomy for familial adenomatous polyposis because despite their benign nature, their uncontrolled intra-abdominal growth with mesenteric infiltration usually makes surgical removal impossible. Multiorgan transplantation is usually the final lifesaving option, although the high peri-operative mortality and the risk of further recurrence of the desmoids are grave drawbacks. If feasible, surgical removal is still the most common approach, although the high reported rate of recurrence, up to 30–40%, should discourage this option in favor of other, more conservative treatments. However, this type of tumor usually responds poorly to traditional adjuvant therapy, including radiotherapy and chemotherapy, probably because of the low cellular density. Several other treatments based on non-steroidal antiinflammatory drugs, interferon, imatinib, radio-, and chemotherapy have all been tried with variable success. Recently, increasing attention has been paid to the effect of different anti-estrogen therapies on desmoids, even if the estrogen receptors (ERα and Erβ) issue is controversial. A 32-year-old Caucasian woman underwent total colectomy and ileorectal anastomosis for diffuse colonic polyposis in 1998. The rectum was spared because the polyps, although large, were few and endoscopically removed and in view of the young age of the patient and her desire for future maternity. Histology of the resected specimen revealed multiple adenomatous polyps, some with early cancer foci invading the submucosa. Her family history included several cases with phenotypical evidence of familiar adenomatous polyposis (FAP). Her father died of cancer of the sigmoid colon; one of her sisters died of cerebellar cancer at the age of 8 years (Turcots syndrome), and another sister was diagnosed with a Gardners variant of FAP, featuring non-resectable intraabdominal desmoids, at the age of 38 years, and treated with bowel transplantation in 1999. The outcome was very poor, featuring several other operations for desmoids recurrence and death 1 year later. Two other members of the same family (paternal uncles) also died of colonic cancer. Genetic testing revealed a deletion of 5 bp in position 3183 in the APC gene in most of the members of this family, including our patient. One year after the endoscopic removal of the polyps, an abdominal computerized tomography (CT) scan revealed a solid mass in her right iliac fossa measuring 8.5 cm in diameter. Another smaller mass, measuring 6.5 cm, was evident medially, with the same characteristics. Three months There are no sources of support for this article.

Perineal Paget's disease: A rare disorder and review of literature

Introduction Extramammary Pagets disease (EMPD) occurs commonly in perineum, vulva and perineal region and is considered as a complex disorder due to different clinical and histological features. Presentation of case A 61 years old woman had a dermatologic evaluation for anal itch and underwent a skin biopsy with diagnostic of Paget disease in perianal region. Pelvic magnetic resonance showed a huge tumor which involved skin, derma and gluteus and she firstly refused any surgical treatment. One year later, because of increasing of the tumor and bleeding, she underwent the surgical procedure with a complete excision, resection of the skin of the anus, inguinal lymphadenectomy and left colostomy. Because of lymph nodes metastasis, a VLS Miles was sequentially performed. She started oncological follow up that showed liver, lung and pelvic metastasis. She survived for 24 months after surgery. Discussion In literature, less than 200 cases of perineal Pagets disease have been reported. EMPD in some cases has an associated adenocarcinoma, which has been associated with a worse prognosis and high mortality. Wrong diagnosis and a superficial consideration of a benign evolution should be considered as the first mistake in clinical practice. Conclusion Our surgical approach is considered in literature as the best one for those cases, followed by the oncological treatment. Those patients need to be better studied and more attention should be paid to the clinical presentation.

Bowel Dysfunction following Nerve-Sparing Radical Hysterectomy for Cervical Cancer: A Prospective Study

Objective: To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients. Material and Methods: Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant. Results: Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy. Conclusions: Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction.

Adipose-derived stem cells (MYSTEM® EVO Technology) as a treatment for complex transsphincteric anal fistula

High fistula-in-ano is a challenge for coloproctologists. Several surgical procedures to treat these fistulas have been developed in recent decades. Loose (or cutting) seton, fistulotomy, ligation of the intersphincteric fistula tract (LIFT) or fistulectomy with endorectal flap are considered sphincter-preserving techniques, but patients complain about discomfort and the prolonged healing period. Application of fibrin glue is considered a valid technique in selected patients. A new frontier in the treatment of perianal fistulas is the application of adipose tissue-derived stem cells (ADSCs). There are many sources of adult stem cells including the bone marrow, but the discovery of ADSCs paved the way for their large-scale use [1]. They can be easily obtained from adipose tissue with minimally invasive techniques which provide a high percentage of stem cells and very low risk of stem cell damage [2]. ADSCs are multipotent and can differentiate into various cell types, and are characterized by immunosuppressive properties and low immunogenicity. Multipotent mesenchymal stem cells [3] and ADSCs [4–6] have been used for autologous transplantation in the treatment of fistulas in patients with Crohn’s disease over the last few years with good results. This is a sphincter-preserving technique and avoids the risk of fecal incontinence associated with conventional management. We describe our experience with MYSTEM® EVO Technology (MySTEM LLC, Wilmington, DE, USA) in an autologous transplantation of ADSC for closure of a complex transsphincteric fistula. The common procedures for adipose-derived stem cell isolation are mainly based on tissue fractionation and enzymatic digestion, requiring many hours, making it unsuitable for direct surgical applications. Recent studies demonstrated the feasibility of isolating adipose stromal cells without the need for enzymatic digestion. These studies reported the processing of the fluid portion of liposuctioned adipose tissue (lipoaspirate fluid), which contains a significant amount of progenitor cells endowed with plastic and trophic features. In our case, we introduce a brand new closed device, MYSTEM® EVO Technology, which allows nonenzymatic tissue separation and rapid isolation of lipoaspirate fluid from human liposuctioned adipose tissue.

Prevention of Anovaginal Fistula during Double-Stapling of Ileal Pouch-Anal Anastomosis

Recto- or anovaginal fistula is a troublesome complication of double-stapling technique in ultralow rectal anastomosis for rectal cancer or in ileal pouch-anal anastomosis for ulcerative colitis. In this study, a technique for preventing this problem by means of separation of the vaginal wall during the stapler firing is described using a flexible spatula introduced through the rectovaginal septum into the peritoneal cavity.ZusammenfassungDie rekto- oder anovaginale Fistel ist eine unangenehme Komplikation der Doppelklammertechnik bei der ultratiefen Rektumanastomose beim Rektumkarzinom oder bei einer ilealen Pouch-analen Anastomose wegen Colitis ulcerosa. In der vorliegenden Studie wird eine Technik zur Vermeidung dieses Problems mittels Separation der vaginalen Wand während der Klammerung durch einen flexiblen Spatel beschrieben, der durch das rektovaginale Septum in den Peritonealraum eingeführt wird.