Ugo Grossi

A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation

Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation.

Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation

Objective The diagnostic accuracy of anorectal manometry (AM), which is necessary to diagnose functional defecatory disorders (FDD), is unknown. Using blinded analysis and standardised reporting of diagnostic accuracy, we evaluated whether AM could discriminate between asymptomatic controls and patients with functional constipation (FC). Design Derived line plots of anorectal pressure profiles during simulated defecation were independently analysed in random order by three expert observers blinded to health status in 85 women with FC and 85 age-matched asymptomatic healthy volunteers (HV). Using accepted criteria, these pressure profiles were characterised as normal (ie, increased rectal pressure coordinated with anal relaxation) or types I–IV dyssynergia. Interobserver agreement and diagnostic accuracy were determined. Results Blinded consensus-based assessment disclosed a normal pattern in 16/170 (9%) of all participants and only 11/85 (13%) HV. The combined frequency of dyssynergic patterns (I–IV) was very similar in FC (80/85 (94%)) and HV (74/85 (87%)). Type I dyssynergia (‘paradoxical’ contraction) was less prevalent in FC (17/85 (20%) than in HV (31/85 (36.5%), p=0.03). After statistical correction, only type IV dyssynergia was moderately useful for discriminating between FC (39/85 (46%)) and HV (17/85 (20%)) (p=0.001, positive predictive value=70.0%, positive likelihood ratio=2.3). Interobserver agreement was substantial or moderate for identifying a normal pattern, dyssynergia types I and IV, and FDD, and fair for types II and III. Conclusions While the interpretation of AM patterns is reproducible, nearly 90% of HV have a pattern that is currently regarded as ‘abnormal’ by AM. Hence, AM is of limited utility for distinguishing between FC and HV.

Severe acute pancreatitis: advances and insights in assessment of severity and management.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Normal values for high-resolution anorectal manometry: a time for consensus and collaboration

To the Editors We read with interest the manuscript recently published in your journal by Lee et al. The authors reported the influence of gender (when adjusted for the effect of age, body mass index, and vaginal delivery) on anorectal function using high-resolution manometry (HRM) in 54 ageand sex-matched asymptomatic healthy Korean volunteers. Over the last 10 years, HRM within the esophagus has revolutionized the diagnosis and management of a number of conditions of esophageal dysmotility. For this reason, investigation of the advantages that anorectal HRM may offer is a topic that is currently attracting significant interest in clinical practice, which now presents an opportunity similar to that of the Chicago process to reach agreement regarding standardization of this new and promising technique. The study by Lee et al. highlights a number of longstanding issues that have bedeviled clinical research within the field of anorectal manometry. Firstly, are the difficulties arising from differences in published results between centers. To date, there are five studies within the literature reporting the use of HRM in healthy populations. Equipment and protocols (including analysis methods) vary widely among published articles, despite the appreciation that this may affect absolute results. For example, Lee et al. report a median anal squeeze increment of 20 mmHg in the female population (n = 27). By contrast, a study by our group, also published within your journal this month, reports a 5th percentile for anal squeeze increment in healthy females (n = 96) of 45 mmHg (with this value suggested as a cutoff for normality). The reasons for these discrepancies are likely numerous. Although we agree with the suggestion by the authors of the influence of ethic characteristics, a recent article presenting results of HRM in healthy Asian volunteers reports values similar to those including participants from Western countries. It is our feeling that limitations in study design are more likely tobethemaindriver fordiscrepanciesbetweenresults. In particular, comparison of the effects of multiple independent variables (such as age, sex, and parity) using multivariate regressionmakes a number of assumptions about the data. Lee et al. aimed to identify the independent effects of four predictors on anorectal HRM parameters in a cohort of only 54 subjects. Tabachnick and Fidell give a formula for calculating sample size requirements (taking into account the number of independent variables: N > 50 + 8 m, where m = number of independentvariables),whichisviolatedinthecurrentstudy. One of the principle challenges will be to establish normative datasets of an adequate size and to promote standardization of the technique so that results are transferrable between institutions, a problem that has similarly compounded traditional practice. We call for such consensus so as to avoid the pitfalls that have affected standard HRM (and all other tests of anorectal function).

Paraneoplastic Acrokeratosis (Bazex Syndrome) in Lung Cancer

A 55-year-old white man, longstanding smoker (40 cigarettes a day for 30 years), with no past or family history of psoriasis, developed scaly erythematous hyperkeratotic lesions of the periungueal region of both hands, distributed symmetrically, first affecting thumb and second finger, then involving the other fingers, except the little finger (Fig 1). These lesions worsened during 1 year; a yellowish discoloration of nails with onychodystrophy involving both hands and feet was observed, together with hyperkeratosis and thickening of palms and soles, while sparing the other acral extremities. After 5 months, the patient underwent umbilical hernioplasty, and a chest x-ray performed at this stage did not show any abnormality. The skin lesions persisted for about 3 years showing resistance to a variety of topical treatments (ie, itraconazole, tioconazole, mometason). Shortly thereafter, about 3.5 years after the skin manifestations, the patient developed a whooping cough, and a chest-x-rays revealed a mass in the upper lobe of the right lung, subsequently confirmed with a computed tomography scan also showing omolateral nodes involvement. He was referred to the Division of Thoracic Surgery, Gemelli Hospital (Rome, Italy) presenting as paronichia-like lesions. All 20 nails showed dystrophic lesions and partial onicholysis resembling psoriasis or postinflammatory paronichia. No perilesional inflammation was seen, and the patient claimed he did not have any inflammation in past. Cultural and direct examination for fungi was negative. Familiar history for psoriasis was negative, and there was not any other sign of psoriasis on the skin and the nails. The patient underwent upper right lobectomy. The postoperative pathological diagnosis was G3 adenocarcinoma of the lung T2-N0-M0; immunohistochemistry showed that constituent cells were positive for cytokeratin 7 and thyroid transcription factor 1, while negative for cytokeratin 20 and synaptophysin. A 3-month course of treatment with cisplatin and navelbine was delivered. The skin lesions drastically improved in a few months, with complete healing in July 2008 (Fig 2). The diagnosis of Bazex syndrome (BS) associated with adenocarcinoma of the lung was given. Twenty-seven-months follow-up after successful surgical resection the patient has no evidence of disease. In 1922, Gougerot and Rupp first recognized paraneoplastic acrokeratosis (PA). The eponymous of BS is ascribed to André Bazex, who reported several cases since his first description of PA associated with a metastatic pyriform sinus cancer in 1965. At the same time, the term BS may also refer to a rare genodermatosis with cancer predisposition described by the same author. In this work, 143 cases of PA have been reviewed, mostly related to supradiaphragmatic squamous cell malignancies and affecting men older than age 40 years. The association with adenocarcinoma of the lung is rare. We observed a striking case of PA whose clinical outcome diverged from the standard three-stage course originally proposed by Bazex and Griffiths. As a rule, a cutaneous paraneoplastic disorder is mostly associated with squamous cell carcinoma of the upper aerodigestive tract and is characterized by a symmetric, psoriasiform, hyperkeratotic eruption of the extremities (ears, finger, toes, nose), which may also involve trunk and limbs. Itching and paining are uncommon, although the former may occur in up to 18% of cases. Hyperkeratotic eruption is typical of BS, some unusual features of the dermatosis have been described, such as hyperpigmented papules, plaques and bullous lesions. Diagnosis is clinical, based on the patient’s medical history and physical examination, paying attention to the characteristic distribution of the lesions. Other conditions such as acral psoriasis, palmoplantar keratoderma, onychomycosis, pityriasis rubra pilaris should be ruled out. To our knowledge, only 15 women (10.6%) with BS have been reported. Although pathogenesis is still unclear, several hypotheses have been proposed, pointing out to the cross reactivity between tumoral and cutaneous antigens as responsible for the skin damage. As observed by Bazex and Griffiths, PA generally present a well-defined three-stage course. In the first stage, acral regions are first involved including nails (77%), ears (76%), fingers (65%), and nose (62%) with no clinical evidence of the underlying tumor. In the

Factors predicting ischemic-type biliary lesions (ITBLs) after liver transplantation

Among biliary complications, ischemic-type biliary lesions (ITBLs) remain a major cause of morbidity in liver transplant recipients, significantly affecting the chance of survival of both patients and grafts. We retrospectively reviewed 10 years of prospectively collected donor and recipient data from April 2001 to April 2011. We evaluated the incidence of ITBL occurrence, exploring the possible predisposing factors, including donor and recipient data. Two hundred fifty-one grafts were harvested: 222 of them were transplanted at our institution, the remaining 29 (11.6%) discarded by our donor team as showing >40% macrovesicular steatosis. Mild-moderate (20%-40%) macrovesicular steatosis (P < .001) and cold ischemia time (P = .048) significantly increased the risk of ITBL, also as an independent risk factor after multivariate analysis.

Pathophysiology of fecal incontinence differs between men and women: a case‐matched study in 200 patients

Fecal incontinence (FI) is a common and socially disabling condition with obstetric trauma considered the principal etiological factor. This study aimed to systematically evaluate symptom presentation and anorectal function in both females and males with FI.

Incidence of Upper Aerodigestive Tract Cancer After Liver Transplantation for Alcoholic Cirrhosis: A 10-Year Experience in an Italian Center

INTRODUCTION The aim of this study was to evaluate the incidence, clinical characteristics, treatment, and outcome of de novo tumors (DNT) of the upper aerodigestive tract in patients with alcoholic cirrhosis after orthotopic liver transplantation (OLT). METHODS Among 225 consecutive OLT performed between January 2002 and January 2012, a total of 205 patients received a first liver allograft. Eleven (4.9%) patients developed DNT (lung, pancreas, bowel, esophagus, larynx, tongue, tonsil, and lymphoma). Among these, we observed 5 patients with DNT of the upper aerodigestive tract. RESULTS The 5 patients with DNT of the upper aerodigestive tract underwent OLT for alcoholic cirrhosis. There were 4 men and 1 woman with a mean age at transplantation of 47 years. The mean period of alcohol abuse was 90 months. The tumors occurred after a mean post-transplantation time of 39 months. The immunosuppressive regimen included Tacrolimus, mTOR, mycophenolate mofetil (MMF), and low-dose steroids. We observed 2 cases of squamous cell carcinoma of the esophagus, 1 case of tonsillar cancer, 1 case of larynx carcinoma, and 1 case of tongue carcinoma. All patients underwent surgical excision. After surgery, 4 patients received chemotherapy and 2 patients radiotherapy. At present, among the 5 patients with DNT of the upper aerodigestive tract, only 2 are alive without disease and 1 is alive with a local recurrence. CONCLUSION The incidence of DNT of the upper aerodigestive tract after OLT is higher among patients receiving a transplant for alcoholic cirrhosis. This could be due to an additional effect of post-transplantation immunosuppression in patients exposed to alcohol before transplantation. We suggest a careful post-transplantation follow-up and more attention to improve early diagnosis.

Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension).

To assess the outcomes of rectal suspension procedures (forms of rectopexy) in adults with chronic constipation.

Food residue granuloma mimicking metastatic disease on FDG-PET/CT

A 31-year-old woman presenting with acute abdomen underwent an emergency Hartmann’s procedure for fecal peritonitis due to perforated adenocarcinoma of the left colon. Shortly after a 7-month course of adjuvant chemotherapy, follow-up contrast-enhanced CT showed multiple peritoneal and hepatic nodules, showing focal intense and homogeneous FDG uptake on FDG-PET/CT, highly suspected for recurrence of disease. Excisional biopsy of the nodules revealed foreign body granulomas made up of alimentary materials surrounded by a fibrous wall. We report a unique case of a false-positive finding secondary to food residues mimicking metastatic disease on FDG-PET in a patient with colon cancer.