Comparison between high-resolution water-perfused anorectal manometry and THD® Anopress anal manometry: a prospective observational study.

AIM: Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by standard high-resolution water-perfused manometry (WPM) with the newer THD® Anopress manometry system. METHOD: This was a prospective observational study. Conventional manometry was carried out using a water-perfused catheter with high-resolution manometry and compared with the Anopress system with air-filled catheters. All patients underwent the two procedures successively in a randomized order. Time to arrive at the resting pressure plateau, resting, squeeze, straining pressure and visual analogue scale (VAS) scores for pain were recorded. A qualitative analysis of the two devices was performed. RESULTS: Between 2016 and 2017, 60 patients were recruited. The time from insertion of the catheter to arriving at the resting pressure plateau was significantly lower with the Anopress compared with WPM: 12 s [interquartile range (IQR) 10-17 s] versus 100 s (IQR 67-121 s) (P < 0.001). A strong correlation between the manometric values of WPM and the Anopress was observed. Both procedures were well tolerated, although the VAS score for insertion of the WPM catheter was significantly higher. The Anopress was easier to use and more time-efficient than the WPM. CONCLUSION: The pressure values obtained with Anopress correlated well with those of conventional manometry. The Anopress has the advantage of being less time-consuming, user-friendly and better tolerated by patients.

Practice parameters for the diagnosis and treatment of anal intraepithelial neoplasia (AIN) on behalf of the Italian Society of Colorectal Surgery (SICCR).

Squamous cell carcinoma (SCC) of the anus is a human papilloma virus (HPV) related malignancy that is preceded by anal intraepithelial neoplasia (AIN) making this cancer, at least theoretically, a preventable disease. In the past 10 years the diagnosis, management and nomenclature of AIN has dramatically changed. Increased life expectancy in human immunodeficiency virus (HIV) positive patients due to highly active antiretroviral therapy (HAART) has caused an increase in the incidence of SCC of the anus. While many experts recommend screening and treatment of anal high-grade squamous intraepithelial lesion (HSIL), there is no consensus on the optimal management these lesions. Therefore, there is a need to review the current evidence on diagnosis and treatment of AIN and formulate recommendations to guide management. Surgeons who are members of the Italian Society of Colorectal Surgery (SICCR) with a recognized interest in AIN were invited to contribute on various topics after a comprehensive literature search. Levels of evidence were classified using the Oxford Centre for Evidence-based Medicine of 2009 and the strength of recommendation was graded according to the United States (US) preventive services task force. These recommendations are among the few entirely dedicated only to the precursors of SCC of the anus and provide an evidence-based summary of the current knowledge about the management of AIN that will serve as a reference for clinicians involved in the treatment of patients at risk for anal cancer.

Acceptability, effectiveness and safety of a Renew® anal insert in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis.

INTRODUCTION: Restorative proctocolectomy has gained acceptance in the surgical management of medically refractive ulcerative colitis and cancer prevention in familial adenomatous polyposis. Incontinence following restorative proctocolectomy occurs in up to 25% of patients overnight. The Renew® insert is an inert single-use device which acts as an anal plug. The aim of this study was to assess the acceptability, effectiveness and safety of the Renew® insert in patients who have undergone restorative proctocolectomy. The device has yet to be assessed in patients who have undergone restorative proctocolectomy. METHOD: This was a prospective study exploring the acceptability, effectiveness and safety of the Renew® insert in improving incontinence in patients who had undergone restorative proctocolectomy. A total of 15 patients with incontinence were asked to use the Renew® insert for 14 days following their standard care. The Incontinence Questionnaire-Bowels was used pre- and posttreatment to assess response and patients were asked to report the perceived acceptability, effectiveness and safety of the device at the end of the trial. RESULTS: The device was acceptable to 8/15 (53%) of patients and was effective in 6/15 (40%). Only 2/15 (13%) of patients raised any safety concerns, and these were minor. The device was associated with a significant reduction in night seepage (P = 0.034). CONCLUSION: In a small study, the Renew® insert can be both acceptable and effective and is also associated with few safety concerns. It is also associated with significant reductions in night-time seepage.

Five year experience of the treatment of squamous cell carcinoma of the anus.

OBJECTIVES: The best treatment of early stage anal squamous cell carcinoma (SCC) is under debated. Wide local excision (WLE) may be considered adequate for stage 1 anal margin cancer. This study demonstrates our experience in treatment of patients with SCC over 5 years. PATIENTS AND METHODS: We conducted a retrospective study of patients who had undergone anal screening or anal cancer surveillance between October 2010 and 2015 in our department. Each patient underwent anal Pap test, HPV test PCR HPV DNA and cytology by Thin Prep. The examinations were performed by Proctostation THD©. Data were collected and analysed. RESULTS: We included 25 patients, 16 male (64%) and 9 female (36%). Twenty-four patients had SCC and 1 patient had adenocarcinoma. Of this cohort: 10 underwent chemoradiotherapy (CRT) because T3-4 N1-2 M0, 13 underwent only surgery because T1/T2 and 2 patients had CRT and surgery because they already have had anal cancer treated in the past with CRT. Seventeen patients (68%) of this cohort, including 5 with micro-invasive SCCs, had regular follow-up without recurrences. Four patients (17%) died from metastatic disease and 4 patients (17%) had recurrent disease. CONCLUSIONS: In this small cohort we demonstrated satisfactory results in treatment of SCCs, underlining the effective role of surgery in early stages of SCC. Screening program and follow up were fundamental to identify early stage and recurrent disease. Also we found the High-resolution video-proctoscopy a valid diagnostic tool.

Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial.

AIM: This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome. METHOD: Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni- and multivariate analyses of the potential predictive factors for failure were performed. RESULTS: The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 ± 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively. Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome. CONCLUSION: THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.

Emergency transanal haemorrhoidal Doppler guided dearterialization for acute and persistent haemorrhoidal bleeding.

AIM: The effectiveness of Doppler guided transanal haemorrhoidal dearterialization (THD) for arresting persistent haemorrhoidal bleeding in patients admitted as an emergency was studied. METHOD: Eleven patients with severe anal bleeding underwent emergency THD as definitive treatment for haemorrhoids. In the majority of patients antiplatelet or anticoagulant therapy was ongoing and severe anaemia was present in six patients. RESULTS: The mean operative time was 39.7 min. Six to nine feeding arteries were ligated. Intra-operative blood loss was nil. Bleeding was well controlled in all patients. No blood transfusion was required. Mean pain score per verbal numeric scale was 3.6 and 1.4 on day 1 and day 3 respectively. The mean time to resumption of normal activities was 8 days. No major complications were experienced. Six months follow-up demonstrated good control of haemorrhoidal disease. CONCLUSION: THD is effective in controlling acute haemorrhoidal bleeding with a low incidence of postoperative complications.

Small bowel mesentery solitary fibrous tumor. A rare neoplasia in a young male.

Extrapleural Solitary Fibrous Tumors (SFT), in particular small bowel mesentery SFTs, are extremely rare neoplasms. We describe the case of a young male hospitalized for unspecific abdominal symptoms and evidence of a well-circumscribed mass arising from the small bowel mesentery. Histopathological and immunohistochemical analysis on the surgical specimen confirmed the diagnosis of SFT. A Pubmed search revealed only another case of small bowel mesentery SFT, confirming the extremely rarity of this tumor.

Small bowel metastasis from lung cancer: a possible cause of acute abdomen. Case report and literature review.

OBJECTIVE: Lung cancer represents the leading cause of tumor death in the world with 50% of patients presenting metastatic disease at the time of diagnosis. Gastrointestinal (GI) lung cancer metastasis were thought to be extremely rare, but a much higher incidence has been noted in several autoptic reports. Clinical relevance of GI metastasis is low, but can increase with the higher number of newly diagnosed patients and with the efficacy of systemic chemotherapy in advanced stages. Prognosis of complicated GI lung cancer metastasis seems to be worse than the natural course of the disease and acute bleeding or perforation of metastatic site can be accelerated by chemotherapy. CASE REPORT: We describe the clinical case of a patient presenting with acute abdomen due to small bowel perforation from GI lung cancer metastasis. A review of the most recent published literature on GI lung cancer metastasis was performed. DISCUSSION: GI metastasis from lung cancer may occur within the clinical course of the disease and require surgical treatment followed by a poor outcome. Percentage of lung cancer patients with GI metastasis can reach level of 14%. Large cells carcinomas causing kidney and adrenal metastasis are more likely associated with GI localization of the disease. CONCLUSIONS: Complications of GI metastases, although rare, must be considered as possible cause of acute abdomen in patients with lung cancer. Identification of clinical indicators of GI metastasis may help in the therapeutic strategy.

Simultaneous surgery for obstructive coronary artery disease and ulcerated gastric cancer.

A patient with ulcerated gastric cancer causing mild anaemia and simultaneous three-vessel coronary artery disease (CAD) underwent "off pump" coronary artery bypass grafting (OP-CABG) and total D2 gastrectomy.

[Metastatic gastric cancer successfully treated with surgery and chemotherapy. Case report]. / Un caso di neoplasia gastrica metastatica trattato con successo con chirurgia e chemioterapia.

A case of long-term survivor 50-year-old man treated for advanced gastric cancer with two liver metastases is described. Patient underwent a total gastrectomy with D2 lymphadenectomy and atipic liver resection. After surgery, chemotherapy with PELF achieved a complete clinical response; six month from the fourth cycle, Ca19.9 levels slowly increased until 185 U/mL and a retro-peritoneal lymphadenopathy was detected by US. Three different chemotherapeutic combinations (FOLFOX, FOLFIRI, FOLFOX4) was administrated but two new liver recurrences spread out. From November 2007 until now, patient received 8 CDF cycles and he obtained a complete clinical response supported by persistent negativity of TC-PET scans. The radiological investigations performed after last admission in our Department for jaundice, revealed multiple liver lesions with Ca 19.9 levels of 6.766 U/mL. The patient required placement of metallic biliary endoprosthesis. He is still alive 41 month after primary surgery. We consider this case a successful example of survival increasing by integrated surgery-chemotherapy treatment but also an expression of the failure of current available therapy in the definitive cure for gastric cancer. Metastatic gastric cancer should be considered a disease treatable but not curable.

[Preliminary experience in treatment of locally advanced gastric adenocarcinoma with peri-operative chemotherapy]. / Esperienza preliminare di chemioterapia perioperatoria nel cancro gastrico localmente avanzato.

AIM: Gastric Cancer (GC) is a poor prognosis neoplasm and it is often diagnosed at advanced stage. Neoadjuvant Chemotherapy (NAC) may increase the possibility of complete surgical resection and improve Overall Survival (OS). PATIENTS AND METHODS: Since November 2006, six patients with gastric adenocarcinoma, diagnosed by endoscopy, endoscopic ultrasonography and total body 18FDG-PET-CT, were enrolled in a program of peri-operative chemotherapy, according to the following inclusion criteria: cT2N+M0 or cT3-4NxM0, age < 75 years, Karnofsky Performance Status > 60%, absence of hepatic, renal and bone marrow failures. The patients undergo three cycles of pre-operative and post-operative chemotherapy based on Epirubicine, Cisplatin, and 5-Fluorouracil (ECF) as MAGIC Trial proposed. Fifteen days after the end of pre-operative chemotherapy the patient undergoes endoscopic ultrasonography and total body 18FDG-PET-CT to evaluate the tumor response to treatment, and then he is addressed to surgery. Thirty days after surgery he starts the post-operative chemotherapy. RESULTS: All patients completed the pre-operative chemotherapy. Five patients underwent D2 subtotal gastrectomy and only one patient D1 total gastrectomy. No peri- and post-operative mortality and morbidity were observed. One month after surgery all patients started chemotherapy. During post-operative chemotherapy two patients developed subclavian vein thrombosis, one patient developed renal failure. CONCLUSIONS: Although surgical resection remains the key component in the treatment of GC, it is clear that improved outcome will depend on a multidisciplinary treatment. NAC is associated with appreciable toxicity and it may improve the OS, allowing the downstaging of the primary tumor and increasing its resecability, as shown by MAGIC trial.

[Laparoscopic intraperitoneal hyperthermic perfusion in palliation of malignant ascites. Case report]. / Chemioipertermia intraperitoneale laparoscopica nel trattamento dell'ascite maligna. Case report.

Malignant ascites is a pathological condition, due to several abdominal and extra-abdominal neoplasms, representing a difficult challenge in treatment. Different medical and surgical options have been proposed, but none of them have shown efficacy, leading only to partial and temporary relief of symptoms. Laparoscopic intraperitoneal chemotherapy may be a valid therapeutic option in patients in whom medical therapies have failed and peritoneovenous shunting is contraindicated. A 49-years old woman with malignant ascites, secondary to peritoneal localization of right pleural mesothelioma, underwent, after failure of medical therapy, laparoscopic intraperitoneal chemotherapy (with Cisplatin 25 mg/m2/L and Doxorubicin 7 mg/m2/L). An important and lasting reduction of ascites and abdominal symptoms was documented till the exitus, due to pulmonary embolism after 11 months. Laparoscopic intraperitoneal chemotherapy may be a good therapeutic option to palliative malignant ascites in patient not eligible for a radical cytoreductive treatment, but further investigations are needed to standardized dosage and perfusion procedure.

Effect of a centralised transfer service on characteristics of inter-hospital neonatal transfers.

OBJECTIVE: To determine the effect of a centralised neonatal transfer service on numbers of neonatal transfers and the time taken for teams to reach the baby. DESIGN: Prospective census of neonatal inter-hospital transfers between May and July 2004. Comparison with a previous census undertaken before introduction of the service. Analysis of requests for antenatal in-utero transfer to the regional emergency bed service. SETTING: Geographically defined area in London and southeast England. PATIENTS: Babies transferred to or from a neonatal unit. INTERVENTIONS: Introduction of a centralised neonatal transfer service. MAIN OUTCOME MEASURES: Numbers of transfers, time taken for teams to arrive to the baby (response time). RESULTS: During the census there were 835 transfers with an increase of 34% from the previous census (n = 619). Most of the increase was in urgent transfers for neonatal intensive care. There was a mean of 4.4 urgent transfers a day, with 3.9 elective and 0.8 short-term transfers. Over the same period in-utero transfers decreased. Response times improved from a median of 2 h in 2001 to 1.45 h in 2004 (p<0.05). The 90th centile fell from 6 h to 4.9 h. CONCLUSION: Following the introduction of a centralised neonatal transfer service, response times improved significantly. An increase in the numbers of transfers for medical intensive care was associated with a reduced number of in-utero transfers. To balance the improved safety and accessibility of neonatal transfer, similar developments may be needed to facilitate in-utero transfer.

[Rectosigmoid junction neoplasms: our experience]. / Le neoplasie della giunzione sigma-retto: esperienze personali.

The Authors report their experience with 25 patients operated for colorectal junction neoplasms from January 1998 to December 2002 in the Section of Oncological Surgery, at Perugia University. According to the international literature, the Authors maintain the absolute functional and anatomical individuality of this part of the large bowel, underlining the peculiarity of the sigmoidal junction neoplasms respect all the others colic sites regarding clinical manifestations, symptoms developing and biological behaviour. The characteristics seem also capable of changing the surgical choice as well as the prognosis of the disease.

[The use of surgical endo-prosthesis in the treatment of choledocolithiasis in the elderly. Personal experience]. / L'uso delle endoprotesi chirurgiche nel trattamento della litiasi della VBP nell'anziano. Esperienze personali.

BACKGROUND: The usefulness of biliary endoprostheses in some selected elderly patients affected by hepato-choledocolithiasis is described. METHODS: In the Department of Surgery, University of Perugia, 119 elderly patients were surgically treated for choledocholithiasis from January 1999 to December 2000. In 44 selected cases#151;oldest patients with thinner hypovascularized ectasic choledochal wall#151; a permanent transpapillary polyurethane prosthesis was placed, after choledocolithotomy with or without sphinterotomy; sometimes prosthesis was placed under the duodenal mucosa. RESULTS: Endoprosthesis had a long duration and gave good results in canalization and periprosthetic flow, in absence of biliary stasis and/or angiocholitis. Only one patient had prostheses displacement. CONCLUSIONS: On the basis of personal experience and considering physiopathology and pathogenesis of biliary stones in the elderly, the authors underline, in selected cases, the need of stenting the hepatocholedochal lumen with the aim of avoiding collapse.

Neonatal and post-natal growth.

Growth velocity is higher in late intra-uterine and early post-natal life than at any time thereafter, and accurate measurements are essential for appropriate monitoring. The accuracy with which such measurements are made and recorded is frequently questionable, however, and short- and medium-term changes in growth may be difficult to interpret in the light of normal variations in the pattern of growth. Infants who are small at birth must be accurately classified because intra-uterine growth retardation and small for gestational age have different implications for both causation and outcome. Prediction of expected growth on the basis of mid-parental height is essential but frequently omitted. Post-natal growth impairment is common in pre-term infants and is often rapid in onset. Poor growth may continue for many months, and catch-up may be incomplete. Early growth failure may have a significant influence on subsequent morbidity and mortality.