Effectiveness of sacral nerve stimulation in fecal incontinence after multimodal oncologic treatment for pelvic malignancies: a multicenter study with 2-year follow-up.

BACKGROUND: To assess whether sacral nerve stimulation (SNS) is an effective treatment for severe fecal incontinence (FI) after radiotherapy (RT)/chemoRT (CRT) in combination with pelvic surgery. METHODS: A multicenter study was conducted on patients with FI that developed after multimodal therapy for pelvic tumors and was refractory to non-operative management, who were treated with SNS between November 2009 and November 2012. Data were prospectively collected and retrospectively analyzed. Cleveland Clinic FI score (CCFIS), FI episodes per week, FI Quality of Life (FIQoL), anorectal manometry and pudendal nerve terminal motor latency were evaluated before and after SNS. RESULTS: Eleven patients (seven females, mean age 67.3 ± 4.8 years) were evaluated in the study period. Multimodal treatments included surgery and CRT (four rectal, two cervical and one prostate cancers), surgery and RT (one cervical and two endometrial cancers) and CRT (one anal cancer). The mean radiation dose was 5.3 Gy, and mean interval between the end of RT and onset of FI was 43.7 ± 23 months. Before SNS, the mean CCFIS and the mean number of FI episodes per week were 15.7 ± 2.8 and 12.3 ± 4.2, respectively. At 12-month follow-up, mean CCFIS improved to 3.6 ± 1.8 (p = 0.003) and the mean number of FI episodes decreased to 2.0 ± 1.9 per week (p = 0.003). These results persisted at 24-month follow-up. Significant improvement was also observed for each of the four domains of FIQoL at 12- and 24-month follow-up. Anorectal manometry values did not change significantly at follow-up. CONCLUSIONS: SNS is feasible and may be an effective therapeutic option for FI after multimodal treatment of pelvic malignancies.

Risk factors for colorectal anastomotic stenoses and their impact on quality of life: what are the lessons to learn?

AIM: The aim of the study was to analyse the incidence of benign colorectal anastomotic stenoses in consecutive patients operated on in a single institution and to assess risk factors for their development. Their impact on quality of life was also evaluated. METHOD: Patient characteristics, indications for surgery, surgical technique and postoperative complications were prospectively recorded. Stenosis was evaluated by rectoscopy at regular intervals, and patients were treated only if symptomatic. After at least 6 months following surgery, patients were asked to respond to the Short Form 36-item quality-of-life questionnaire during a telephone interview. RESULTS: Of the original 211 patients considered, 195 underwent a follow-up rectoscopy and were included in the study. Benign stenosis were found in 26 (13%), and 19 (73%) symptomatic patients were treated successfully (15 with endoscopic dilatation and four with radial diathermic surgical incisions). Risk factors for anastomotic stenosis according to univariate analysis were female sex, diverticulitis, mechanical anastomosis, and anastomosis located between 8 and 12 cm from the anal verge. The significant risk factors identified by multivariate analysis were diverticulitis (OR 5, P=0.002) and mechanical anastomosis (OR 9, P=0.04). The self-perceived quality of life of patients with stenosis was significantly worse compared with controls. CONCLUSION: Since diverticulitis and mechanical anastomosis are risk factors for anastomotic stenosis, surgeons should take this into account when they are considering what type of anastomotic technique to utilize.

Polymyositis, dermatomyositis and malignancy: a further intriguing link.

The association between malignancy and autoimmune myositis has been largely described and confirmed by numerous epidemiological studies. The temporal relationship between the two pathologic conditions can vary: malignancy may occur before, at the same time or following the diagnosis of myositis. Beside these observations, the molecular mechanisms underlying this association are still unknown, even though it has been demonstrated a possible antigenic similarity between regenerating myoblasts and some cancer cell populations. To better identify peculiar histopathologic features common to cancer and myositis, we screened muscle biopsies from patients affected with polymyositis, dermatomyositis, myositis in association to cancer, and from patients affected with newly diagnosed cancer, but without myositis. Similarly to the histopatologic features that were observed in the muscle from myositis patients, especially in those with cancer associated myositis, in patients affected with malignancy at the clinical onset of disease we observed early sign of myopathy, characterized by internally nucleated and regenerating myofibers, most of them expressing the neural cell adhesion molecule. The hypothesis that in a particular subset of individuals genetically predisposed to autoimmunity, an initial subclinical tumor-induced myopathy may result in an autoimmune myositis, represents a further intriguing link behind the association of these two conditions.

Extensive anal condylomatosis: prognosis in relation to viral and host factors.

OBJECTIVE: To evaluate the clinical course of extensive anal condylomatosis in relation to treatment modalities, patient comorbidity and immune function, and associated papillomavirus (HPV) sequences. METHOD: Clinical data, treatment modalities and follow-up were recorded and analysed in relation to host and viral type. Histology, immunohistochemistry and molecular analyses for HPV search and typing were performed on formalin-fixed paraffin-embedded samples. RESULTS: Sixteen patients [14 males, median age 41.8 years (range 19-66)] affected by extensive anal condylomatosis [10 Buschke-Lowenstein Tumors (BLT) and 6 condylomatosis] treated in three different Italian institutions were included. There was associated preoperative anal intraepithelial neoplasia grade 3 (AIN3) in one and invasive carcinoma in three patients. After radical resection (n = 16) recurrence occurred in 4/10 (40%) BLT patients. Malignancy before or after treatment developed in 5/16 (31.25%) patients. HPV sequences were present in all the samples of 15 evaluable patients (types 6 or 11, 9 patients; type 16, 6 patients). A statistically significant association was found between presence of HPV type 16 and both malignancy and recurrence. Viral variant L83V was present in 3/4 HPV 16 positive recurrent cases. CONCLUSION: Radical resection resulted in a favourable clinical course. Typing of HPV sequences in the management of patients affected by extensive anal condylomatosis may be useful.

Colpocystodefecography in obstructed defecation: is it really useful to the surgeon? Correlating clinical and radiological findings in surgery for obstructed defecation.

OBJECTIVE: Colpocystodefecography images the pelvic floor with the dynamics of defecation, but various authors claim that it overestimates clinical findings. The aim of this study was to evaluate the pre- and postoperative consistency between clinical and colpocystodefecographic findings in patients undergoing surgery for obstructed defecation. METHOD Between June 2001 and September 2003, 20 patients underwent transvaginal posterior colpoperineorrhaphy and rectal mucosal prolapsectomy with one circular stapler for symptomatic rectocele and concomitant anorectal prolapse. They were prospectively evaluated both before surgery by designed questionnaire on constipation and incontinence, proctological, gynaecological and urological examinations, colpocystodefecography and anorectal manometry, and after operation at 6 months by questionnaire and a proctological check-up. The mean follow-up was 30 months (24-48 months). RESULTS: At 6 months the questionnaire revealed a major response in terms of symptoms. The proctological visit confirmed the absence of rectocele in 19 (95%) patients, while the anorectal prolapse had completely disappeared in 17 (85%) patients. Postoperative colpocystodefecography demonstrated a general reduction in the dimensions of the rectocele, which had completely disappeared in five (25%) patients; 40% of the patients had a persistent anorectal prolapse. CONCLUSION: Preoperative data analysis showed a statistically significant correlation between clinical and radiological findings. Postoperatively the global clinical assessment correlated well with patient satisfaction, while there was evidence of a statistically significant difference between the radiological and clinical findings. Routine postoperative use of colpocystodefecography is unjustified unless there is clinical evidence of surgical failure.

Prospective randomized study on perioperative enteral immunonutrition in laparoscopic colorectal surgery.

BACKGROUND: Perioperative nutrition for patients undergoing colon surgery seems to be effective in reducing catabolism and improving immunologic parameters. A relatively low-fiber and highly absorbable diet may facilitate the intestinal cleansing and loop relaxation fundamental for laparoscopic surgery with a lower dose of iso-osmotic laxative. METHODS: From 1 February 2004 to 30 July 2005, 28 patients referred to our unit with colon disease (neoplasms and diverticular disease) amenable to laparoscopic surgery were prospectively randomized into two groups of 14 patients each. For 6 days preoperatively, the patients in group 1 were given 750 ml/day of a diet enriched with arginine, omega-3 fatty acids, and ribonucleic acid (RNA) associated with low-fiber foods. They had 1 day of intestinal preparation with 3 l of iso-osmotic laxative. On postoperative day 2, they were fed orally with the same diet. The patients in group 2 preoperatively received a low-fiber diet. They had 2 days of preparation with iso-osmotic laxative (3 l/day). On postoperative day 3, oral nutrition was restored. Intraoperatively, we evaluated loop relaxation and intestinal cleanliness. Clinical trends were monitored in both groups, as well as adverse reactions to early nutrition. The nutritional (albumin, prealbumin) and immunologic (lymphocyte subpopulations, immunoglobulins) biohumoral parameters were evaluated at the first visit, on the day before surgery, on postoperative day 7, and 1 month after surgery. RESULTS: The two groups did not differ in terms of age, gender, distribution of disease, or baseline anthropometric, biohumoral, or immunologic parameters. There was a significant increase in CD4 lymphocytes on the day before surgery as compared with baseline parameters (p < 0.05) in group 1, but not in group 2. There was no statistically significant difference between the two groups in intestinal loop relaxation or cleanliness or in postoperative infectious complications. CONCLUSIONS: Perioperative immunonutrition proved to be safe and useful in increasing the perioperative immunologic cell response. It may contribute toward improving the preparation and relaxation of the intestinal loops despite the shorter intestinal preparation.

Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?

INTRODUCTION: Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse. MATERIALS AND METHODS: One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease. RESULTS: There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence. CONCLUSION: Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

Laparoscopic treatment of post-hysterectomy colovaginal fistula in diverticular disease. Case report.

Colonic diverticular disease is a benign condition typical of the Western world, but it is not rare for even the 1st episode of diverticulitis to carry potentially fatal complications. The evolution of a peridiverticular process generally poses problems for medical treatment and exposes patients to repeated episodes of diverticulitis, making surgical treatment necessary in approximately 30% of symptomatic patients. One of the most worrying complications of diverticulosis is internal fistula. The most common types of fistula are colovesical and colovaginal, against which the uterus can act as an important protective factor. The symptoms and the clinical and instrumental management of patients with diverticular fistulas are much the same as for patients with episodes of acute diverticulitis. Staging of the disease (according to Hinchey) should be done promptly so that the necessary action can be taken prior to surgery, implementing total parenteral nutrition (TPN), nasogastric aspiration and broad-spectrum antibiotic treatment. The best surgical approach to adopt in patients with diverticulitis complicated by fistula is still not entirely clear, though the 3-step strategy is currently tending to be abandoned due to its high morbidity and mortality rates. There is a widespread conviction, however, that the 2-step strategy (Hartmann, or resection with protective stomy) and the 1-step alternative should be reserved, respectively, for patients in Hinchey stages 3, 4 and 1, 2 with a situation of attenuated local inflammation. The 1-step approach seems to be safe and effective. This report describes a case of colovaginal fistula in a patient with colonic diverticulosis who had recently undergone hysterectomy, but who, unlike such cases in the past, was treated in a single step using a laparoscopic technique.

Early rupture of subclavian vein catheter: a case report and literature review.

Prolonged venous access devices (PVADs) have become indispensable in antiblastic protocols for the treatment of cancer patients, in anti-infection protocols for acquired immunodeficiency syndrome (AIDS) patients and in the management of chronic malabsorption syndromes. Using these catheters carries the risk of several complications, and some are potentially lethal, for example, cardiac embolization of catheter fragments. Rupture is a complication almost exclusive to catheters positioned percutaneously: after using this technique, device malfunction can occur due to catheter kinking after its excessively medial introduction in the subclavian vein. The early recognition of any pinch-off sign (POS) is fundamental in preventing catheter rupture that frequently follows this complication. Other factors can be involved in early rupture, for example, excessive force on a syringe used to clear a catheter that shows early signs of malfunction, or a strength defect in the materials used in the catheter construction. This report describes an early rupture case of an initially correctly positioned catheter and reviews 20 such cases in the recent literature.

[How to prevent saphenous nerve injury. A personal modified technique for the stripping of the long saphenous vein]. / Come prevenire le lesioni del nervo safeno. Una tecnica personale modificata per lo stripping della grande safena.

BACKGROUND: In literature the incidence of paresthesia caused by long stripping (LS) of the saphenous vein (SV) varies widely. Best results have been reported with the invagination technique by Van Der Stricht. However, this technique is associated with a high incidence of vein rupture and incomplete stripping. The aim of this study is to test a personal technique to avoid the SV rupture and to reduce the incidence of saphenous nerve injury. METHODS: Sixty-eight patients underwent LS of the SV from groin to ankle under monolateral spinal anesthesia on a one-day surgery basis using a personal technique combining external and invaginated saphenous stripping. All patients underwent a clinical re-evalutation 1, 3, 6, 12, 24 and 48 months after the operation. RESULTS: No intraoperative complications were recorded. Stripping of the long saphenous vein was complete in all cases without any rupture of the veins. Only one postoperative hematoma of the leg (1.5%) which was naturally reabsorbed, was recorded; four patients (5.9%) had transitory saphenous nerve injury. Permanent saphenous nerve damage was found in only one of 68 patients (1.5%). All the patients were discharged on the day of operation and we did not register any prolonged hospitalization. CONCLUSIONS: The result of our approach was a very low postoperative complication rate (1.5% of permanent neurological damage) without any rupture of the vein.

New immunosuppressive treatment in kidney transplantation.

BACKGROUND: Mycophenolate mofetil (MMF) has been successfully introduced into clinical practice with evident benefits for renal transplant recipients. SUBJECTS AND METHODS: To evaluate some clinical results of MMF introduction, two groups of subjects underwent cadaveric renal transplants over the last 3 years and were retrospectively investigated. The first group (AZA group) contained 40 subjects (26 males and 14 females) on triple-drug therapy with steroids, cyclosporine and azathioprine (AZA). The second group (MMF group) contained 25 patients ( 19 males and 6 females) on the same regime with steroids and cyclosporine but MMF was administered as a third drug instead of AZA. The AZA group received renal transplant after a mean dialytic time of 32 +/- 19 months and the AZA group's dialytic time was 39.9 +/- 17 months. Clinical data, collected after a minimum 12 months observational period included a crude mortality rate and survival analysis recognized by Kaplan-Meyer curve, creatinine, creatinine clearance, rejection episodes and major clinical events such as infections and acute tubular necrosis. RESULTS: One subject died in each group. For kidney graft survival, Kaplan Meyer survival analysis showed a mean survival time of 1170.04 days in the AZA group vs 845 in the MMF group without statistical significance. Graft survival demonstrated 5:40 (12.5%) graft losses in the AZA group vs no kidney transplant loss in the MMF group (the only deceased patient had a well functioning kidney). The curve of graft cumulative proportion survival analysis demonstrated a more improved survival in the MMF group, but this difference did not reach a statistical significance (p = 0.07). Acute rejection episodes in the AZA group were 37.5% vs. 20% in the MMF group. In both groups, CMV infection was successfully treated with specific antiviral agents. CONCLUSIONS: MMF represents an important step towards induction and maintenance of immunosuppression. Our experience in a relatively small cohort investigated in a single center, demonstrates encouraging results regarding graft survival in comparison to those detected in conventional triple drug therapy. Surprisingly, in spite of stronger immunosuppressive treatment, the prevalence of CMV infections was not statistically different in the MMF versus the AZA group.

Mycophenolate mofetil (MMF) versus azathioprine (AZA) in pancreas transplantation: a single-center experience.

AIM: Advances in immunosuppression and careful monitoring for rejection are largely responsible for improved results in pancreas transplantation. We conducted a retrospective study to establish the effectiveness of immunosuppressive therapy with mycophenolate mofetil (MMF) instead of azatioprine (AZA) in pancreas transplantation and to assess adverse effects in the two different immunosuppressive regimes. SUBJECTS AND METHODS: Since 1991, 27 pancreas transplantations were performed in 25 patients at our Institute. For induction therapy, immunosuppressant protocol consisted of quadruple immunosuppressive therapy with cyclosporine, steroids, antilymphocyte globulin and AZA in 13 patients or MMF in 12 patients respectively. RESULTS: Acute rejection occurred in 76% of patients in the AZA group compared with 53% in the MMF group. Steroid-resistant rejection was observed in 7% in the MMF group compared to 38% of patients on AZA (p < 0.01). Two kidney grafts were lost due to acute rejection in the AZA group, one pancreas was lost due to acute rejection and one to chronic rejection in the MMF group. There were no significant differences in CMV infection. Severe fungal infections were noted in 2 patients treated with MMF. Malignancy occurred in 1 patient (pancreas graft lymphoma) in MMF. CONCLUSIONS: In conclusion, patients treated with MMF required less frequent and less intensive treatment for acute rejection. However, its short- and long-term side effects should be further investigated.

Carotid endarterectomy in women: early and long-term results.

BACKGROUND: Although many randomized trials and other multicenter studies have demonstrated the benefits of carotid endarterectomy (CEA) in selected symptomatic and asymptomatic patients, including women, there is a remarkable lack of reports regarding the outcome of CEA with respect to sex. To analyze and compare the outcome of CEA in men and women in a single-group experience, we reviewed a consecutive series of 619 CEAs performed in 539 patients, 371 men (423 CEAs) and 168 women (196 CEAs). METHODS: Data collection was retrospective up to August 1, 1992 and prospective for all 405 patients treated thereafter. RESULTS: Women were significantly less likely than men to have overt evidence of coronary artery disease (P < .001) and had a significantly higher incidence of diabetes (P < .001). No perioperative death occurred in the female group (P = NS), and no statistical difference was found in perioperative stroke risk incidence. Women had a significantly higher incidence of late occlusive events (P = .01), which were all asymptomatic. No late stroke occurred in the female group (P = NS). Life-table cumulative survival rates at 1, 3, 5, and 7 years were 99.3%, 90.5%, 85.9%, and 82.3%, respectively, in women, and 98.9%, 91.9%, 85.2%, and 79.6% in men (log-rang P = .8). CONCLUSIONS: These findings show that perioperative stroke risk and mortality rates, as well as late stroke-free, mortality, and recurrence rates, in patients undergoing CEA, are comparable in men and women. Further, larger comparative studies are necessary to provide more information on the benefit and durability of CEA in asymptomatic patients, but the results of this study suggest that the early and late outcomes are excellent and comparable in symptomatic and asymptomatic men and women.

Laparoscopic treatment of lymphocele after kidney transplantation.

BACKGROUND: Laparoscopic treatment of pelvic lymphocele secondary to kidney transplant has gained popularity in the last few years, although lesions of the urinary tract (ureter, renal pelvis, and bladder) have been reported frequently. To evaluate the result of this treatment and the associated risk of urinary tract lesions, we reviewed our experience and reports in the medical literature on open and laparoscopic surgery. METHODS: From 1991 to 1999, we laparoscopically treated 12 patients (7 men and 5 women; median age, 43 years; range, 17-59 years) with symptomatic pelvic lymphocele causing a deterioration of renal function because of compression on the ureter in 10 of the 12 patients and lymphocele compression of the iliac vein in the other 2 patients. In nine patients, the lymphocele wall was opened and sutured to the peritoneum to keep the window open. In two patients, an omentoplasty was performed, and in the remaining patient, both techniques were used. All patients were followed up clinically with ultrasound and biochemistry for a median period of 33 months (range, 1-96 months). Using Medline, we reviewed the medical literature from 1980 to 1998 and collected 252 cases in which operations had been performed to drain an internal lymphocele secondary to kidney transplantation. RESULTS: Laparoscopic treatment was successful in 11 of the 12 patients. One patient was converted to open surgery because of a lesion in the transplanted ureter. One patient needed repeat laparoscopy 24 hours after the operation because of bleeding from the peritoneal window. The median duration of the operation was 120 min (range, 70-200 min), and the median postoperative hospital stay was 5 days (range, 2-12 days). None of the patients needed to discontinue oral cyclosporine assumption. The serum creatinine level dropped significantly after surgery (p < 0. 05). No symptomatic recurrences were observed. Of the 252 patients found in the medical literature, in 129 the procedure was performed with open surgery and in 123 laparoscopically (our 12 patients included). The prevalence of iatrogenic lesions to the urinary tract increased threefold with the use of laparoscopic surgery (from 1.6% in open surgery to 7% in laparoscopy). The recurrence rate of symptomatic lymphocele, however, decreased from 15% to 4%. CONCLUSIONS: Laparoscopic drainage of posttransplantation lymphocele is a relatively simple method for treating this complication, although it bears the burden of an increased incidence of urinary tract lesions, as confirmed by a review of the literature. The major advantage of the laparoscopic approach is the absence of postoperative ileus with the opportunity to continue the enteral immunosuppressive regimen and a lower recurrence rate. These data suggest that laparoscopic lymphocele treatment might be considered the therapy of choice, provided the iatrogenic lesions of the urinary tract diminish as more experience with this technique is gained.