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.

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel.

BACKGROUND: Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing. METHODS: A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470 nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months. RESULTS: Thirty patients (16 males, median age 52 years, range 26-72 years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30 months (range 6-24 months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30 mm were associated with a primary healing rate of 58.3% while tracts longer than 30 mm were cured in only 16.6% of cases (p < 0.02). CONCLUSIONS: Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.

Risk of hepatitis C virus infection in a population exposed to biological materials.

BACKGROUND: Hepatitis C virus is an important cause of acute and chronic hepatitis and it is an agent parenterally transmitted. Workers handling biological materials may be exposed to high concentration of virus-infected fluids. METHODS: The seroprevalence of hepatitis C virus antibodies was investigated in a population of 809 subjects exposed to varying levels of biological risk owing to the handling of human fluids or tissues and in 408 controls. The exposed group was subdivided in three subgroups according to low and occasional (262), intermediate but continuous (311), and high (236) exposure to biological materials. RESULTS: The seroprevalence of hepatitis C antibodies was low (1.40%) in all subjects. The risk groups showed no significant differences with respect to the control group; the most exposed group showed a seroprevalence of 1.27%. Age but not sex appeared significantly correlated with seroprevalence of positive antibodies (chi 2 = 5.949, P < 0.025). Aspartate aminotransferase and alanine aminotransferase showed a highly significant increase (P < 0.01 and P < 0.001, respectively) in subjects with positive hepatitis C antibodies, other than a high significant prevalence of values above the normal limit (chi 2 = 26.613, P < 0.001 and chi 2 = 39.164, P < 0.001, respectively). Among 17 positive hepatitis C virus subjects, 8 (47.1%) were positive for hepatitis B virus, but not for its antigen. CONCLUSIONS: Hepatitis C virus infection appears to be a low risk for people employed in the biomedical field, yet infection is associated with a significant liver involvement.

Seroprevalence of hepatitis A markers in subjects exposed to biological risk.

OBJECTIVES: The seroprevalence of hepatitis A virus antibodies was investigated in a population of 1051 subjects, of whom 376 were controls and 675 were exposed to different degrees of biological risk. METHODS: The exposed group was subdivided into subjects at low (242), intermediate (265), and high (168) biological hazard; all subjects were employed in the biomedical field. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were also determined. RESULTS: The seroprevalence of positive hepatitis A antibodies was 44.9% in all subjects but was significantly higher in males (50.6%) than in females (34.2%) and increased according to age (25.9% in subjects aged < or =40 years and 62.2% in subjects aged >40 years). No difference related to exposure to the biological risk was observed. The prevalence of transaminases at levels above normal values (chi2 = 4.079, P<0.05 for AST and chi2 = 4.806, P<0.05 for ALT) and mean values (AST P<0.05; ALT P<0.001) appeared significant in hepatitis A virus-positive subjects. On the other hand, excluding individuals with positive hepatitis C virus antibodies (16) and positive hepatitis B virus surface antigen (12), a prevalence of transaminase alterations was not observed, but mean levels of ALT lasted significantly longer in subjects with positive hepatitis A virus antibodies (P<0.01). CONCLUSIONS: The results confirm that hepatitis A virus is not a risk for employees in the biomedical field, but the presence of hepatitis A virus antibodies suggests a possible, though not clinically evident, liver involvement.

Glutamine transaminase K intranephron localization in rats determined by urinary excretion after treatment with segment-specific nephrotoxicants.

Glutamine transaminase K(GTK) excretion assessed in urine and by kidney histology was evaluated in rats after single treatment with 1.0 mg/kg i.p. of mercuric chloride, 100 mg/kg i.p. of hexachloro-1:3-butadiene (both S3, pars recta, segment-specific nephrotoxicants) and 25 mg/kg s.c. of potassium dichromate (S1-S2, pars convoluta, segment-specific nephrotoxicant). The aim was to correlate segment-specific injury and enzyme excretion in order to assess, using non-vasive methods, localization of GTK along the proximal tubule. Mercuric chloride and hexachloro-1:3-butadiene produced early focal damage in the pars recta (focal necrosis was shown 10 h after treatment, and diffuse necrosis appeared later at 34 and 24 h after treatment). Changes of the pars convoluta were occasional and delayed (72 h after treatment for both substances). On the contrary, potassium dichromate induced damage of the pars convoluta (vacuolar degeneration and focal necrosis were evident 24 h and 48 h after treatment, respectively), whereas the pars recta was affected later (focal vacuolar degeneration was observed 72 h after treatment). Increase urinary GTK excretion was early after treatment with mercuric chloride and hexachloro-1:3-butadiene (significant increase was observed within 10 h), with a peak for both substances 24 h after treatment, in agreement with the necrosis of the pars recta. Potassium dichromate induced a significant increase of enzyme excretion in urine also 24 h after injection, according to histological features showing vacuolar degeneration of the pars convoluta; the peak of excretion was reached 48 h after treatment (delay was due, probably, to s.c. administration). The results show that GTK increased in urine after treatment with S3 and S1-S2 specific nephrotoxicants; the combination of histological examination and urinary enzyme supports the evidence that the enzyme is distributed along the whole of the proximal tubule.