Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer.

PURPOSE: The aim of this study is to provide a prospective analysis of post-operative and oncological outcomes in patients affected by locally advanced rectal cancer (LARC), who obtained a major/complete clinical response after pre-operative radio-chemotherapy (RCT) and were treated with local excision (LE) by trans-anal endoscopic microsurgery (TEM) to confirm a pathological complete response (pCR) after to neo-adjuvant RCT. METHODS: All patients with LARC treated by pre-operative RCT and full-thickness LE by TEM (2000-2014) were included in the study. If the pathological analysis confirmed near complete or pCR, intensive follow up was proposed. If the pathological response was incomplete, a radical resection with TME was proposed. Post-operative (according to Clavien's classification), functional and long-term oncological outcome were analyzed. RESULTS: 36 patients were treated by TEM. The median post-operative hospital stay was 5 days. The post-operative morbidity was 41.6% (no grade ≥3). At pathological analysis, 23 specimens were ypT0 TRG1, and 4 were ypT1 TRG2. In 9 cases (ypT>1 and/or TRG>2), radical surgery with TME was proposed but 3 refused it. Median follow-up was 68 months. One local recurrence and 4 distant metastases occurred. The 5-yr actuarial local control, overall survival and disease-free survival were 96.0%, 92.0% and 82.8%. CONCLUSIONS: In case of major or complete clinical response of LARC after pre-operative RCT, LE by TEM can be used to confirm the pathological response. This avoids the necessity of radical surgery and, in our experience, this approach seems to guarantee oncological safety with the functional advantages of an organ-sparing procedure.

Elderly kidney transplant recipient with intermittent fever: a case report of leishmaniasis with acute kidney injury during liposomal amphotericin B therapy.

We present a case report of visceral leishmaniasis in an elderly kidney transplant recipient (age, 73 years) with high intermittent fever in the 2 months before admission. Symptoms started 16 years after transplant. The patient received appropriate treatment with liposomal amphotericin and experienced transient increases in serum creatinine levels. Progression to dialysis was avoided with short duration of therapy (5 consecutive days, plus 1 more dose 1 week apart, a schedule alternative to 15-21 days [supported by the literature]) and a temporary reduction in tacrolimus exposure. After 4 months, recurrence of symptoms without other explanation required a second bone marrow aspirate; it revealed the persistence of amastigote forms. Visceral leishmaniasis is a potentially life-threatening infection; to the best of our knowledge, this is the oldest transplanted patient with a case of leishmaniasis described in the literature.

'Distal Doppler-guided dearterialization' is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization.

AIM: Transanal haemorrhoidal dearterialization (THD® Doppler) is a surgical procedure involving Doppler-guided ligation of haemorrhoidal arteries to reduce arterial flow. With proximal Doppler-guided dearterialization, arterial ligation is achieved by introducing the proctoscope completely into the anal canal and lower rectum. In the present study, distal Doppler-guided dearterialization (DDD) is performed in the distal 2 cm of the lower rectum. Immediate and short-term results were evaluated. METHOD: One hundred patients with bleeding haemorrhoids, with or without muco-haemorrhoidal prolapse, underwent THD® Doppler procedure, using DDD of the haemorrhoidal arteries 2 cm above the anorectal junction. Mucopexy was performed in patients with haemorrhoidal prolapse. RESULTS: The operation time was 20 ± 7 min for dearterialization alone (10 patients), and 30 ± 10 min when mucopexy was added (90 patients). Morbidity included: transient haemorrhoidal thrombosis (two patients); urinary retention (five patients); submucosal abscess (one patient). No patient complained of faecal incontinence. At a median follow-up of 7.3 (3-17) months, all patients reported an improvement in symptoms. No patients reported bleeding. CONCLUSION: DDD of the haemorrhoidal arteries could be a simplified and more effective method of applying THD.

Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula.

AIM: The surgical treatment of a complex anal fistula remains controversial, although 'sphincter-saving' operations are desirable. The Gore Bio-A® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug. METHOD: Eleven patients with a complex anal fistula underwent insertion of Gore Bio-A® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow-up period, patients underwent clinical and physical examinations and three-dimensional endoanal ultrasound. RESULTS: Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow-up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow-up appointment. CONCLUSION: Implanting a Gore Bio-A® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.

Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review.

AIM: The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect. METHOD: The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life. RESULTS: Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies. CONCLUSION: Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications.

BACKGROUND: Dearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries. METHODS: Fifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated. RESULTS: Haemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001). CONCLUSION: This study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization.

Immunohistochemical investigation of the nitrergic system in the taste organ of the frog, Rana esculenta.

We have studied by immunocytochemistry, the taste discs of the frog, Rana esculenta, with the aim of providing morphological and neurochemical data on the nitrergic system and of assessing the eventual presence of intrinsic neurons associated with the gustatory organs. In taste discs, antibodies against neuronal nitric oxide synthase (nNOS) revealed a positive immunoreaction in the taste receptor cell bodies and processes. The basal cells were also stained. All the fungiform papillae contained intragemmal nerve fibers showing nNOS immunoreactivity; these fiber were mainly located in the basal plexus. Immunoreactive nerve fibers were also visible at the periphery of the papilla-contacting ciliate cells, which form a ring around the taste disc. In conclusion, the findings obtained in this study suggest that the occurrence of nNOS-immunoreactivity in basal cells, taste cells and nerves might reflect a role for nitric oxide in taste mechanisms of Amphibia. The results may also sustain the physiological implication of NO as a molecule involved in the local target function of maintaining the taste bud mucosal integrity and in regulating the blood flow to the epithelium.

Effects of monensin on Na+/K(+)-ATPase and Ca(++)-AtPase activities in chick skeletal muscle and myocardium after subacute treatment.

Chicks were treated at 2 weeks of age with 4,15, 40, 100 and 150 mg/kg of monensin, an ionophore used for its anticoccidial and growth-promoting properties. In the present immunohistochemical study, the expressions and distribution of Na+/K(+)-ATPase and Ca(++)-ATPase were studied in myocardium and skeletal muscles (pectoral and quadriceps femoris). We detected an increase of Na+/K(+)-ATPase immunostaining with prominent staining of the sarcolemma and a slight increase of Ca(+)-ATPase with prominent staining of the sarcoplasma.

Mitochondria-rich cells in anuran amphibia: chloride conductance and regional distribution over the body surface.

The distribution and density (D(mrc)) of mitochondria-rich cells (MR cells) in skin epithelium, were determined over the whole body surface in nine species of anuran Amphibia that live in a variety of habitats. It was found that the more terrestrial species (beginning with Hyla arborea) have a higher density of MR cells in their pelvic region. In the skin of aquatic (Xenopus laevis) or fossorial (Pelobates syriacus) species, D(mrc) is evenly distributed over the whole body surface. In dorsal skin pieces of H. arborea that lack detectable MR cells, transepithelial voltage activation did not induce Cl(-) conductance as it did in ventral pieces. Skins from Bufo viridis and X. laevis, both have MR cells in their skin, differ markedly in their biophysical properties: a Cl(-) specific current conductance is predominant in the skin epithelium of B. viridis, and is absent in X. laevis. In the latter, anionic conductance is due to glandular secretion. The biophysical properties cannot therefore be related solely to the presence or density of MR cells. Mitochondria-rich cells are sites of Cl(-) conductance across the skin of those amphibians that show this property, but must have different function(s) in other species. It is suggested that the specific zonal distribution of MR cells in the species that were examined in this study could be due to ion exchange activity and water conservation in more terrestrial environments.

Neuronal nitric oxide synthase (nNOS) expression in the epithelial neuroendocrine cell system and nerve fibers in the gill of the catfish, Heteropneustes fossilis.

We studied immunohistochemically the localization of neuronal nitric oxide synthase (nNOS) in gills of an Indian catfish species, Heteropneustes fossilis. It is shown that most of the epithelial neuroendocrine cells that are present in gill filaments and lamellae stained positively. Co-localization of nNOS and endothelin was also shown in neuroendocrine cells. A dense plexus of nNOS-containing nerve fibers was present beneath the gill epithelium, associated with efferent filament arteries and the basal side of neuroendocrine cells. nNOS immunopositive neurons were not found in gill areas. nNOS immunopositive neuroendocrine cells appeared to differ from neuroepithelial cells in gills of various teleost species, which are considered as oxygen-sensitive receptors and are present in the distal halves of gill filaments. Other types of neuroendocrine cells have been identified previously in other areas of gills using antibodies to serotonin and endothelin peptides. These cell types are likely to be involved in chemical regulation of the physiology of gill cells. In relation to the function of the other cell types, our data on nNOS localization suggest that NO is a wide-spread transmitter in the gill of the Indian catfish. It may play a role both in the local regulation of vascular tone and in inhibitory innervation of the gill.

Lectin binding patterns in amphibian skin epithelium.

Seven lectins (PNA, DBA, WGA, UEA-I, RCA, SBA, Con A) were used to localize glycoconjugates in the skin of 10 species of Amphibia, 7 anurans (Bufo marinus, Bufo bufo, Rana ridibunda, Rana pipiens, Hyla arborea, Pelobates syriacus and Xenopus laevis) and 3 urodeles (Salamandra salamandra, Triturus vulgaris and Ambystoma mexicanum). It was found that every lectin has a specific binding pattern in the skin of each species. No common pattern could be established, either among frogs or toads, nor for a particular lectin. Each lectin bound specifically and selectively to a particular epithelial component, which differed from one species to the other. A number of lectins showed selective binding to mitochondria-rich cells, but, again, a pattern in positivity could not be found. It is concluded that lectin histochemistry does correlate with cellular function. Our data can be applied in studies of epithelium and skin development, and of changes that occur during adaptation to the environment by amphibian species.

Lectin binding pattern and band 3 localization in toad skin epithelium and the effect of salt acclimation.

Seven lectins were employed to localize glycoconjugates in the skin of a toad (Bufo viridis). Each of the lectins exhibited a particular, specific and selective binding pattern. Peanut lectin (PNA) and WGA bound to mitochondria-rich (MR) cells, but WGA bound also abundantly, in the dermis. Band 3-like protein, as indicated by the reaction with polyclonal anti band 3 antibody, was localized exclusively in MR cells. Ionic acclimation (200 mmol/L NaCl, or 50 mmol/L KCl) affected profoundly the binding pattern of the lectins. High NaCl acclimation resulted also in diminishing anti band 3 antibody binding, whereas in skins of KCl-acclimated toads the staining remained similar to the control. The binding of WGA but not PNA, corresponded with the same cells that stained with anti band 3 antibody. PNA in concentration of > 10 micrograms/mL reduced reversibly, both the resting and activated Cl- conductance by 25-30%. Based on differential binding of band 3, WGA and PNA, these observations provide conclusive verification of the presence of at least two populations of MR cells in the toad skin epithelium. It is suggested that the PNA positive MR cells may correspond to a beta-type MR cell. The information can be used to study molecular mechanisms that are involved in ionic acclimation.

Paraneurons in the gills and airways of fishes.

This chapter describes the distributional patterns of the neuroendocrine cells in the respiratory surfaces of fishes and their bioactive secretions which are compared with similar elements in higher vertebrates. The neuroendocrine cells in the airways of fishes differentiate as solitary and clustered cells, but the clusters are not converted into neuroepithelial bodies which are reported in terrestrial vertebrates. The dipnoan fish Protopterus has innervated neuroendocrine cells in the pneumatic duct region. In Polypterus and Amia the lungs have neuroendocrine cells that are apparently not innervated. Two types of neuroendocrine cells are found in the gill of teleost fishes. These cells are very different by their location, structure and immunohistochemistry. Advanced studies on functional morphology of neuroendocrine cells in fish airways are still necessary to increase our understanding of their multifunctional role in the gill area.

Localization of immunoreactive endothelin in the neuroendocrine cells of fish gill.

Immunohistochemical tests have demonstrated for the first time the presence of endothelins in the neuroendocrine cells of fish gill. We have sought co-localization of endothelins with serotonin and neuropeptides which are regarded as neuroendocrine markers of pulmonary diffuse neuroendocrine systems in higher vertebrates. Regarding their endocrine and paracrine activities in mammals, endothelins are considered as peptide hormones and growth factors regulating respiratory function. The roles of endothelins in the gill await investigation based on the multifunctional organization of this organ.

Enkephalin immunoreactivity in the paraneurons of the tiger salamander (Ambystoma tigrinum) tongue.

Immunohistochemical tests have demonstrated the presence of leu-5-enkephalin and other bioactive compounds (serotonin and neuron-specific enolase) in the basal cells of lingual taste buds in Ambystoma tigrinum; there was also a weak reaction for met-5-enkephalin. Similar reactions were obtained from particular cells dispersed within the lingual epithelium, which are provisionally identified as Merkel cells.

Neuroendocrine cells in the gills of the bowfin Amia calva. An ultrastructural and immunocytochemical study.

Neuroendocrine (NE) cells were localized by electron microscopy and immunocytochemistry in the gill epithelium of bowfin Amia calva. The NE cells are dispersed in whole epithelium of the gill as solitary cells without intraepithelial innervation. All the observed NE cells do not reach the surface of the epithelium. The NE cells are characterized by a large nucleus with patches of condensed chromatin, numerous mitochondria, a well developed Golgi apparatus and a few dense core vesicles of various size scattered in the cytoplasm. Dense core vesicles range from 100 to 560 nm in diameter, while a clear space between the electron dense core ant the limiting membrane ranges from 20 to 240 nm. Immunocytochemical observations reveal the presence of general neuroendocrine markers such as neuro-specific enolase and bioactive substances: serotonin, leu-enkephalin and met-enkephalin. we demonstrated the presence of endothelin - for the first time in fish - and suggested a local paracrine role for the NE cells. Some ultrastructural aspects and the immunocytochemical characteristics of NE cells of bowfin gills are common with those encountered in such cells of other lower vertebrate species.

Distribution patterns of cytokeratins in epidermis and horny teeth of the adult sea lamprey, Petromyzon marinus.

An immunohistochemical characterization of cytokeratins in the skin tissues of the sea lamprey, Petromyzon Marinus was performed using a panel of monoclonal antibodies. Cytokeratins typical for simple epithelia have been detected in the epithelial cells, with a 8/18 pair expression. Granular cells and skein cells showed a labelling of cytokeratins 7, 8, 18 and 19, that is observed also in the non-keratinized layers of the horny teeth. Similar cytokeratins occur in the outermost cell layers of the epidermis; cytokeratin 19 shows a comparatively weaker reaction. These results suggest that the cytokeratin patterns in the above types of cells of adult epidermis are quite different from those in ammocoetes where the expression of cell specific cytokeratins may be correlated with specific programs of epidermal differentiation.

Distribution patterns of the paraneuronal endocrine cells in the skin, gills and the airways of fishes as determined by immunohistochemical and histological methods.

The neuro-endocrine cells of fish skin and respiratory surfaces, and their bioactive secretion as far as is known, are reviewed, and compared with similar elements in tetrapods, particularly amphibians. In the skin of teleost fish, immunohistochemistry has shown that Merkel cells react for serotonin, neuron-specific enolase and enkephalins. The pharmacology is not established in dipnoans or lampreys. In some teleosts, neuromasts react for substance P and leu-enkephalins; substance P is also reported from some ampullary organs (electroreceptors). Taste buds of teleosts may react for enkephalin and substance P. Basal cells of taste buds react for serotonin and neuron-specific enolase. Some unicellular skin glands of teleosts express bioactive compounds, including serotonin and some peptides; this ectopic expression is paralleled in amphibian skin glands. The dipnoan Protopterus has innervated pulmonary neuro-endocrine cells in the pneumatic duct region with dense-cored vesicles. In Polypterus and Amia the lungs have serotonin-positive neuro-endocrine cells that are apparently not innervated. In fish gills, a closed type of neuro-endocrine cell reacts for serotonin, an open type for enkephalins and some calcium-binding proteins (calbindin, calmodulin and S-100 protein). The functions of neuro-endocrine cells in fishes await investigation, but it is assumed they are regulatory.

Distribution of immunoreactive Tamm-Horsfall protein in various species in the vertebrate classes.

A sheep antibody to human Tamm-Horsfall protein, the major protein in normal urine, was used in an immunohistological study of organs of 48 species of vertebrate animals, representing the classes Mammalia, Aves, Reptilia, Amphibia, Osteichthyes and Chondrichthyes. Immunoreactivity was shown in the thick limb of the loop of Henle in the kidney of mammals, but there was no reactivity with tissues of birds or reptiles. Superficial layers of the skin of several amphibians and fish, superficial layers of the oral mucosa and gills of fish, and the distal tubules of the kidney of some amphibians, reacted with the antibody. Immunoreactivity with mammalian kidney was removed by passage of the antibody down an immunoadsorption column coated with human Tamm-Horsfall protein, and amphibian immunoreactivity was removed by incubation of the antibody with material prepared from frogs in the same way as Tamm-Horsfall protein. These findings suggest that immunoreactive Tamm-Horsfall protein appeared early in vertebrate phylogeny, initially in skin and gills and later in kidney, and that although conserved in evolution, it shows antigenic differences between amphibians and mammals. Its distribution is consistent with the hypothesis that is acts as a waterproofing agent.