Usefulness of endorectal ultrasound after preoperative radiotherapy in rectal cancer: comparison between sonographic and histopathologic changes.

PURPOSE: Our aim was to assess the advantages of endorectal ultrasound after preoperative radiotherapy in rectal cancer, its reliability in tumoral staging, and its capacity to identify completely sterilized lesions. METHODS: From 1994 to 1997, 29 patients with rectal cancer were systematically subjected to endorectal ultrasound before and after preoperative radiotherapy. Each patient was administered 30 to 50 Gy, followed by surgery six to eight weeks after completion of radiotherapy. Endorectal ultrasound was performed using a biplanar (linear and sectorial) endorectal probe. The morphologic, quantitative, and echo-pattern changes of the irradiated tumor were examined. Results of ultrasound findings before and after radiotherapy and a histologic examination of the surgical specimens were compared. Histopathologic studies were used to evaluate macromicroscopical radiation-induced changes, case by case. A comparison between tumoral shrinkage and fibrotic replacement was made using the semiquantitative Dworak's method. RESULTS: Morphologically and quantitatively, postradiation endorectal ultrasound showed the reappearance of anatomic cleavage planes, a considerable shrinkage of the tumor, and in low rectal tumors, an increase in the distance from the anorectal ring in more than 50 percent of the cases. These data had a direct influence on surgical treatment. Histologic examination showed that, in 28 out of 29 cases, fibrosis was the most dominant component of the irradiated lesions, varying by more than 50 to 100 percent of the lesion (four cases pTO). A comparison of postradiation endorectal ultrasound with histopathology revealed that fibrosis became the morphologic basis of ultrasound images; therefore, after radiotherapy, what endorectal ultrasound staged was no longer the tumor but the extent of fibrosis in the rectal wall. A histopathologic examination showed that the residual tumor, when present, was always within the fibrosis, never outside or separate from it. Postradiation endorectal ultrasound showed echo-pattern changes. Some of the changes (more echogenic and nonhomogeneous lesions) were histologically related to the persistence of the tumor to a considerable degree; other changes (reappearance of parietal layers) were related to complete sterilization of lesions in two of three cases. CONCLUSIONS: From the morphologic and quantitative point of view, postradiation endorectal ultrasound provides oncologists and surgeons useful information to assess treatment effectiveness and plan the surgical approach. From the tumor staging point of view, our report presents a completely new concept: that six to eight weeks after radiotherapy, endorectal ultrasound no longer stages the tumor, but rather the fibrosis that takes its place. However, postradiation endorectal ultrasound is a valid tool, because the extent of fibrosis in the rectal wall is a direct indication of the depth of residual cancer. A residual tumor, when present, is always inside the fibrosis. Finally, however, as regards the capacity of endorectal ultrasound to exclude or indicate complete sterilization of the lesion, the actual significance of the echo-pattern changes we observed needs to be assessed further by studies on a large number of cases.

Mesenteric cystic neoformations: report of two cases.

The authors present two case reports of mesenteric cystic neoformations which they themselves observed and, with the help of the literature regarding this pathology, discuss the problems of both diagnosis and treatment.

Intestinal protozoa in HIV-infected patients: effect of rifaximin in Cryptosporidium parvum and Blastocystis hominis infections.

In HIV-1 infected patients severe enteritis and chronic diarrhea are often documented as a consequence of multiple opportunistic infections. We analyzed 48 HIV-1 positive patients for the presence of intestinal pathogenic protozoa. Patients with CD4 > or = 200/mm3 showed a higher prevalence of a single pathogenic protozoa than patients with CD4 < or =200/mm3, who showed the presence of multiple protozoal infections. Patients who proved positive for only a single protozoa, Cryptosporidium or Blastocystis, were also positive, by stool culture, for the presence of Proteus mirabilis (3 samples), Citrobacter freundii (3 samples), Escherichia coli (one sample) or Enterobacter cloacae (one sample). Treatment with rifaximin (600 mg, 3 times a day, for 14 days) was efficacious in resolving the clinical symptoms and clearing protozoan infections in HIV-1 infected patients with CD4 > or = 200/mm3, who presented enteric and systemic symptoms due to Criptosporidium or Blastocystis associated with enteropathogenic bacteria.

Squamous-cell carcinoma developing within anal lichen planus: report of a case.

AIM: We present a case of squamous-cell carcinoma developing within perianal lichen planus. This is a chronic or recurrent cutaneous and/or mucosal dermatosis affecting less than 1 percent of the population. Neoplastic degeneration of cutaneous lichen planus is rare; only one case of squamous-cell carcinoma developing within perianal lichen planus has been described up until now in the international literature. CASE REPORT: Our case involved a 68-year-old woman with chronic, long-term lichen planus spreading all over the vulva and perianal region and the mucosa of the anal canal, where squamous-cell carcinoma developed within the perianal lichen planus. Treatment consisted of wide, circular excision of the perianal skin and mucosectomy of the anal canal up to as far as 1 cm above the dentate line. Reconstruction was performed by means of two V-Y bilateral subcutaneous flaps. CONCLUSION: Wide excision was performed not only to remove the squamous-cell carcinoma but also the lichen planus to prevent recurrence of metachronous or synchronous squamous-cell carcinoma. Follow-up at one year after surgery showed no local recurrence of either lichen planus or squamous-cell carcinoma, which suggests that surgical removal should be the therapy of choice for long-term, chronic perianal lichen planus that has proved to be resistant to medical therapy.

[Cystic lymphangioma of the mesentery. A case of intestinal obstruction and a brief review of the literature]. / Linfangioma cistico del mesentere. Un caso di occlusione intestinale e breve revisione della letteratura.

Mesenteric cystic lymphangioma is a rare pathology which is not often described in the literature. Moreover, its etiopathogenesis is still uncertain. It may remain asymptomatic or it may present aspecific painful abdominal symptoms of the sub-acute type correlated with compressive phenomena or, more rarely, with acute intestinal obstruction. Surgery is the only form of treatment for both acute and sub-acute abdominal forms. The authors report a case of two mesenteric cystic lymphangiomas of the ileum which led to the onset of intestinal obstruction caused by ileal volvulus in a 45-year-old man.

[Surgery of anal fistulas]. / La chirurgia delle fistole anali.

The authors report a study on 120 patients with anal fistula (111 males and 9 females). The average age was 44.3 years (median 44, SD +/- 14.807). 64.1% of patients had an intersphincteric fistula, 23.3% hanal transphincteric fistula, 1.6% a suprasphincteric fistula, 7.5% a horseshoe fistula and the 3.3% an extrasphincteric fistula. We treated 14 patients (11.66%) with direct surgical treatment. The other 106 had various types of treatment depending on the localisation and the involvement of the anorectal sphincter. We had 11 cases (9.1%) of complications, such as recurrence in 5 patients (4.1%) transitory incontinence in 2 cases (1.6%) and finally postoperative bleeding in 3 patients (2.5%).

[Rubber band ligation of hemorrhoids. Our experience]. / La legatura elastica delle emorroidi. Nostra esperienza.

The authors present their series of rubber band ligation of hemorrhoids performed from 1991 to 1994 in the Unità di Colon Proctologia of Modena, that is located in the Second Division of Surgery of the Surgical Department of Modena University. In that period 158 patients were treated. Age range was between 17 and 93 years old, and patients were affected by II and III degree of hemorrhoids. The complications verified were: 14 cases of recurrence (8.8%), 2 cases of severe bleeding, no case of perineal sepsis or urinary retention. Other complications of less importance were 89 cases of pain (56.3%), not severe bleeding in 23.41% of patients. Results show that this method of treatment of hemorrhoids, used by experts, is the first choice treatment of this pathology.

Vertical subcutaneous pedicle flaps for posterior perineal reconstruction. Report of three cases.

PURPOSE: Loss of a certain amount of cutaneous tissue of the perineal region may be remedied by first intention with creation of cutaneous flaps, thus preventing second intention healing. METHODS: We present three emblematic cases in which the posterior perineal region was reconstructed by means of vertical subcutaneous pedicle flaps, subsequent to cutaneous tissue loss after surgery for extensive condilomas or neoplastic pathologies. RESULTS: Tissue loss was repaired by means of a V-Y type vertical subcutaneous pedicle flap, constructed laterally of the extirpation zone and advanced in a median direction. In all cases, no ischemia or infection of flaps occurred; sphincteral continence and long-term aesthetic results have proved to be satisfactory. CONCLUSIONS: Vertical pedicle subcutaneous flaps are well vascularized, extremely mobile, and easy to perform and have no serious postoperative complications.