Endoscopic pilonidal sinus treatment (EPSiT) in recurrent pilonidal disease: a prospective international multicenter study.

BACKGROUND: Pilonidal disease (PD) is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. Recurrent PD after surgical treatment is frequent event for the 25-30% of cases. The present study evaluated endoscopic pilonidal sinus treatment (EPSiT) in recurrent and multi-recurrent PD. METHODS: Of the consecutive prospective patients with recurrent PD, 122 were enrolled in a prospective international multicenter study conducted at a secondary and tertiary colorectal surgery centers. Primary endpoint was to evaluate short- and long-term outcomes: healing rate/time, morbidity rate, re-recurrence rate, and patient's quality of life (QoL). RESULTS: Complete wound healing rate was occurred in 95% of the patient, with a mean complete wound healing time of 29 ± 12 days. The incomplete healing rate (5%) was significantly related to the number of external openings (p = 0.008), and recurrence was reported in six cases (5.1%). Normal daily activity was established on the first postoperative day, and the mean duration before patients returned to work was 3 days. QoL significantly increased between the preoperative stage and 30 days after the EPSiT procedure (45.3 vs. 7.9; p < 0.0001). CONCLUSIONS: The EPSiT procedure seems to be a safe and effective technique in treating even complex recurrent PD. It enables excellent short- and long-term outcomes than various other techniques that are more invasive.

Video-assisted anal fistula treatment in the management of complex anal fistula: a single-center experience.

BACKGROUND: Video-assisted anal fistula treatment (VAAFT) is now a mature technique, supported by many short-term published case series. METHODS: We designed a monocentric, retrospective and observational study in order to evaluate early and long-term outcomes of VAAFT in the treatment of primary and recurrent complex anal fistula. Between November 2011 and March 2014, 224 consecutive patients affected by complex perianal fistula underwent Video Assisted Anal Fistula Treatment. Fifty-two were affected by primary and 172 by recurrent disease. We registered all intra and postoperative complications and healing rate. Median follow-up was 48 months (range 27-60 months). RESULTS: In the primary fistula group, 40 of the 52 patients were completely healed within 3 months after surgery (77%); at 12 months, considering also 12 patients (23%) treated with a second VAAFT due to recurrent disease, the overall healing rate was 92.3% In the second group with recurrent anal fistula (N.=172), primary healing was observed in 110 patients (64%; P=0.1) within 3 months after surgery and increases to 80.2%, after 12 months (P=0.06). Few patients required analgesics in the postoperative period (N.=33, 14.7%), the remaining did not require pain killers at all. All patients were able to resume daily activities within 7 days from surgery (range 2-12 days). Main limitation of our study was its retrospective and monocentric design. CONCLUSIONS: VAAFT seems to be a safe and effective technique for treating primary and recurrent perianal fistula, providing a very good healing rate without sphincters impairment and allowing a very quick return to normal activities.

Ligation of the intersphincteric fistula tract (LIFT): a minimally invasive procedure for complex anal fistula: two-year results of a prospective multicentric study.

INTRODUCTION: The surgical management of anal fistulas is still a matter of discussion and no clear recommendations exist. The present study analyses the results of the ligation of the intersphincteric fistula tract (LIFT) technique in treating complex anal fistulas, in particular healing, fecal continence, and recurrence. METHODS: Between October 2010 and February 2012, a total of 26 consecutive patients underwent LIFT. All patients had a primary complex anal fistula and preoperatively all underwent clinical examination, proctoscopy, transanal ultrasonography/magnetic resonance imaging, and were treated with the LIFT procedure. For the purpose of this study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula, or preexisting incontinence. Patient's postoperative complications, healing time, recurrence rate, and postoperative continence were recorded during follow-up. RESULTS: The minimum follow-up was 16 months. Five patients required delayed LIFT after previous seton. There were no surgical complications. Primary healing was achieved in 19 patients (73%). Seven patients (27%) had recurrence presenting between 4 and 8 weeks postoperatively and required further surgical treatment. Two of them (29%) had previous insertion of a seton. No patients reported any incontinence postoperatively and we did not observe postoperative continence worsening. CONCLUSION: In our experience, LIFT appears easy to perform, is safe with no surgical complication, has no risk of incontinence, and has a low recurrence rate. These results suggest that LIFT as a minimally invasive technique should be routinely considered for patients affected by complex anal fistula.

Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain?

BACKGROUND: Chronic idiopathic anal pain is a common, benign symptom, the etiology of which remains unclear. Traditional treatments are often ineffective. This study investigated the efficacy of sacral nerve stimulation in treating chronic idiopathic anal pain. METHODS: Twelve patients (10 women and 2 men; mean age, 61.0 +/- 10.3 years; range, 48-82 years) implanted with a permanent device for sacral nerve stimulation were followed in the Italian Group for Sacral Neuromodulation (GINS) Registry. All patients had frequent chronic anal or perianal pain; 75 percent had previously undergone pelvic surgery. Pharmacologic and rehabilitative therapy had yielded poor results. Changes from baseline to last follow-up examination were evaluated for scores on a visual analog pain scale (0-10) and the Short-Form 36 (SF-36) health status questionnaire. Manometric measurements recorded at last follow-up were compared with preimplantation values. RESULTS: In one patient, the permanent device was removed because of technical failure. After a mean follow-up of 15 (range, 3-80) months, visual analog pain scores had significantly improved (from 8.2 +/- 1.7 to 2.2 +/- 1.3, P < 0.001). SF-36 physical component scores increased from 26.27 +/- 5.65 to 38.95 +/- 9.08, P < 0.02). Scores on the mental component showed improvement, although not significant. Postimplantation changes in manometric functional data were not significant, but sensitivity thresholds showed a considerable decrease. CONCLUSIONS: Long-term follow-up data showing improvements in scores on the visual analog pain scale and quality of life questionnaire indicate that, before adopting more aggressive surgical procedures, SNS should be considered for patients with chronic idiopathic anal pain in whom pharmacologic and biofeedback treatments have failed to produce effective results.

Evaluation of CD44 variant 6 expression and clinicopathological factors in pulmonary metastases from colon carcinoma.

Although relatively little is known about the molecular mechanisms underlying tumor progression, recently CD44 glycoproteins and the c-Met receptor tyrosine kinase have been identified as potentially important components of the metastatic cascade. CD44 is a family of transmembrane receptors generated from a single gene by alternative splicing and differential glycosylation. Important biological processes involving CD44 glycoproteins include cell adhesion, lymphocyte homing, hematopoiesis, tumor progression and metastasis. The precise mechanism via which CD44 promotes tumorigenesis have not yet been elucidated. We evaluated the expression of adhesion molecule CD44 variant 6 in pulmonary metastases from colorectal carcinomas and its correlation with clinicopathological parameters. Twenty patients were randomly selected from the patients who had undergone a resection of pulmonary metastasis from colorectal cancer. Formalin-fixed, paraffin-embedded archival specimens of tumor tissues and adjacent normal mucosa from these patients were the subjects of the present study. Immunoreactivity for CD44 was quantified. Specimens were considered positive if almost 25% of the neoplastic cells were stained. CD44 v6 expression was related to the interval between colon resection and metastases diagnosis, the number of pulmonary metastases, and the survival after lung resection. No statistical correlation was found between CD44 v6 positivity and disease-free interval after colon resection, number of metastases or 2-year survival after lung resection. Probably CD44 v6 is necessary and sufficient to confer metastatic potential to carcinoma cells increasing the migration capacity and participating in invasion via changes in adhesion to the extracellular ligands, but is not necessary to modify the clinical history of the metastases. Therefore the evaluation of CD44 v6 expression in lung metastases does not influence the therapeutic scheme.

Correlation between chromogranin-A expression and pathological variables in human colon carcinoma.

BACKGROUND: The possible association between neuroendocrine pattern and cancer prognosis could have substantial clinical implications, but the studies performed have generated conflicting results. As chromogranin-A (CGA) and dense-core granules are expressed concordantly, CGA expression may be used as a marker for cells expressing the complete neuroendocrine cell phenotype. MATERIALS AND METHODS: Fifty-six patients with primary colon carcinoma who underwent potentially curative surgery were analyzed. For immunohistochemical study a monoclonal antibody specific for human chromogranin A was used. The tumor was considered positive when the number of CGA cells was higher than 10% in the section. The relation between CGA-positivity and depth of parietal invasion, lymph-node status and differentiation grade was examined. RESULTS: We observed positive immunostaining in 22 cases out of 56 (39.3%). Significant association was found between CGA-positivity and lymph-node metastasis. CONCLUSION: CGA overexpression could reflect a more aggressive tumor. If our results are confirmed, we should consider the CGA + colon cancer patients at risk for lymph-node disease and therefore include them in a adjuvant chemotherapeutic protocol.