Rectal sparing approach after preoperative radio - and/or Chemo-therapy (ReSARCh): a prospective, multicentre, observational study

BACKGROUND

Rectal-sparing approaches for patients with rectal cancer who achieved a complete or major response following neoadjuvant therapy constitute a paradigm of a potential shift in the management of patients with rectal cancer, however their role remains controversial. The aim of this study was to investigate the feasibility of rectal-sparing approaches to preserve the rectum without impairing the outcomes.

METHODS

This prospective, multicentre, observational study investigated the outcomes of patients with clinical stage II-III mid-low rectal adenocarcinoma treated with any neoadjuvant therapy, and either transanal local excision or watch-and-wait approach, based on tumor response (major or complete) and patient/surgeon choice. The primary endpoint of the study was rectum preservation at a minimum follow-up of two years. Secondary endpoints were overall, disease-free, local and distant recurrence-free, and stoma-free survival at three years.

RESULTS

Of 178 patients enrolled in 16 centres, 112 (62.9%) were managed with local excision and 66 (37.1%) with watch-and-wait. At a median (interquartile range) follow-up of 36.1 (30.6-45.6) months, the rectum was preserved in 144 (80.9%) patients. The 3-year rectum-sparing, overall, disease-free, local recurrence-free, distant recurrence-free survival was 80.6% (95%CI 73.9-85.8), 97.6% (95%CI 93.6-99.1), 90.0% (95%CI 84.3-93.7), 94.7% (95%CI 90.1-97.2), and 94.6% (95%CI 89.9-97.2), respectively. The 3-year stoma-free survival was 95.0% (95%CI 89.5-97.6). The 3-year regrowth-free survival in the watch-and-wait group was 71.8% (95%CI 59.9-81.2).

CONCLUSIONS

In rectal cancer patients with major or complete clinical response after neoadjuvant therapy, the rectum can be preserved in about 80% of cases, without compromise the outcomes.

Outcomes of Laparoscopic Surgery in Very Elderly Patients with Colorectal Cancer: A Survival Analysis and Comparative Study

(1) Background: Colorectal cancer (CRC) is a global health concern, particularly among the elderly population. This study aimed to assess the impact of laparoscopic surgery on CRC patients aged ≥80 years. (2) Methods: We conducted a retrospective analysis of prospectively collected data from consecutive CRC patients who underwent surgery at our institution between July 2018 and July 2023. The patients were categorized into three groups: those aged over 80 who underwent laparoscopic surgery (Group A), those aged over 80 who underwent open surgery (Group B), and those under 80 who underwent laparoscopic surgery (Group C). We examined various clinical and surgical parameters, including demographic data, medical history, surgical outcomes, and survival. (3) Results: Group A (N = 113) had shorter hospital stays than Group B (N = 23; p = 0.042), with no significant differences in complications or 30-day outcomes. Compared to Group C (N = 269), Group A had higher comorbidity indices (p < 0.001), more emergency admissions, anemia, low hemoglobin levels, colonic obstruction (p < 0.001), longer hospital stays (p < 0.001), and more medical complications (p = 0.003). Laparotomic conversion was associated with obstructive neoplasms (p < 0.001), and medical complications with ASA scores (p < 0.001). Both the medical and surgical complications predicted adverse 30-day outcomes (p = 0.007 and p < 0.001). Survival analysis revealed superior overall survival (OS) in Group A vs. Group B (p < 0.0001) and inferior OS vs. Group C (p < 0.0001). After a landmark analysis, the OS for patients aged 80 or older and those under 80 appeared to be similar (HR 2.55 [0.75-8.72], p = 0.136). (4) Conclusions: Laparoscopic surgery in very elderly CRC patients shows comparable oncological outcomes and surgical complications to younger populations. Survival benefits are influenced by age, comorbidities, and medical complications. Further prospective multicenter studies are needed in order to validate these findings.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

INTRODUCTION

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.

METHODS

A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.

CONCLUSIONS

In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Long-Standing Ulcerative Colitis May Trigger a Multilineage Cancerization Field

Longstanding/relapsing inflammation characterizing ulcerative colitis (UC) has been associated to an increased risk of colon mucosa neoplastic transformation. We describe the clinicopathological features of a UC-related poorly-differentiated neuroendocrine carcinoma coexisting with a conventional adenocarcinoma. This case supports UC as a multilineage cancerization field.

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.

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.

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.

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.

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.

Selection criteria for surgery in patients with obstructed defecation, rectocele and anorectal prolapse

The aim of this study was to evaluate the impact of applying strict selection criteria to patients with symptoms of obstructed defecation, rectocele and rectal prolapse who were candidates for surgery. From June 2001 to September 2003, 20 patients underwent surgery in our clinic for symptomatic rectocele and anorectal prolapse. They were evaluated prospectively using a dedicated questionnaire (KESS), a proctological and gynaecological examination, colpo-cysto-defecography and anorectal manometry before surgery and 6 months postoperatively. Strict selection criteria were used for surgery. After 6 months the questionnaire showed an important improvement in symptoms. The symptoms of obstructed defecation and vaginal bulging improved significantly. The average KESS score dropped from 17.65 preoperatively to 5.8 six months after surgery. In the treatment of pelvic floor disease, it is important to evaluate both the uro-gynaecological and the proctological symptoms with the utmost care, obtaining an accurate clinical picture with the aid of dedicated questionnaires and a thorough clinical examination. Evaluation of the effectiveness of surgery for constipation necessarily includes assessing the strength of the indications for surgery, irrespective of the surgical technique adopted, but there is currently no standardised test method for recording and comparing the symptoms of constipation.

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.

Colitis cystica profunda of the rectum: report of a case and review of the literature

Colitis cystica profunda is a rare intestinal lesion. Because of its clinical expression (rectorrhagia, mucorrhea and abdominal pain) and the way it appears to current imaging techniques this disease presents features which can be associated with colon neoplasm. Its diagnosis has to be confirmed histologically, and its etiology remains unclear. The following is a case report of colitis cystica profunda recurring 20 years after a first episode in a white woman, who had had an anterior resection of the sigmoid colon and upper rectum to deal with a colitis cystica profunda-induced stenosis of the sigmoid colon and at 41 underwent the transanal removal of a polypoid lesion. A review of 20 cases in the literature showed that colitis cystica profunda has a predilection for the male and generally affects the medial and lower rectum and the sigmoid colon. The literature also confirmed the association with ulcerative rectocolitis, Crohn's disease and rectal prolapse. The type of treatment varies from surgical, medical, and endoscopic to no treatment at all.

Laparoscopic-assisted resection is safe and effective for colorectal malignancies: a single-centre experience

The aim of the study was to evaluate laparoscopic-assisted colorectal resection for malignancies in terms of effectiveness, safety and medium-term survival, comparing our results with those reported in literature. From November 2000 to March 2004, 78 patients with colorectal malignancies underwent laparoscopic-assisted resection. All anastomoses were performed extracorporeally. Where indicated, patients underwent pre- or post-operative chemo-radiotherapy. All patients were followed up at regular intervals for a mean period of 18 months (2-42). The conversion rate was 14.1% and mean intraoperative blood loss was 120 cc. The post-operative morbidity rate was 15.3%. The mean number of lymph nodes removed was 12 (3-38) and all resection margins were clear and adequate. The observed overall and "disease-free" survival rates were similar to those reported in literature. Although the body of evidence needs to be increased, our findings and the data in the literature suggest that laparoscopic-assisted resection for colorectal malignancies is safe and effective, also in the medium and long term.

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.

Insertion of prolonged venous access device: a comparison between surgical cutdown and percutaneous techniques

The use of totally implantable prolonged venous access devices (TIPVAD) in chemotherapy for oncological patients is now consolidated practice, whereas the choice between surgical cutdown and the percutaneous technique is still a controversial matter. The aim of this study was to retrospectively evaluate the validity and safety of the surgical approach by comparison with percutaneous techniques. Over a period of 17 months, 106 patients (mainly oncological cases) underwent surgical cutdown for TIPVAD placement in the cephalic vein. During a mean follow-up of 8 months (range 1-21), we evaluated the surgical and management complications and compared them with reported results obtained with the percutaneous technique. We observed a lower incidence of pneumothorax, 2 cases of malfunction due to kinking, and no catheter fractures, while management complications were similar to the findings in the literature. In expert hands, the surgical approach is a fast, safe technique with a lower rate of intraoperative complications than the percutaneous approach and less discomfort for the patient. Adequate training of medical and paramedical staff is the most important factor in making TIPVAD reliable and safe in the long term.

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour): a case report of conservative surgery

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour) is a rare interesting infectious disease caused by the papillomavirus serotypes 16 and 18. In January 2002 a 47-year-old heterosexual male presented with Buschke-Lowenstein tumour and reported having had the disease for 12 years. The patient underwent thorough screening for sexually-transmitted diseases (which proved negative), abdominal CT, transanal US-endoscopy, inguinal ultrasound, chest X-ray and anorectal manometry, which revealed only localized disease. He was treated conservatively with radical local excision of the lesions. No postoperative complications were observed. Twelve months after surgery, there has been no local or remote recurrence and faecal continence is normal. The treatment of choice for Buschke-Lowenstein tumour is controversial; there is no evidence to support the need for demolitive surgery or chemo- and/or radiotherapy. The majority of authors prefer abdominoperineal amputation, but in our opinion conservative surgery is the best choice, especially in terms of the patient's quality of life.

Role of transperineal Doppler and ultrasound in evaluating anal sphincter injury after stapled haemorrhoidopexy

The stapler treatment first described by Longo is considered by some authors to be a good technical solution for mucohaemorrhoidectomy. The aim of the present prospective study was to assess the function and morphology of the internal and external anal sphincters preoperatively and one month after surgery by means of a clinical examination, anorectal manometry and transperineal ultrasound. Ten patients (6 M, 4 F) underwent rectal mucosal prolapsectomy according to Longo. Anoscopy, anorectal manometry and transperineal ultrasound were performed in all patients preoperatively and again one month after surgery. The thickness and integrity of the internal and external anal sphincters were ascertained and colour Doppler was performed to assess the presence, quantity and size of any haemorrhoid swellings. All anatomical specimens underwent histological examination in search of smooth muscle fibres. Anorectal manometry revealed no postoperative sphincter tone defects. Transperineal ultrasound detected no postoperative sphincter lesions and the presence of venous swellings (always present at preoperative colour Doppler) never persisted at postoperative follow-up. The mean follow-up was 52.7 days (range: 31-151). Transperineal ultrasound proved useful in demonstrating the lifting of the mucohaemorrhoid prolapse within the ampulla of the rectum one month after surgery. The Longo procedure, in our albeit limited experience, caused no sphincter lesions.

[How to prevent saphenous nerve injury. A personal modified technique for the stripping of the long saphenous vein]

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.

[Advantages of surgical treatment of hemorrhoids with mechanical sutures]

The use of circular staplers for the treatment of haemorrhoids is a new technique that makes for better correction of the physiopathology of the condition, affords greater patient comfort and reduces health-care expenditure. This technique, which was invented by A. Longo in 1993, pulls up the haemorrhoidal cushions into their anatomical position, reduces or avoids postoperative pain, sparing the sensitive fibres of the anal canal, avoids anal canal stenosis and is not complicated by faecal incontinence. The authors present their experience in 41 patients affected by symptomatic haemorrhoidal prolapse and treated with a mucosal rectal prolapsectomy using a circular stapler. Each patient was followed up for 6 months to assess the incidence of complications and the degree of patient satisfaction. The results were compared with those reported in the literature, obtained using the Milligan-Morgan procedure. The Longo technique, which can be performed in the one-day surgery setting, allows very good relief of postoperative pain, rapid functional recovery and an early return to work, with a saving in health-care expenditure as compared with conventional treatment.

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.

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.

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.