Comparative study using indocyanine green and patent blue dye for sentinel lymph node biopsy in patients with early-stage cervical cancer.

BACKGROUND: Lymphatic involvement is the most important prognostic factor in early-stage cervical cancer. Sentinel lymph node biopsy is a viable alternative to systematic lymphadenectomy and may identify metastases more precisely. OBJECTIVE: To compare two tracers (indocyanine green and patent blue) to detect sentinel nodes. METHODS: A single-center, retrospective study of women treated due to early-stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 IA1 with lymphovascular invasion, IA2, and IB1). Location and tracer of all detected sentinel nodes had been documented for a prospective, multicenter trial (SENTIX trial). All sentinel nodes were sent to frozen section and final analysis through ultrastaging using a standard protocol. RESULTS: Overall, 103 patients were included. Bilateral detection rate for indocyanine green (93.2%) was significantly higher than for blue dye (77.7%; p=0.004). Their combined use significantly increased the bilateral detection to 99.0% (p=0.031). While 97.4% of all sentinel nodes were located below the common iliac vessels, no para-aortic nodes were labeled. Simultaneous bilateral detection with both tracers was found in 71.8% of the cases, of which the sentinel nodes were identical in 91.9%. Nine positive nodes were detected among seven patients (6.8%), all marked with indocyanine green while patent blue labeled six. Frozen section failed to detect one of three macrometastases and three of four micrometastases (sensitivity 43%; negative prediction value 96%). CONCLUSION: Anatomical distribution and topographic localization of the sentinel nodes obtained with these tracers were not different. Indocyanine green provided a significantly higher bilateral detection rate and had superior sensitivity to detect positive nodes compared with patent blue. Combining indocyanine green and blue dye increased the bilateral detection rate significantly.

A hemangioma of the sigmoid colon mesentery presenting as a retroperitonealtumor: a case report and review.

Hemangiomas of the gastrointestinal tract and mesentery are uncommon benign vascular lesions. While spontaneous bleeding is the hallmark of the gastrointestinal tumor variant, clinical signs of mesenteric hemangiomas are mostly unspecific. Despite the increasing imaging quality of computerized tomography (CT), in most cases the final diagnosis is established through surgery and histopathologic analysis of a macrobiopsy.We present a case report of a 20-year-old female patient who was admitted with progressive abdominal distension and suffered from persistent abdominal pain for 3 months. A large retroperitoneal tumor mass was detected on the CT scan. Due to radiographic signs of an intraabdominal liposarcoma, an explorative laparotomy was performed revealing a large hemangioma originating from the mesosigmoid.Although rare, gastrointestinal hemangiomas should be kept in mind by oncological visceral surgeons as one differential diagnosis of large intraabdominal tumorous masses, especially in young adults.

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas.

PURPOSE: The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas. METHODS: We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively. RESULTS: In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28 ± 16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery. CONCLUSIONS: FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review.

PURPOSE: This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety. METHODS: Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334). RESULTS: BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES. CONCLUSIONS: There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment. KEY MESSAGES: • The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.

Triple-target treatment versus low-frequency electrostimulation for anal incontinence: a randomized, controlled trial.

BACKGROUND: In the nonsurgical treatment of anal incontinence, the combination of amplitude-modulated medium-frequency stimulation and electromyographic biofeedback (EMG-BF), known as triple-target treatment (3T), is superior to EMG-BF alone. The aim of this trial is to compare 3T with the standard treatment, low-frequency stimulation (LFS). METHODS: 80 patients with anal incontinence of Grade I or higher who presented to physicians or centers specialized in coloproctology were enrolled in this multicenter randomized trial with blinded observer. The trial had an open parallel-group design. Randomization was performed centrally by telephone. The primary endpoint was the Cleveland Clinic Score (CCS) after self-training at home with either 3T or LFS in two 20-minute sessions per day for 6 months. The secondary endpoints included the proportion of patients regaining continence, and the patients' quality of life (QoL). On completion of the trial as planned, the results were evaluated with an intention-to-treat analysis. STUDY REGISTRATION: DRKS00000138 (http://register.germanctr.de). RESULTS: 39 patients were randomized to 3T, and 41 to LFS. After 6 months of treatment, the CCS (mean ± standard deviation) was 3.1 ± 4.2 in the 3T group and 9.6 ± 3.9 in the LFS group. The median improvement in the CCS at 6 months compared to baseline was 7 points greater in the 3T group than in the LFS group (95% CI: 5-9, p<0.001). Anal continence was regained by 54% of the 3T patients, but none of the LFS patients (95% CI for the difference: 37.18% - 69.91%, p<0.001). QoL scores were higher in all dimensions in the 3T group than in the LFS group. No major adverse effects occurred in either group. CONCLUSION: 3T is superior to LFS in the treatment of anal incontinence. The available evidence suggests that the success of 3T is based on the combined effect of biofeedback and medium-frequency stimulation. LFS of the type applied in this trial has no effect. 3T should be used in routine clinical practice instead of LFS.

Does the STARR procedure change the pelvic floor: a preoperative and postoperative study with dynamic pelvic floor MRI.

BACKGROUND: Obstructed defecation syndrome is a multifactorial disorder of the defecation process. Stapled transanal rectal resection has been used to restore function in patients suffering from obstructed defecation syndrome. OBJECTIVE: The aim of this study was to use preoperative and postoperative dynamic pelvic floor MRI combined with clinical parameters to evaluate the outcome of stapled transanal rectal resection. DESIGN AND SETTING: A prospective cohort study was conducted in a tertiary care center. PATIENTS: A group of 140 women with obstructed defecation syndrome were evaluated. INTERVENTION: All 140 patients were initially treated conservatively with laxatives, increased fluid intake, pelvic floor exercises, and biofeedback. Stapled transanal rectal resection was performed in 30 patients with rectocele who did not show improvement in symptoms after at least 6 months of conservative treatment. MAIN OUTCOME MEASURES: Preoperative diagnostic workup consisted of dynamic pelvic floor MRI, clinical examination, coloscopy, and clinical scores (Cleveland Clinic constipation score, German Working group on Coloproctology continence score, and SF-36 quality-of-life questionnaire). Postoperatively, patients were reevaluated at 3 months by means of dynamic pelvic floor MRI, clinical examination, and clinical scores; clinical scores were repeated at 6 months after the operation. RESULTS: Postoperative dynamic pelvic floor MRI performed after a median of 3.4 months showed a decrease in rectocele size from 3.3 (interquartile range, 2.8-3.8) cm to 1.5 (1.2-2) cm (P < .001). The number of patients with intussusception decreased from 21 (70%) before the operation to none after the operation (P < .001). The size of cystoceles did not change. The number of patients with incomplete evacuation was significantly reduced (P < .001). With a mean follow-up of 18 ± 4 months, patients showed a significant improvement in the quality-of-life score (P < .001) but not in the continence scores. CONCLUSIONS: Stapled transanal rectal resection is an effective treatment option for patients with obstructed defecation syndrome associated with rectocele and intussusception.

Dramatic regression and bleeding of a duodenal GIST during preoperative imatinib therapy: case report and review.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract. The majority of GISTs is located in the stomach. Only 3-5% of GISTs are located in the duodenum associated with an increased risk of gastrointestinal bleeding as primary manifestation. With response rates of up to 90%, but complications like bleeding due to tumor necrosis in 3%, imatinib mesylate dramatically altered the pre- and postoperative therapy for GIST patients. CASE PRESENTATION: A 58-year-old female patient presented with acute upper gastrointestinal bleeding 2 weeks after a giant GIST of the duodenum had been diagnosed. Neoadjuvant imatinib therapy had been initiated to achieve a tumor downsizing prior to surgery. During emergency laparotomy a partial duodenopancreatectomy was performed to achieve a complete resection of the mass. Histology revealed a high-malignancy GIST infiltrating the duodenal wall. Adjuvant imatinib therapy was initiated. At follow-up (19 months) the patient is still alive and healthy. CONCLUSION: Giant GISTs of the duodenum are rare and - in contrast to other localizations - harbour a higher risk of serious bleeding as primary manifestation. Tumor necrosis and tumor bleeding are rare but typical adverse effects of imatinib therapy especially during treatment of high-malignancy GIST. In GIST patients with increased risk of tumor bleeding neoadjuvant imatinib therapy should thoroughly be performed during hospitalization. In cases of duodenal GIST primary surgery should be considered as treatment alternative.

Triple target treatment (3T) is more effective than biofeedback alone for anal incontinence: the 3T-AI study.

PURPOSE: The efficacy of EMG-biofeedback and low-frequency electrical stimulation for the treatment of anal incontinence has not been proven. Our purpose was to evaluate a novel therapeutic concept, termed triple target treatment, which combines amplitude-modulated medium-frequency stimulation and EMG-biofeedback. METHODS: Patients with anal incontinence were randomly assigned to the triple target regimen or EMG-biofeedback alone for a 9-month treatment period in a multicenter randomized clinical trial with blinded observers (ClincialTrials.gov registration number NCT00525291). Primary end points were changes in the Cleveland Clinic score and the adapted St. Mark's (Vaizey) score at 9 months compared with baseline. Secondary end points included therapy acceptance and proportion of patients achieving continence or improvement in grade or frequency of incontinence. RESULTS: We enrolled 158 patients with anal incontinence. The median decrease in the Cleveland Clinic score from baseline to 9 months was 3 points greater for the triple target regimen than for EMG-biofeedback (95% CI, 1-4; P = .0024). The improvement was 8 points for the triple target regimen (95% CI, 7-9) and 5 points for EMG-biofeedback (95% CI, 4-7). Results were similar for the Vaizey score. Of patients treated for at least 3 months, continence was achieved by 50% of patients with the triple target regimen and 25.8% of those with EMG-biofeedback. CONCLUSIONS: The combination of amplitude-modulated medium-frequency electrostimulation with EMG-biofeedback in the triple target regimen is superior to EMG-biofeedback alone in the treatment of anal incontinence. Therapy programs for fecal incontinence are most effective if patients participate for longer than 2 to 3 months.

Surgical treatment of complex anal fistulas with the anal fistula plug: a prospective, multicenter study.

PURPOSE: This study was designed to analyze the efficacy of the Surgisis Anal Fistula Plug for the closure of transsphincteric anorectal fistulas. METHODS: Patients with single transsphincteric anorectal fistulas were prospectively enrolled. Setons were used in all tracts for at least eight weeks before surgery. Continence, surgical variables, complications, and healing rates were recorded. Surgery was performed in a standardized manner. The fistula tract and external opening were debrided, the tract was irrigated, and the plug was placed. The external opening was left open. Success was defined as the absence of drainage and closure of the external opening. Follow-up examinations were performed at 2 days, 2, 4, 6, and 12 weeks, and 6 and 12 months after surgery. RESULTS: Sixty patients were enrolled. Seventeen patients were smokers, and ten had diabetes mellitus. The mean surgical time was 23 (range, 13-50) minutes; no morbidity occurred. The overall success rate after 12 months was 62%. Nineteen fistulas recurred, and four fistulas never completely healed. The success rate was significantly lower in smokers and diabetics. Two patients had a plug dislodgement, and plugs were successfully replaced. No change in continence was observed. CONCLUSION: Because there is still no standard for the treatment of high transsphincteric fistulas and because recurrence rates are high for all procedures performed, new techniques are needed for this complex disease. Our success rate of 62% is promising because this technique can be used as a first approach to close the fistula tract without destruction of the sphincter muscle.

Transvaginal rectal repair: a new treatment option for symptomatic rectocele?

PURPOSE: Widely differing surgical methods have been propagated to correct symptomatic rectocele. With transvaginal rectal repair (TVRR), we evaluate a method to reestablish the continuity of the rectal muscle wall, strengthen the weakened tunica muscularis, and restore normal rectal capacity and function. METHODS: Between 1997 and 2003, 102 female patients were treated by TVRR in cases of symptomatic rectocele. Patients without improvement following a stringent conservative treatment for a minimum of 3-6 months were selected for TVRR procedure. Patients with intussusception and slow-transit constipation were excluded from the study. To achieve optimal stabilization of the rectal wall, a transverse gathering of the rectocele was performed by a transvaginal access. RESULTS: Average patient age was 60.9 years (47-76 years), operation time was 36.5 minutes (29-67 min.), in-hospital treatment lasted 4.1 days (2-7 days), and follow-up was 18.1 months (3-48 months). We observed complications in 11% of cases. Three months after the operation, 81% of the patients were symptom-free or improved. Following an average observation time of 18.1 months (3-48 months), 70% were still symptom-free or improved. CONCLUSIONS: TVRR allows easy access for rectocele repair with a low rate of complications.