Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient.

BACKGROUND: Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS: The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS: A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS: Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION: Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS: Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.

Cancer stem cells as functional biomarkers.

According to the American Association of Cancer Research (AACR), a Cancer Stem Cell is a cell within a tumor that possesses the capacity to self-renew and to cause the heterogeneous lineages of cancer cells that constitutes the tumor [1]. Cancer Stem Cells (CSCs) are involved in the metastatic process, in the resistance to therapeutic treatments of many types of human cancers and consequently in the onset of recurrences. Numerous translational studies have been conducted to understand CSC characteristics and evaluate association between CSC-related biomarkers and clinical outcomes. The CSC theory can explain also a tumor relapse after that a tumor has been completely surgically removed (R0 macroscopical zero residual resection) or after an apparently complete response to chemotherapy. CSCs, in fact, showed a marked ability to reduce intracellular accumulation of chemotherapic agents by active drug extrusion, increased chemoresistance and survival, as well as elevated membrane transporter activity. In addition, it is possible that these cancer stem cells may nest in the "secured" (niche) sites of our body, where they may remain undisturbed for a long time, even years, until a stimulus arrives to awaken them, causing the disease to resume. CSCs, in fact, are able to use a variety of cellular pathways to survive to anticancer treatments. More recently CSCs have been described in several solid tumors, expressing specific biomarkers. Another field of research should be focused on the realization of diagnostic instruments to follow up patients after R0 surgical resection or after a complete response for an early detection and management of relapse and metastasis.

Does anxiety or waiting time influence patients' tolerance of upper endoscopy?

BACKGROUND/AIMS: Endoscopy is an essential and very commonly used procedure for the evaluation of a multitude of gastrointestinal symptoms. Although it is increasingly required, patients often wait on arrival at the endoscopy unit until they are called for the procedure. It is not clear whether or not this waiting time may have an impact on patient's tolerance during upper endoscopy. Our study attempts to address this. PATIENTS AND METHODS: We studied consecutive outpatients who underwent endoscopy from September to December, 2013. Gender, age, body mass index (BMI), previous endoscopic experiences, antidepressant therapy, and the time interval between arrival at the endoscopy unit and the onset of examination was recorded. Anxiety before the procedure, pain, and discomfort were rated by a numeric rating scale (0 = no pain/discomfort encountered to 10 = extremely painful/uncomfortable). RESULTS: One hundred and five consecutive outpatients (male = 52; mean age = 45.3 years; age range = 20-86 years) were included in the study. The mean BMI was 25 ± 4.8; mean waiting time from registration to the procedure was  172 min (time range = 30 - 375 mins). Mean patients' pre-examination anxiety level was 3 ± 3.84, mean discomfort score was 4.3 ± 3.09 and mean pain score was 3.4 ± 3.03. The level of pain and discomfort was significantly higher in patients with higher levels of pre-procedure anxiety. No differences were found in terms of anxiety, pain and discomfort among patients divided according to waiting time. CONCLUSIONS: According to our data, waiting time does not have a significant impact on the perception of pain and discomfort related to the endoscopic procedure. On the other hand, high pre-procedural levels of anxiety were associated with a low tolerance. Further multicenter randomized trials are needed to clarify the impact of waiting time.