[Topical use of glyceryl-trinitrate in the treatment of anal fissure]. / Uso topico di gliceril-trinitrato nel trattamento della ragade anale.

AIM: Anal fissure is associated with hypertonia of the internal anal sphincter and pain. Lateral internal sphincterotomy, the most common treatment, may cause permanent injury to the anal sphincter, which can lead to fecal incontinence. The aim of this study was to evaluate the effectiveness of topical glyceryl trinitrate (GTN) ointment in the treatment of anal fissure. METHODS: Twenty-four patients (12 males and 12 females, mean age 45 years) with anal fissure received 0.4% GTN gel twice a day for a minimum of six weeks. All patients were followed at regular intervals of 2, 6, 12 weeks to assess symptom outcome, rate of healing, adverse effects and recurrence rate. RESULTS: The symptomatology was significantly improved already from the second week of treatment in 18 patients (75%). Thirteen patients (54%) healed after six weeks, and 14 (58%) after 12 weeks, while three patients (13%) partially healed but asymptomatic. Fecal incontinence was absent. In two patients (8%) treatment was interrupted because of severe headaches. At the end of the treatment, only three patients (13%) underwent lateral sphincterotomy. CONCLUSIONS: Topical application of GTN ointment heals anal fissures and represents an alternative to the traditional first-line treatment of surgical sphincterotomy.

[Treatment of functional diseases after rectum anal surgery: effectiveness of rehabilitation of the pelvic pavement]. / Trattamento dei disturbi funzionali dopo la chirurgia retto-anale: efficacia della riabilitazione del pavimento pelvico.

AIM: Anorectal dysfunction is routinely treated at the Center for Pelvic Floor Rehabilitation, San Giovanni University Hospital, Turin, Italy. Of a total of 147 patients treated between April 2007 and May 2008, 44 (30%) received pelvic floor rehabilitation following anorectal surgery. With this study we wanted to evaluate the response of patients with constipation and/or fecal incontinence to postsurgical pelvic floor rehabilitation designed to regain full or partial anorectal function and so improve their quality of life. MATERIAL AND METHODS: The study population was 44 patients, subdivided into 3 groups. One group (n=25) consisted of patients with fecal incontinence, which was further split into two subgroups: subgroup A (n=10) with direct involvement of the anal sphincter at surgery and subgroup B (n=15) without sphincter involvement. The second group (n=12) included patients with constipation. The third group (n=7) included patients with constipation and incontinence; this group was further split into 2 subgroups: those in which constipation (n=5) and those in which incontinence (n=2) was predominant. Pre- and postrehabilitation anorectal function was compared using two types of assessment: 1) clinical evaluation with the Wexner incontinence scale and 2) diagnostic evaluation with anorectal manometry in patients with fecal incontinence (plus transanal sonography to determine anatomic damage in the subgroups in which the sphincter had been involved) and defecography in those with constipation (plus transit radiography to exclude intestinal colic-associated constipation). RESULTS: The number of patients classified as having severe incontinence decreased from 8 to 1 (-87.5%), those with moderate incontinence decreased from 8 to 4 (-50%); 20 out of 25 patients presented with mild dysfunction at the end of the rehabilitation program. No difference in response to treatment was found between the two subgroups of patients with fecal incontinence nor among those with constipation. Of those with predominant constipation, none were classified as having severe dysfunction; the number of those with moderate dysfunction decreased from 13 to 7 (-54%). CONCLUSIONS: The study results show that, when sufficiently motivated, patients with fecal incontinence and constipation following anorectal surgery respond positively to pelvic floor rehabilitation.

Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study.

BACKGROUND: The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer. METHODS: A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted. RESULTS: The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001). CONCLUSIONS: As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Human CD38 and its ligand CD31 define a unique lamina propria T lymphocyte signaling pathway.

CD38, a nonlineage-restricted surface glycoprotein, is an ecto-enzyme (ADP ribosyl cyclase/cADPR hydrolase/EC 3.2.2.6) that regulates cytoplasmic Ca2+ and cell-cell interactions. The molecule also delivers trans-membrane signals, despite a structural ineptitude to the scope. To reconcile these issues in a unitarian model, we compared the effects of CD38 signaling in circulating and residential T lymphocytes, the latter represented by those colonizing the intestinal lamina propria. Results are as follows: 1) LP T cells express an enzymatically active form of CD38, characterized by a modified ratio between cyclase and hydrolase functions; 2) LP T cells do not mobilize Ca2+ upon CD38 ligation, as seen in PB T cells (this condition is due to a lack in activation of PLC- g, constantly observed in PB T lymphocytes); 3) The early steps of CD38 signaling involve activation of lck, syk, and LAT; 4) Late events include synthesis and release of IL-2, IL-4, IL-5, IL-10, IFN-g and GM-CSF; 5) The uniqueness of the CD38 pathway in LP T cells is not caused by impaired interactions with the CD31 ligand. The differences observed concern the signaling machinery that CD38 exploits for its own use and not the interplay with its ligand.

[Neuronal dysplasia of the colon. A case report]. / Displasia neuronale del colon. Descrizione di un caso clinico.

A clinical case of Neuronal Intestinal Dysplasia (NID) is reported. This is an important pathology which is part of congenital alterations of bowel's innervation. This disease consists of two forms (A and B) which occur during different ages causing problems in intestinal motility with consequent various symptoms. Actually NID is diagnosed easier than in the past because histopathological techniques are very refined and permit to distinguish NID from cases once classified as Hirschsprung's disease. Histology can show an increase of Ach and Ldh activity in cholinergic fibers of lamina propria and of circular layer of intestinal wall. In this report a chronic status of constipation refractory to medical therapy has been treated with a total colectomy and an ileo-rectal anastomosis, resulting in a complete resolution of symptoms.

Altered expression of androgen-receptor isoforms in human colon-cancer tissues.

Many groups have examined of androgen the effects on normal and neoplastic colon tissues, but no clear picture has hitherto emerged. In particular, the presence and the function of the androgen receptor (AR) has only partially been investigated in the past. The present study reports analysis of expression of the AR gene as messenger RNA and as protein in surgical samples of neoplastic colon mucosa and of corresponding healthy surrounding tissue. Specific binding for DHT, demonstrating the presence of AR, was observed in almost all the samples (2 samples out of 12 were negative). No significant difference was observed between healthy and neoplastic mucosa, or between male and female patients. A further characterization of AR was performed with Western blot, using 2 different primary antibodies. Both AR isoforms, AR-B and AR-A, were detected in healthy mucosa, while only AR-A, resolving at 87 kDa, was observed in neoplastic mucosa. RT-PCR analysis revealed the transcript for AR in both healthy and neoplastic mucosa in 10 samples; no message was detectable in 2 samples (negative also for binding); 2 additional samples presented AR mRNA only in healthy colon mucosa, 2 others only in neoplastic mucosa. In addition, a variant AR messenger RNA, probabily derived from alternative splicing, was observed. We found that AR is expressed both in healthy and in neoplastic colon mucosa, either as mRNA or as protein. Neoplastic colon tissue shows a characteristic loss of expression of the AR-B isoform, while AR-A expression is maintained. These findings underscore the possible role of androgen and its receptor in colon carcinogenesis.

Analysis of the distribution of human CD38 and of its ligand CD31 in normal tissues.

Human CD38 is a 45 kD ectoenzyme endowed with ADP-ribosyl cyclase and hydrolase activities. The molecule plays a central role in lymphocyte activation, proliferation and selectin-type adhesion with endothelial cells (HEC). A HEC surface molecule displaying all the features of a CD38L has been identified by means of a mAb (Moon-1), able to block CD38-mediated adhesion processes. The 130 kD molecule recognized by Moon-1 is CD31, a member of the Ig superfamily. This paper reports on the analysis of the surface expression of CD38 and CD38L in various human tissues of adult origin and compared in some instances to the fetal (9-14 weeks) counterparts. This was achieved by means of immunohistochemical techniques and analysis of purified cell populations. Among the specimens analyzed, CD38 is expressed by a vast array of cells of lymphatic origin as well as by the skeletal and cardiac muscle fibers, the bronchi (epithelial cells), the parotid gland (ductal epithelial cells) and hepatic sinusoids. On the contrary, CD31 proved constantly expressed by HEC at high levels, independent of the organ or tissue analyzed or of the kind of vessel. Other cells expressing CD38L were found in the lymphoid compartment (follicle mantle B cells and plasma cells), in the lungs (alveolar ducts, alveoli and lymphatic vessels) and in the kidney (glomerular cells). Interestingly, no fetal organ or tissue ever expressed CD38 and its ligand. The above results were enriched by the analysis of the expression of the two molecules on purified populations including mononuclear cells from the lamina propria of the gastro-intestinal tract and broncho-alveolar lavage lymphocytes.

[Extrahepatic gastrinoma. Report of a clinical case]. / Gastrinoma extrapancreatico. Descrizione di un caso clinico.

Gastrinoma is a rare neoplasia producing gastrina, the hormone responsible of the clinic manifestations related to Zollinger-Ellison syndrome. The localization of gastrinoma is pancreatic or extrapancreatic (usually in Stabile and Passaro triangle). We present a case report concerning an extra-pancreatic gastrinoma not localized in this area and included in a lymph node. This is an extremely infrequent localization (2.4%). There are two different opinions about this localization. Some authors think that this is always a secondary lesion of a small primary neoplasia usually asymptomatic. Other authors think that there are primary lymph nodal gastrinomas that could be safely removed with excision of lymph node. The infrequent localisation of this case induced us to report this experience in order to contribute to the comprehension of this pathology.

[Complications of the surgical treatment of hemorrhoids and its therapy]. / Le complicanze della terapia chirurgica delle emorroidi ed il loro trattamento.

Hemorrhoidal disease is a common problem in a proctological ambulatory. Surgery is the best therapy for fourth degree hemorrhoids and the complication rate is 10-20%: postoperative urinary retention etiology is unknown but it may be caused by dysfunction of bladder muscles in response to pain and by an excessive perioperative somministration of fluids; delayed hemorrhage (i.e., 7-10 days postoperative) needs an inpatient care and the treatment ranges from bedside and packing to hemorrhoid pedicle suture ligation in the operating room. Anal stenosis is most commonly a result of a prior improper hemorrhoidectomy: it may be mild, moderate or severe; V-Y and C-anoplasty are the best therapy, also for ectropion. Rubber band Ligation and Sclerotherapy are the most common treatment of internal hemorrhoids: external hemorrhoid trombosis and delayed hemorrage are frequent complications.

[Refractory ascites: a fifteen-year experience with the peritoneovenous shunt]. / L'ascite irriducibile: 15 anni di esperienza con la derivazione peritoneo-venosa (DPV).

The authors consider the various causes of ascites and they also develop the concept of refractory ascites. They consider the various possibilities of medical and dietary therapy whose failure constitutes the basis for a surgical approach. In the latter case it is being considered the Peritoneo Venous Shunt (PVS) that employs different types of valves. In the light of their personal experience, matured over a period of 15 years, in which 75 valves were positioned in 64 patients and precisely: 55 valves of Le Veen, 15 Hakim and 5 Denver, it is emphasized that the best results, as for as mortality and morbidity goes, were obtained through careful attention in the preoperative stage and during surgery itself with the privileged use of a Le Veen's valve. For such motives, since in a high percentage of these patients there persists a poor prognosis a year away from the onset of refractory ascites, a PVS seems proposable anyway and even though this will not alter the pathological outcome, there's a clear improvement in the quality of life without precluding any other surgical approach. Finally, the authors outline the possibilities offered by the Transjugular Intrahepatic Portosystemic Shunt (TIPS), as a new original approach for the resolution of refractory ascites.

[Rhabdomyosarcoma. Presentation of a case with abdominal localization]. / Il rabdomiosarcoma. Presentazione di un caso a localizzazione addominale.

The Authors report a case of rhabdomyosarcoma observed in a 17-year-old boy. They emphasize that this rare form has an extremely rapid evolution, and in this case was also in an unusual site and of abnormal size. The difficulty of an early diagnosis and the impossibility of radical surgery are also underlined.

[Mesenteric fibromatosis in Gardner's syndrome]. / La fibromatosi mesenterica nella sindrome di Gardner.

The paper reports a case of mesenteric fibromatosis with familial polyposis, an association which was diagnosed as Gardner's syndrome, and highlights the complications connected to mesenterial desmoid tumours. In addition, the importance of radical surgical therapy of these neoplasias is underlined. Lastly, it is hypothesised that full screening of patients affected by familial polyposis might show a greater incidence of association between widespread polyposis and pathological changes attributable to Gardner's syndrome.

[Ano-rectal candidiasis]. / La candidosi ano-rettale.

The presence of candida and other fungi was investigated in 300 patients referred with anal problems of diverse aetiology. Candida was present in 13% and played a pathogenic role in about 50% of all positive cultures. It is concluded that cultural tests for fungal pathogens should always be performed in cases of anal itching or burning combined with other anal skin problems.

[Cloacogenic carcinoma of the anus. Description of a clinical case]. / Carcinoma cloacogenico dell'ano. Descrizione di un caso clinico.

A clinical case of cloacogenic anal carcinoma is reported. These neoplasms, deriving from embryonal residuals at different levels of the ano-rectal junction, have a better prognosis than squamous carcinomas; the surgical alternative to abdomino-perineal resection is a simple local exeresis for small tumours that do not invade the muscular layer, with a good radical result as reported by the literature.

[First experiences with trans-rectal echotomography in perianal abscess pathology]. / Prime esperienze di ecotomografia trans-rettale nella patologia ascessuale perianale.

Trans-rectal ultrasound with a 5 MHz probe was used to examine 16 patients who had perianal fistulas and 5 of them underwent one or more surgical explorations. In 11 cases, all surgically checked, sonography was able to demonstrate a pararectal abscess and accurately image the site, size, extension and--in some cases--the fistula itself. It can be advised that, using high frequency probes (7 or 10 MHz), transrectal ultrasound could provide even more exact diagnostic information in anorectal pathology.