Adding Narrow-Band Imaging to Chromoendoscopy for the Evaluation of Tumor Response to Neoadjuvant Therapy in Rectal Cancer.

BACKGROUND: Endoscopic assessment is crucial in diagnosing clinical complete response after neoadjuvant therapy in rectal cancer. OBJECTIVE: The purpose of this research was to evaluate the benefits of adding narrow-band imaging endoscopy to conventional chromoendoscopy in predicting pathologic complete response in the surgical specimen. DESIGN: This was a prospective nonrandomized study. SETTINGS: This was an ad hoc study of a prospective phase II trial at a single comprehensive cancer center that evaluated oncologic outcomes of a neoadjuvant therapy for rectal cancer. PATIENTS: Patients with high-risk stage II to III low rectal cancer who received neoadjuvant modified folinic acid, fluorouracil, and oxaliplatin plus bevacizumab followed by chemoradiotherapy and surgery were included. INTERVENTION: Tumor response after neoadjuvant therapy was evaluated using conventional white light endoscopy plus chromoendoscopy then followed by using narrow-band imaging based on a predefined diagnostic protocol. MAIN OUTCOME MEASURES: Diagnostic accuracy for predicting pathologic complete response and inter-rater agreement between an expert and trainee endoscopists were compared between the assessments using conventional white light endoscopy plus chromoendoscopy and the assessment adding narrow-band imaging. RESULTS: In total, 61 patients were eligible for the study, and 19 had pathologic complete response (31.1%). Although the addition of narrow-band imaging correctly converted the diagnosis in 3 patients, overall diagnostic improvement in predicting pathologic complete response was limited (conventional chromoendoscopy vs adding narrow-band imaging: accuracy, 70.5% vs 75.4%; sensitivity, 63.2% vs 73.7%; specificity, 73.8% vs 76.2%; positive predictive value, 52.2% vs 58.3%; and negative predictive value, 81.6% vs 86.5%). A κ value for the inter-rater agreement improved from 0.599 to 0.756 by adding narrow-band imaging. LIMITATIONS: This was a single-center study with a relatively small sample size. CONCLUSIONS: Despite the limited improvement in diagnostic accuracy, adding narrow-band imaging to chromoendoscopy improved inter-rater agreement between the expert and nonexpert endoscopists. Narrow-band imaging is a reliable and promising modality for universal standardization of the diagnosis of clinical complete response. See Video Abstract at http://links.lww.com/DCR/B275. ADICIÓN DE IMÁGENES DE BANDA ESTRECHA A LA CROMOENDOSCOPÍA PARA LA EVALUACIÓN DE LA RESPUESTA TUMORAL A LA TERAPIA NEOADYUVANTE EN EL CÁNCER DE RECTO: La evaluación endoscópica es fundamental para valorar la respuesta clínica completa después de la terapia neoadyuvante en el cáncer de recto.Evaluar los beneficios de agregar endoscopia de imagen de banda estrecha a la cromoendoscopía convencional para predecir la respuesta patológica completa en la muestra quirúrgica.Estudio prospectivo no aleatorizado.Un estudio ad hoc de un ensayo prospectivo de fase II en un solo centro integral de cáncer que evaluó los resultados oncológicos de una terapia neoadyuvante para el cáncer rectal.Pacientes con cáncer rectal bajo de alto riesgo en estadio II-III que recibieron ácido folínico neoadyuvante modificado, fluorouracilo y oxaliplatino más bevacizumab seguido de quimiorradioterapia y cirugía.La respuesta tumoral después de la terapia neoadyuvante se evaluó mediante endoscopia de luz blanca convencional más cromoendoscopía, seguido de imágenes de banda estrecha basadas en un protocolo de diagnóstico predefinido.La precisión diagnóstica para predecir la respuesta patológica completa y el acuerdo entre evaluadores entre un experto y un endoscopista en entrenamiento se compararon entre las evaluaciones utilizando endoscopia de luz blanca convencional más cromoendoscopía y la evaluación agregando imágenes de banda estrecha.En total, 61 pacientes fueron elegibles para el estudio, y 19 tuvieron una respuesta patológica completa (31.1%). Aunque la adición de imágenes de banda estrecha convirtió correctamente el diagnóstico en 3 pacientes, la mejora diagnóstica general en la predicción de la respuesta patológica completa fue limitada (cromoendoscopía convencional versus adición de imágenes de banda estrecha: precisión, 70.5% versus 75.4%; sensibilidad, 63.2% versus 73.7%; especificidad, 73.8% versus 76.2%; valor predictivo positivo, 52.2% versus 58.3%; y valor predictivo negativo, 81.6% versus 86.5%). Un valor de kappa para el acuerdo entre evaluadores mejoró de 0.599 a 0.756 al agregar imágenes de banda estrecha.Un estudio de centro único con un tamaño de muestra relativamente pequeño.A pesar de la mejora limitada en la precisión diagnóstica, agregar imágenes de banda estrecha a la cromoendoscopía mejoró el acuerdo entre evaluadores entre los endoscopistas expertos y no expertos. La imagenología de banda estrecha es una modalidad confiable y prometedora para la estandarización universal del diagnóstico de respuesta clínica completa. Consulte Video Resumen en http://links.lww.com/DCR/B275.

Early Outcomes of a High-Resolution Anoscopy-Based Anal Cancer Screening Program Among People With HIV Enrolled in an Integrated Health Care System.

BACKGROUND: Few studies have examined outcomes of high-resolution anoscopy (HRA)-based screening for people with HIV infection (PWH), a population at increased risk for anal cancer. SETTING: Large integrated health care system. METHODS: Cohort study of 13,552 people with HIV infection, comparing incidences of anal cancer and advanced anal cancer (higher stage, recurrence, death, or surgical salvage) before and after HRA became available (2008). Calendar time was divided as 1998-2007, 2008-2010, and 2011-2012. Rate ratios (RRs) were obtained from Poisson regression models with adjustment for baseline demographic and health variables. Cohort cases during 2008-2012 were included in a nested case-control study, evaluating association of screening with anal cancer (33 cases, 330 controls) and advanced anal cancer (19 cases, 190 controls). Odds ratios (ORs) for receipt of screening were obtained from conditional logistic regression models with adjustment for baseline demographic and health history variables. RESULTS: Compared with 1998-2007 (pre-HRA), 2008-2010 adjusted RRs were 1.32 [95% confidence intervals (CI): 0.77 to 2.27; P = 0.31] for anal cancer and 2.11 (95% CI: 0.99 to 4.48; P = 0.053) for advanced anal cancer; and 2011-2012 adjusted RRs were 0.35 (95% CI: 0.12 to 0.99; P = 0.048) for anal cancer and 0.23 (95% CI: 0.03 to 1.77; P = 0.16) for advanced anal cancer. Individual history of screening did not reach statistical significance for anal cancer (OR 1.7; 0.6-4.6) or advanced anal cancer (OR 0.44; 0.1-3.8). CONCLUSIONS: Despite the possible effect of secular trends, we found 2008-2012 incidence trends for anal cancer and advanced anal cancer that seem consistent with expected findings of a beneficial screening program.

TEM in the treatment of recurrent rectal cancer in elderly.

INTRODUCTION: Transanal microscopic surgery is an important application of minimally invasive surgery of rectum, allowing realization of complex transanal intervention. PATIENTS AND METHODS: During the period between January 2002 and December 2010, seven patients, five men and two women, average age 75 years, with early rectal cancer recurrence were selected for this type of surgical palliative procedure. The selection of the patients is made by: transrectal ultrasonografy, colonoscopy and abdominal ultrasonografy, to rule out liver metastases, CT with and without enema, PET CT. Follow-up is approximately 12-30 months. RESULTS: The pathologic staging confirms the complete excision of recurrences. Then patients are referred for more complementary therapies. DISCUSSION: The significance of conservative treatment for local recurrence of rectum adenocarcinoma is still controversial because the recurrence is an expression of tumor spread not controlled by oncological surgical and radio/chemo therapy. CONCLUSION: In selected subjects such as the elderly, based on equal oncological treatment, the reduction of surgical trauma, preservation of anatomical integrity and resolution of symptoms are important results.

Resultados de la hemorroidopexia con sistema hemorpex en el tratamiento quirúrgico ambulatorio de las hemorroides / Hemorpex system: A new procedure for the treatment of haemorrhoids

Introducción Se presenta una nueva técnica para la intervención de hemorroides, consistente en el reposicionamiento de los paquetes hemorroidales, para lo que se emplea un proctoscopio rotatorio denominado Hemor Pex System® (HPS). Se realiza de forma ambulatoria, con mínimo dolor postoperatorio y rápida incorporación a la vida laboral. Objetivos Presentar la experiencia obtenida con esta técnica durante 3 años de seguimiento en 2 instituciones en Génova, Italia. Pacientes y método Desde enero de 2003 hasta junio de 2006 se intervinieron 1.112 pacientes diagnosticados de hemorroides (grados II, III y IV) con la técnica de HPS. Se realizó un estudio prospectivo no aleatorizado en 2 hospitales, en el que se tuvo en cuenta el dolor postoperatorio, la incidencia de complicaciones y la recurrencia de síntomas. Resultados Se intervino a 1.112 pacientes, de los cuales 719 han concluido el seguimiento. La edad media fue de 47 años. En el 92% de los casos la intervención se realizó bajo anestesia local. El tiempo medio quirúrgico fue de 20 ± 5min. Al 97% de los pacientes se lo dio de alta a las 6h de la intervención. El dolor postoperatorio inmediato, según la escala analógica visual, estuvo ausente (0) en 38 casos, fue ligero (1 a 3) en 431 casos, fue medio en 218 casos y fue intenso en 32 casos. Conclusiones Los autores consideran que es un procedimiento seguro, con una corta curva de aprendizaje para los cirujanos y, sobre todo, aporta una gran reducción en el dolor postoperatorio para el paciente (AU)

Introduction We present a new technique for the surgical treatment of haemorrhoids, consisting of the repositioning of haemorrhoid cluster, using a rotating Proctoscope called Hemor Pex System® (HPS). This procedure is performed as an outpatient procedure, with minimal postoperative pain and rapid integration into working life. Objectives To present the experience with this technique during 3 years of follow up in two institutions in Genoa, Italy. Patients and methods from January 2003 to June 2006, 1112 patients with grade II, III and IV haemorrhoids were operated on using the HPS technique, in two different hospitals. Prospectively analyzed the following parameters: postoperative pain, incidence of complications and recurrence of symptoms. Results A total of 1112 patients were operated, of whom 719 have completed the follow-up. The mean age was 47 years. In 92% of cases the intervention was performed under local anaesthesia. The average time of surgery time was 20+/−5min. A total of 97% of patients were discharged at 6h after surgery. The immediate postoperative pain, according to the Visual Analogue Scale (VAS): absent (0) in 38 cases, slight (1-3) in 431 cases, 218 medium and intense in 32 cases. Conclusions We believe HPS is a safe procedure, with a short learning curve for surgeons, and in particular leads to a great reduction in post-operative pain for the patient (AU)

The fate of anastomotic sinuses after total mesorectal excision for rectal cancer.

OBJECTIVE: Chronic anastomotic sinus is a recognized complication of total mesorectal excision (TME) surgery. We observed two patients who developed new tumours within chronic anastomotic sinuses 6 and 19 years after initial surgery. The aim of this study was therefore to report the incidence and outcome of anastomotic sinuses, thus identifying those at potential risk of malignant change. METHOD: We retrospectively reviewed patient records and radiology reports to identify potentially curative rectal cancer cases between 1998 and 2005. RESULTS: In a consecutive series of 100 TMEs with ileostomy, there were 70 males and 30 females, aged 66 (33-88) years. Anastomosis was by double staple technique. A policy of instant enema was used prior to ileostomy closure. Eighty-six patients had instant enemas. Of the 14 that did not, four died prior to enema, one returned to theatre for sepsis, three had their anastomoses assessed by sigmoidoscopy alone. Six had incomplete records. Of the 86 patients, eight presacral sinuses were identified. Three sinuses closed spontaneously. Five persisted of whom two required further surgery. CONCLUSION: Persistent anastomotic sinuses occurred in 5% after curative TME. Malignant transformation can occur. Active treatment for chronic sinuses should, therefore, be considered.

Gangrena de Fournier. Perspectivas actuales / Fournier´s gangrene. Current perspectives

La Gangrena de Fournier (GF) es una fascitis necrotizante sinérgica, multimicrobiana, de origen infeccioso, que produce gangrena de piel de región genital, perineal, o perianal. Su mayor frecuencia se observa en pacientes de 20 a 50 años, los varones se afectan más que las hembras en proporción 10:1 y la tasa de mortalidad aún es alta. El manejo clínico debe ser rápido y oportuno, con aplicación intravenosa de líquidos, electrolitos y antibióticos de amplio espectro; a fin de lograr la estabilización hemodinámica del paciente antes de la intervención quirúrgica. La cirugía precoz con debridamiento extenso de tejidos desvitalizados, constituye la base principal del mismo

The Fournier Gangrene (FG) is a synergistic, polymicrobial, necrotizing fasciitis with infectious origin that produces gangrene of the perineal, genital or perianal skin. The number bigger than cases happens between 20 at 50 years, the males are affected more than the females in proportion 10:1 and the mortality rate is high yet. The clinical manage of the GF must be fast and opportune with intravenous application of fluids, electrolytes and systemic broad-spectrum antibiotic therapy; and avoid the hemodynamic stabilization of the patient before the surgery. The precocious surgery with debridament of the necrotizing tissues constitutes the main objective of the treatment

Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries?

BACKGROUND: Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. METHODS: This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. RESULTS: There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. CONCLUSIONS: Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience.

BACKGROUND: Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks. METHODS: A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia. RESULTS: Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture. CONCLUSIONS: Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

The hypothalamic hamartoma: a model of subcortical epileptogenesis and encephalopathy.

Although uncommon, the hypothalamic hamartoma (HH) is often associated with a devastating clinical syndrome, which may include refractory epilepsy, progressive cognitive decline, and deterioration in behavioral and psychiatric functioning. Contrary to conventional thinking which attributed seizure origin to cortical structures, the hamartoma itself has now been firmly established as the site of intrinsic epileptogenesis for the gelastic seizures (i.e., characterized by unusual mirth) peculiar to this disorder. It also appears that the HH contributes to a process of secondary epileptogenesis, with eventual cortical seizure onset of multiple types in some patients. Anticonvulsant medications are known to be poorly effective in this disorder. Treatment, including some innovative approaches to surgical resection, is now targeted directly at the HH itself, with impressive results. Younger patients, in particular, may avoid the deteriorating course described earlier. Access to tissue from larger numbers of patients at single or collaborating centers specializing in HH surgery will allow for research into the fundamental mechanisms producing this little understood disorder. Refractory epilepsy associated with HH is the premier human model for subcortical epilepsy and an excellent model for secondary epileptogenesis and epileptic encephalopathy.

A review of conservative and surgical management of anal fissure.

BACKGROUND: Anal fissures are one of the common perianal conditions presenting with bleeding, itching, and pain of varying severity. The method of treating this pathology should preferably be the one that results in optimal clinical outcome, is less painful, and is patient friendly. Despite a plethora of techniques in vogue, an ideal management of this condition continues to be a subject of debate. MATERIALS AND METHODS: A Medline database was used to perform a literature search for articles relating to the term 'anal fissure'. CONCLUSION: Analysis of the available literature shows that by far, medical manipulation of the internal sphincter should be the first-line treatment in anal fissure. A surgical therapy is called for if the medical therapy fails or there is a recurrence.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Depth of colorectal biopsies with proctoscopic forceps.

It has been suggested that a barium enema may safely follow a colorectal biopsy superficial to the muscularis propria within 24 hours, but that the colon radiograph should be postponed 3 to 7 days following a biopsy including this layer. The authors prospectively studied 67 colorectal biopsies obtained with the Wolf 3-mm (grasping) and 5-mm (cutting) proctoscopic forceps from 49 patients to determine the depth of the biopsies. The 5-mm biopsies were not significantly deeper than the 3-mm biopsies (p greater than 0.5). In 18 patients biopsied with each instrument, the 3-mm biopsy was deeper in two cases (11%), the 5-mm biopsy was deeper in three cases (17%), and the biopsies were of equal depth in 13 cases (72%). None of the biopsies with either forceps reached the muscularis propria. The authors concluded that it may be unnecessary to wait longer than 24 hours before performing a barium enema after colorectal biopsy with these forceps.

Flexible fiberoptic sigmoidoscopy.

The 35-cm flexible fiberoptic proctosigmoidoscope is a cost-effective instrument for the family physician. Nonendoscopists have mastered its use with no reported complications. Patient tolerance is high compared to tolerance for the rigid scope. The pathology yield per procedure is two to four times greater than that reported with the rigid sigmoidoscope. Yields with the 35-cm instrument have matched those documented with the 65-cm fiberoptic instrument.

Colonoscopic polypectomy.

The colonoscopic management of 86 patients with polypoid lesions of bleeding from the colon of intermittent nature is discussed. There were 145 polyps found in 85 of these patients. Adenomatous polyps occurring in the sigmoid colon above the reach of the standard sigmoidoscope was the most common finding and pathological diagnosis. Adenocarcinoma of the colon occurred in two patients and invasive carcinoma of a polyp was found in three other patients. Five other patients had polyps that demonstrated a carcinoma in situ. The definitive treatment of these complicated polyps is outlined. The importance of barium enema examination on follow-up of polyp and carcinoma patients and on patients with polyps found at standard sigmoidoscopy is stressed. The possibility of colonoscopic follow-up in lieu of colectomy and ileoproctostomy is suggested for patients with multiple polyps of the colon who do not belong to the familial polyposis group.