Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer.

BACKGROUND: Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. METHODS: This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. RESULTS: Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. CONCLUSION: Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov).

Comparative transcriptome profiling of the response to Pyrenochaeta lycopersici in resistant tomato cultivar Mogeor and its background genotype-susceptible Moneymaker.

Breeding for resistance is the most effective tool for controlling the corky root disease of tomato caused by Pyrenochaeta lycopersici. A comparative RNA-Seq-based transcriptomic analysis was conducted at 96 hpi (hours post infection) on two tomato cultivars: resistant Mogeor and its genetic background, and susceptible Moneymaker to investigate the differences in their transcriptomic response and identify the molecular bases of this plant-pathogen interaction. The number of differentially expressed genes (DEGs) identified was much higher in the susceptible than in the resistant genotype; however, the proportion of upregulated genes was higher in Mogeor (70.81%) than in Moneymaker (52.95%). Gene Ontology (GO) analysis enabled identification of 24 terms shared by the two cultivars that were consistent with responses to external stimulus, such as fungal infection. On the other hand, as many as 54 GO were enriched solely in Moneymaker, including terms related to defense response and cell wall metabolism. Our results could support the previous observations in other pathosystems, that susceptibility and resistance have overlapping signaling pathways and responses, suggesting that the P. lycopersici resistance gene pyl might be a recessive allele at a susceptibility locus, for which different candidate genes were identified based on the differences in induction or expression levels, observed between the resistant and susceptible genotype. MapMan analysis highlighted a complex hormone and transcription factors interplay where SA- and JA-induced pathways are modulated in a similar way in both genotypes and thus take part in a common response while the ethylene signaling pathways, induced mainly in susceptible Moneymaker, seem putatively contribute to its susceptibility.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse.

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel.

BACKGROUND: Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing. METHODS: A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470 nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months. RESULTS: Thirty patients (16 males, median age 52 years, range 26-72 years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30 months (range 6-24 months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30 mm were associated with a primary healing rate of 58.3% while tracts longer than 30 mm were cured in only 16.6% of cases (p < 0.02). CONCLUSIONS: Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.

Validating production of PET radionuclides in solid and liquid targets: Comparing Geant4 predictions with FLUKA and measurements.

The Monte Carlo toolkit Geant4 is used to simulate the production of a number of positron emitting radionuclides: 13N, 18F, 44Sc, 52Mn, 55Co 61Cu, 68Ga, 86Y, 89Zr and 94Tc, which have been produced using a 13MeV medical cyclotron. The results are compared to previous simulations with the Monte Carlo code FLUKA and experimental measurements. The comparison shows variable degrees of agreement for different isotopes. The mean absolute deviation of Monte Carlo results from experiments was 1.4±1.6 for FLUKA and 0.7±0.5 for Geant4 using TENDL cross sections with QGSP-BIC-AllHP physics. Both agree well within the large error, which is due to the uncertainties present in both experimentally determined and theoretical reaction cross sections. Overall, Geant4 has been confirmed as a tool to simulate radionuclide production at low proton energy.

Repair of transperineal recto-urethral fistula using a fibrin sealant haemostatic patch.

AIM: Recto-urethral fistula (RUF) is a rare complication of radical prostatectomy. We report a transperineal approach using a fibrin sealant haemostatic patch. METHOD: Five consecutive patients who developed RUF following radical prostatectomy had a direct transperineal repair with a haemostatic patch (TachoSil®) and were assessed at a median follow-up of 35.5 (21-45) months. RESULTS: There were no early postoperative complications. The average length of hospital stay was 5 (4-7) days. One patient developed recurrence 4 weeks after removal of the urethral catheter. Following healing in four patients the stoma was reversed at a median interval of 3 months, and 9.5 (7-10) months following the prostatic surgery. In the four patients with successful closure there was no case of recurrence or anorectal or urinary dysfunction at a median follow-up of 35.5 (21-45) months. CONCLUSION: Direct transperineal repair of RUF reinforced with a fibrin haemostatic patch of TachoSil is safe and effective.

The concept of minimum detectable activity of radionuclide activity meters and their suitability for routine quality control of radiopharmaceuticals. An experimental study.

Radionuclide activity meters ("dose calibrators") are ionization chambers designed to measure relatively high amount of activities which are normally contained in radiopharmaceuticals. However, in the current radiopharmacy practice, these radiation detectors have been proposed to be used in measurements of samples with lower activity, such as in routine quality control (QC) tests. To check the feasibility of such measurements, in this work we assessed the performance of four different devices in the lower range of detectability, by means of experimental measurements of a radioactive sample. Accuracy and precision of each device was evaluated as a function of the activity contained in the sample in order to estimate a threshold value, or minimum detectable activity (MDA), which, according to our operational definition, may be used to express the concept of Limit of Quantification (LoQ). Moreover, a generalized procedure for the estimation of the MDA was established, which, being device- and radionuclide-independent, it may be adopted by every laboratory. Our results showed a significant variability in the MDA achieved by different activity meters. Hence a single QC test may result feasible with one specific instrument, and not with another one. Moreover, feasibility depends also on the confidence level required for each test. For these reasons, each activity meter should be qualified for its MDA or LoQ by each laboratory according to a procedure such as that described in this paper.

Monte Carlo modeling provides accurate calibration factors for radionuclide activity meters.

Accurate determination of calibration factors for radionuclide activity meters is crucial for quantitative studies and in the optimization step of radiation protection, as these detectors are widespread in radiopharmacy and nuclear medicine facilities. In this work we developed the Monte Carlo model of a widely used activity meter, using the Geant4 simulation toolkit. More precisely the "PENELOPE" EM physics models were employed. The model was validated by means of several certified sources, traceable to primary activity standards, and other sources locally standardized with spectrometry measurements, plus other experimental tests. Great care was taken in order to accurately reproduce the geometrical details of the gas chamber and the activity sources, each of which is different in shape and enclosed in a unique container. Both relative calibration factors and ionization current obtained with simulations were compared against experimental measurements; further tests were carried out, such as the comparison of the relative response of the chamber for a source placed at different positions. The results showed a satisfactory level of accuracy in the energy range of interest, with the discrepancies lower than 4% for all the tested parameters. This shows that an accurate Monte Carlo modeling of this type of detector is feasible using the low-energy physics models embedded in Geant4. The obtained Monte Carlo model establishes a powerful tool for first instance determination of new calibration factors for non-standard radionuclides, for custom containers, when a reference source is not available. Moreover, the model provides an experimental setup for further research and optimization with regards to materials and geometrical details of the measuring setup, such as the ionization chamber itself or the containers configuration.

Asthma management among different specialists: results from a national Italian survey.

In Europe more than 50% of asthmatic treated patients have a not well-controlled asthma. The present survey aims at investigating how different specialists approach asthmatic patients. A web anonymous questionnaire was randomly administered to 604 General Practitioners (GPs), 241 Pneumologists and 131 Allergists. It concerned: epidemiology, diagnostic workup, follow-up and risk factors, treatment and future risk. A general agreement emerges about asthma diagnostic work-up. All categories are aware of the impact of comorbidities on asthma. LABA/inhaled steroids combination is considered the first choice treatment. Surprisingly, depot steroids and long-acting beta2 agonists (LABA) alone are still prescribed by GPs. Concerning monitoring tools, Allergists rely on inflammation biomarkers, whereas reduction of rescue medication is more relevant for GPs. Asthma Control Test (ACT) is considered time consuming by more than 50% of all physicians and is not known by most of GPs. Adherence is considered a crucial problem in asthma management. All categories seem to have a good knowledge about asthma. The cultural background may account for mild differences in asthma control tools and treatment options. GPs have a pivotal role in discriminating patients who need specific assessment by specialists. It is thus important that GPs and specialists share common tools for recognizing and managing those patients.

Occurrence of Fusarium Wilt Caused by Fusarium oxysporum f. sp. spinaciae on Spinach (Spinacia oleracea) in Southern Italy.

Fusarium oxysporum f. sp. spinaciae (Sherb.) W.C. Snyder & H.N. Hansen is the causal agent of Fusarium wilt of spinach (Spinacia oleracea L.), a serious disease of spinach worldwide (1). In September 2011, several plants of an unknown spinach variety grown for the production of packaged ready-to-eat salads (4th range) in a greenhouse in southern Italy (Pontecagnano, Salerno) showed yellowing of older leaves, reduced root development, blackening of the vascular tissues, and wilting of 60-day-old plants; necrotic lesions at the taproot base were occasionally present. Yield losses up to 70% were observed. Small portions of symptomatic tissues from the basal vascular stem were disinfected with sodium hypochlorite (1% active Cl2), rinsed with sterile water, and then placed on potato dextrose agar (PDA) amended with neomycin (50 ppm), chloramphenicol (50 ppm), and streptomycin (100 ppm). Pink to white colonies with a fluffy aerial mycelium rapidly developed; pale orange sporodochia containing thin walled macroconidia, mostly 3-septate, short to medium length, with a curved apical cell and a notched or foot-shaped basal cell were present. Oval to reniform, 0-septate microconidia were formed on typical single short monophyalides or abundantly on false heads. Chlamydospores were formed singly or in pairs in 1-month-old plates. On the basis of these morphological characters, the fungus was identified as F. oxysporum. In order to confirm the diagnosis, DNA from a single spore culture of an isolate (11-113PANT3) was extracted, amplified by PCR using primers EF 1H and EF 2T (2) corresponding to a segment of the transcription elongation factor 1α (EF-1α) gene, and the PCR product sequenced at GenChron (Rome, Italy). A homology search in GenBank using the BLASTn algorithm showed 100% identity of the obtained sequence with several sequences of formae speciales of F. oxysporum, including the NRRL26871, corresponding to F. oxysporum f. sp. spinaciae. For the pathogenicity tests, 15-day-old spinach seedlings of the variety Spargo F1 were inoculated at the cotyledon stage by dipping the roots for 5 min in a monosporic conidial suspension of the isolate 11-113PANT3 at a concentration of 1 × 106 CFU ml-1. Twenty plantlets in two replicates were inoculated and incubated in a growth chamber at 26°C. The same number of uninoculated plants were used as controls. Yellowing of leaves and vascular blackening was observed in all inoculated plants that wilted and died within 10 days. The colonies re-isolated from all the inoculated plants were identified morphologically as F. oxysporum, thus fulfilling Koch's postulates. Experiments were repeated twice. Based on host source and sequence similarity, the fungus was identified as F. oxysporum f. sp. spinaciae. To our knowledge, this is the first report of this species on spinach in Italy. Since this first report, Fusarium wilting of spinach has been frequently observed in other greenhouses, and it is becoming of concern for Italian salad mix producers. Continuous cropping and high-input cultivation systems are among the possible factors favoring the spread of the fungus. The management of the disease could be achieved through the adoption of crop rotation, the use of partially resistant cultivars, and by spinach seed treatments. References: (1) J. C. Correll et al. Plant Dis. 78:653, 1994.(2) K. O'Donnell et al. Proc. Nat. Acad. Sci. 95:2044, 1998.

Emerging technologies in coloproctology: results of the Italian Society of Colorectal Surgery Logbook of Adverse Events.

BACKGROUND: The aim of this paper is to present the results of the Italian Society of Colorectal Surgery [or Società Italiana di Chirurgia Colorettale (SICCR)] Logbook of adverse events (AE) occurring in relation to emerging technologies in coloproctology (ETCs), over a 3-year period. METHODS: A total of 245 AE were reported (patients age: mean = 49.6 years, range = 20-75 years; gender: 155 = F, 90 = M). The "observations" originated from the same institution of the AEs in 44 cases (18.0%), while 201 patients (82.0%) had been operated on somewhere else. RESULTS: The three most reported ETCs were: Procedure for prolapsed haemorrhoids (PPH) (n = 120-48.9%), stapled transanal rectal resection (STARR (n = 96-39.2%), and transanal haemorrhoidal dearterialization (THD) (n = 11-4.5%). PPH, STARR, and THD together accounted for n = 227 (92.6%) observations. For the three main reported ETCs, the various AEs are listed. Chronic pain after PPH was 46/120 (38.3%), and after STARR of 21/96 (21.9%). The overall re-operation rate was n = 135 (55.1%) versus n = 110 (44.9%) no reoperation. In particular, for the three main reported ETCs, n = 68/120 (56.7%) following an AE after PPH, n = 47/94 (50.0%) following an AE after STARR, and n = 6/11 (54.5) following an AE post-THD. The various types of treatment to solve AE after each of the three most observed ETCs are reported in the text. CONCLUSIONS: Our results do not allow us to draw statistical conclusions; however, this was not the aim of our survey. ETCs are important, yet they are not without major risks. Manufacturers should help colorectal surgeons to convey the right message to patients.

Laparoscopic low ventral rectocolpopexy (LLVR) for rectal and rectogenital prolapse: surgical technique and functional results.

BACKGROUND: Laparoscopic ventral rectopexy limits the risk of autonomic nerve damage, and the colpopexy allows correction of a concomitant prolapse of the middle compartment. The aim of this study is to describe a modified laparoscopic ventral rectocolpopexy procedure with a low approach to the sacral hollow (laparoscopic low ventral rectocolpopexy: LLVR). We propose this technique to manage combined rectogenital prolapse. METHODS: Between November 2006 and June 2009, all patients with symptomatic rectal prolapse associated with genital prolapse and/or enterocele underwent LLVR. Demographics, results of imaging studies, mortality, morbidity, and functional outcome were retrospectively analyzed. RESULTS: Thirty patients underwent LLVR: two patients suffered from a full-thickness rectal prolapse while 28 had symptomatic recto-anal intussusception. The mean operating time was 94 ± 39 minutes. Conversion to laparotomy was never needed. Hospital stay ranged between 2 and 14 days (mean of 5 ± 2.5 days). No mortality was recorded and only two complications occurred (6.6%): one trocar site incisional hernia and one vaginal suture erosion in a patient who had concomitant hysterectomy. After a mean follow-up of 13.9 months, constipation was completely resolved or improved in 92.8% patients. Significant reduction in the mean Altomare obstructed defecation score (14.7-5.6; p < 0.05) was recorded. Preoperative incontinence improved after the procedure in all patients affected. No new cases of postoperative constipation or fecal incontinence were registered. Only one case of recurrence in a patient with recto-anal intussusception was recorded (3.4%), after 19 months. CONCLUSIONS: Laparoscopic low ventral rectocolpopexy is safe and associated with very low morbidity. In the medium term, it provides good result for prolapse and associated symptoms.

Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids.

AIM: Doppler-guided transanal haemorrhoid dearterialization (THD) and stapler haemorrhoidopexy (SH) have been demonstrated to be less painful than the Milligan-Morgan procedure. The aim of this study was to compare the effectiveness of THD vs SH in the treatment of third-degree haemorrhoids in an equivalent trial. METHOD: One hundred and sixty-nine patients with third-degree haemorrhoids were randomized online to receive THD (n = 85) or SH (n = 84) in 10 Colorectal Units in which the staff were well trained in both techniques. The mean follow-up period was 17 (range 15-20) months. RESULTS: Early minor postoperative complications occurred in 30.6% of patients in the THD group and in 32.1% of patients in the SH group. Milder spontaneous pain and pain on defecation were reported in the THD group in the first postoperative week, but this was not statistically significant. Late complications were significantly higher (P = 0.028) in the SH group. Residual haemorrhoids persisted in 12 patients in the THD group and in six patients in the SH group (P = 0.14). Six patients in the SH group and 10 in the THD group underwent further treatment of haemorrhoids (P = 0.34). No differences were found in postoperative incontinence. The obstructed defecation score (ODS) was significantly higher in the SH group (P < 0.02). Improvement in quality of life was similar in both groups. Postoperative in-hospital stay was 1.14 days in the THD group and 1.31 days in the SH group (P = 0.03). CONCLUSION: Both THD and SH techniques are effective for the treatment of third-degree haemorrhoids in the medium term. THD has a better cost-effective ratio and lower (not significant) pain compared with SH. Postoperative pain and recurrence did not differ significantly between the two groups.

Prediction of (89)Zr production using the Monte Carlo code FLUKA.

The widely used Monte Carlo simulation code FLUKA has been utilized to prototype a solid target for the production of (89)Zr by irradiation of a metallic (89)Y target foil in a 16.5MeV proton biomedical cyclotron, through the reaction (89)Y(p, n)(89)Zr. Simulations were performed with and without an Al energy degrader. In the setup of the geometry of the target, state of the art support tools, like SimpleGeo, were used for accurate, detailed modeling. The results permitted a quick assessment of all possible radionuclidic contaminants and confirmed that the use of an energy degrader avoids production of the most important impurity, (88)Zr. The estimated value for the activity produced in one hour of irradiation at 20µA is 384 ± 42MBq; this is encouraging, indicating possible production of clinically significant amounts of activity with the relatively simple target setup adopted. Initial experimental tests gave results in excellent agreement with simulations, confirming the usefulness and accuracy of FLUKA as a tool for the design and optimization of targets for the production of PET radionuclides.

A nationwide audit of the use of radiotherapy for rectal cancer in Italy.

BACKGROUND: There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. METHODS: We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. RESULTS: Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients corresponding to 58% of rectal cancers operated by SICCR members in 2005. Radiotherapy was used in 307/682 (45.0%) patients. Preoperative radiotherapy was used in 236/682 (34.6%), postoperative radiotherapy in 71/682 (10.4%) cases and no radiotherapy in 375 (55.0%) cases. Of the 236 patients who underwent preoperative radiotherapy, only 24 (10.2%) received short-course radiotherapy, while 212 (89.8%) received long-course radiotherapy. Of the 339 stage II-III patients, 159 (47%) did not receive any radiotherapy. Radiotherapy was more frequently used in younger patients (P < 0.0001), in patients undergoing abdominoperineal resection (APR) (P < 0.01) and in the north and center of Italy (P < 0.001). Preoperative radiotherapy was more frequently used in younger patients (P < 0.001), in large volume centers (P < 0.05), in patients undergoing APR (P < 0.005) and in the north-center of Italy (P < 0.05). CONCLUSION: Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.