Enhanced recovery after surgery efficacy in an older patients and high-risk population affected by colorectal cancer: a more than 1000 patients experience.

AIM: Enhanced recovery after surgery programs aims to standardize care, improving colorectal surgery outcomes. Older patients are a challenge population for these programs. The aim of this manuscript is to explore the effect of application Enhanced recovery after surgery protocol among older patients and high-risk patients undergone colorectal surgery for cancer. METHOD: Since January 2005, until September 2016, 1189 consecutive patients underwent elective Colorectal Surgery and treated according to our Enhanced recovery after surgery protocol. Patients are divided in three groups according to age: Group1 under 69 y-o (control group), Group2 70 to 79 y-o and Group3 over 80 y-o. Primary end point was Time to Readiness to Discharge. RESULTS: Median Time to Readiness to Discharge was 4 days (3-30) in Group 1, 5 (3-47) in Group 2 and 5 (3-19) in Group 3. Length of stay in Group 1 had a median length of 6 days (3-58), in Group 2 of 8 days (3-70) and in Group 3 of 8 days (3-53). CONCLUSIONS: Once more Enhanced recovery after surgery program has showed its efficacy in colorectal surgery field. Moreover, our experience has underlined the need to concentrate efforts mainly on older and high-risk patients.

Quality of life among five-year survivors after treatment for very low rectal cancer with or without a permanent abdominal stoma.

BACKGROUND: Low rectal cancers situated less than 5 cm from the anal margin are still usually treated with abdomino-perineal excision (APE). Our aim is to compare the quality of life (QOL) of five-year survivors treated for low or very low rectal cancer with an advanced/complex coloanal procedure with the QOL of patients submitted to a standard APE with a definitive abdominal stoma. METHODS: Sixty-two patients, operated on radically for low or very low rectal cancer, who came for their fifth year follow-up visit and were free from cancer, were studied. Thirty patients (group 1) had an APE with permanent abdominal stoma. Thirty-two patients (group 2) had undergone a radical advanced and complex procedure to avoid the abdominal stoma. The patients received the European Organisation for the Research and Treatment of Cancer (EORTC) QOL-30 generic and the CR38 colorectal cancer QOL questionnaires with the recommendation to return the questionnaire to the hospital. The Mann-Whitney U-test and chi (2) Fisher test were employed for statistical analysis. RESULTS: All questionnaires were returned. Patients without a terminal abdominal stoma had a better score in six categories of the QOL 30 and in two categories of the CR38. No differences were observed in the other variables examined. CONCLUSIONS: After five years, cancer-free patients operated on for low or very low rectal cancer have a better QOL if a definitive terminal abdominal stoma was avoided.

The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results.

The purpose of the paper is to compare Goligher Classification with the Single Pile Hemorrhoid Classification (SPHC) to show the possible bias and limits of Goligher's use and the possible advantage with the employment of the new classification. SPHC considers the number of pathological piles(N), the characteristics of each internal pile and the characteristics of each external pile, reporting the presence of a fibrous inelastic redundant pile(F), the presence of the subversion of dentate line or the congestion of the external pile(E) and the presence of not tolerated skin tags(S). From September 2010 to December 2012, 197 consecutive patients were analysed according to both classifications. Considering pathological piles, I and II Goligher patients showed a complete agreement between pathological pile and grade, III Goligher patients had 80.5 % of pathological piles of III grade while IV Goligher patients had only 44.3 % of IV grade pathological piles (p < 0.001). Regarding the distribution of the other anatomical variables: F, E, S described in SPHC, the results showed that F was present in 18.3 % while ES was present in 46.2 %. Goligher's Classification has showed to be an inadequate tool to overview surgical outcome or to compare surgical procedure, particularly for high grades, while SPHC showed to be a feasible instrument both to describe and to compare patients affected by hemorrhoid disease.

Cancer reoccurrence in the conserved breast - diagnostic features in a consecutive series of 102 cases.

Diagnostic features of 102 consecutive cases of cancer reoccurrence in the conserved breast are reported. The sensitivity of palpation, mammography, cytology or ultrasonography was 75.5%, 58.7%, 77.4% and 77.8%, respectively. Mammography failures were not due to natural breast density and could probably be explained by the masking effect of surgical scar and distortion. Most failures at cytology were due to inadequate sampling. Palpation should always be associated with mammography in the follow-up of the conserved breast. Aspiration cytology should.be performed incase of any abnormality seen at palpation or mammography.

Orthotopic liver transplantation in the pig: a surgical experience with 124 liver transplants.

From January 1988 to June 1990 one-hundred-twenty-four orthotopic liver transplantation (OLT) were performed in pigs, using a surgical procedure already described in the literature but with two major modifications. One of these modifications was the end-to-end microsurgical anastomosis of the proper hepatic arteries of the donor and recipient; the second one was the reduction in length of the donor suprahepatic vena cava to 1-2 mm before anastomosing it with the recipient suprahepatic vena cava at the level of the diaphragm. The first 24 transplants were used to develop the surgical technique. The latter was then applied to all subsequent 100 transplants, and results are herein presented. Good outcome of surgery appeared to depend on the modifications adopted in surgical technique, use of a pump-driven veno-venous bypass during the anhepatic phase of surgery, administration of cyclosporin A postoperatively, and training of the operator.

Tailored excisional treatment for high-grade haemorrhoidal disease.

Patients affected by high-grade haemorrhoid with a fibrous internal pile or an important external component are suitable for an excisional procedure. The aim of this study is to evaluate the outcome of different excisional treatments such as Milligan and Morgan haemorrhoidectomy, Ferguson haemorrhoidectomy and Pexy-excision carried out according to a tailored treatment on each pathological pile. All the consecutive patients that underwent an excisional procedure for high-grade haemorrhoids in two different centres were considered for the present study. From January 2010 to December 2012, 135 patients affected by high-grade haemorrhoidal disease were treated with excisional procedures. No statistically significant differences were noted regarding age, sex distribution, symptoms, Goligher grade, length of surgery, number of pathological piles treated and number of pathological piles excised for each patient between groups. The Ferguson and Pexy-excision procedures yield better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year. Excisional procedures are safe and effective for the treatment of high-grade haemorrhoids mostly if performed according to a tailored project. An increase in the number of pathological piles treated corresponded to an increase in the need of analgesics regardless of the procedure performed.

Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms.

PURPOSE: The purpose of this study was to use electromyography to examine the behavior of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation in patients with symptoms of obstructed defecation and in normal subjects to highlight differences of clinical significance. METHODS: A total of 35 patients (31 females) aged 20 to 80 (mean, 53.7 +/- 13.3) years with unprepared bowel who had normal colon transit time and obstructed defecation symptoms and 12 voluntary control subjects (7 females) aged 23 to 68 (mean, 48 +/- 11.5) years underwent an electromyography evaluation of the activity of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation. The patients were also examined in separate sessions with defecography and anal manometry. RESULTS: During attempted defecation, puborectalis muscle and external sphincter always reacted in the same manner. When evaluated with pubococcygeus muscle, three main patterns of activity were observed either in patients or in controls: 1) coordinated activation pattern; 2) coordinated inhibition pattern; and 3) uncoordinated or equivocal pattern: activation of pubococcygeus muscle with inhibition of puborectalis muscle/external sphincter, activation followed by inhibition of the three muscles, and activation followed by inhibition of pubococcygeus muscle and no change in the others. We never observed activation of puborectalis muscle/external sphincter concomitant with inhibition of pubococcygeus muscle. The inhibitory coordinated pattern occurred significantly (P = 0.01) more frequently in controls than in patients. These subjects also presented a significantly (P = 0.01) lower frequency of pubococcygeus muscle inhibition. CONCLUSIONS: Either activation or inhibition appears as a physiological behavior, possibly adopted in different circumstances, of the pelvic floor muscles during attempted defecation. The higher prevalence of coordinated inhibitory patterns in normal subjects and the lower frequency of pubococcygeus muscle inhibition in patients with symptoms of obstructed defecation, however, suggests that a loss of inhibition capacity progressing from pubococcygeus muscle to puborectalis muscle/external sphincter muscles could determine the insurgence of obstructed defecation symptoms in some subjects, who should therefore benefit from biofeedback retraining aimed at reacquisition of the inhibition capacity of all muscles of the pelvic floor during defecation.

Anatomic plane of separation between external anal sphincter and puborectalis muscle: clinical implications.

PURPOSE: The possible existence of an anatomic and functional separation between the external sphincter and the puborectalis muscle has been reported in the medical literature. In this article we confirm, by means of anatomic and clinical observations, the presence of such a separation, focusing on its importance in understanding the pathway of diffusion for some suppurative anal lesions and to plan advanced sphincter-sparing procedures. METHODS: Twenty adult anatomic specimens of the anal region (12 from women) were cut in the sagittal, coronal, and paracoronal planes, stained with hematoxylin and eosin, and examined. The pelvic floor musculature was examined in three patients undergoing postanal repair operations. Thirty primary posterior and posterolateral anal fistulas, preoperatively classified as transsphincteric (22) or suprasphincteric (8) were carefully traced during and after staged fistulotomy in 30 (11 female) patients, and their relationship with puborectalis muscle and external sphincter was evaluated. An attempt was made peranally to separate the external sphincter from the puborectalis muscle in four patients (3 females) aged 56 to 65 years with rectal cancers 4 to 5 cm from the anal verge so as to perform a sphincter-sparing procedure. RESULTS: A connective plane of separation between puborectalis muscle and external sphincter was clearly identified in 14 (70 percent) anatomic specimens. In three (21 percent) cases the two muscles presented a pronounced overlapping arrangement. An anatomicofunctional separation between puborectalis muscle and external sphincter was easily demonstrated during post-anal repair operations. All fistulous tracks ran between the external sphincter and puborectalis muscle, despite the pronounced upward direction of the ones preoperatively classified as suprasphincteric. A plane of separation between puborectalis muscle and external sphincter was identified and developed in four patients with very low rectal cancers. An abdominoperanal rectolevatorial excision was performed. A coloanal anastomosis was performed on the residual lower anal canal. CONCLUSION: An anatomic plane of separation is present between the puborectalis muscle and the external sphincter. The presence of this plane is important to help understand the diffusion of some suppurative anal lesions and to plan advanced sphincter-sparing procedures.