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Postoperative bleeding is a common complication after endoscopic polypectomy, particularly after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, despite prophylactic clipping can reduce its occurrence. Cyanoacrylate glue has recently been proposed as a useful tool in reducing bleeding in surgery because of its adhesive and haemostatic properties. The aim of this study is to evaluate the usefulness of endoscopic application of a modified cyanoacrylate glue in the prevention of early or delayed post EMR bleeding. This is a pilot study. Inclusion criteria were patients between 18 and 75 years old affected by sessile or flat colonic polyps larger than 2 cm. Patients enrolled in the study were randomized in two groups: group A (EMR) and group B (EMR with the application of 0.3 ml of N-butyl-2-cyanoacrylate + methacryloxysulfolane—Glubran 2®). Fifteen patients in both group A and B were enrolled. There were no intraoperative complications but haemostatic clipping was necessary in 3 patients in each group because of active bleeding. Delayed (after 24 h) bleeding occurred in two patients (13.3%) in group A requiring hospital readmission and re-do endoscopy with apposition of haemostatic clips. No case of bleeding was recorded in group B (p = 0.48). The results of this pilot study suggest a potential role of local spray application of Glubran®2 in reducing post-procedural bleeding.

Dear Editor: Endometriosis largely affects women, particularly during the fertile age, causing dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility in about 30 % of patients [1]. Its occurrence is estimated to be about 10 % in women in reproductive age, while postmenopausal endometriosis is much less frequent, affecting up to 2–4 % of women, usually in patients with a history of premenopausal disease. Pelvic deep endometriosis infiltrating the rectum and surrounding tissues usually causes severe symptoms, especially pain and obstruction, and its treatment is challenging, because of risk of injury of the pelvic organs and because of the high recurrence rate. Furthermore, even if endometriosis is a benign condition, it has the potential for malignant transformation [2], which occurs in 0.7–1 %, particularly in the ovaries [3]. The endometrial heterotopic tissue is functionally capable of responding to exogenous, endogenous, or local hormonal stimuli, and this estrogen dependence is considered central to its development and progression. For this reason, endometriosis is widely viewed as a disease of the premenopausal age, which normally regresses after menopause because of the lower production of estrogens, even if rare occurrence of endometriosis has been reported in postmenopausal period. In that case, the adipose tissue is supposed to become the main site of endogenous estrogen production even if unopposed hormonal replacement therapy is usually prescribed. However, the onset of deep endometriosis in postmenopausal women submitted to hysterectomy and bilateral oophorectomy for fibromatosis and without hormonal therapy is very rare and represents a conundrum with difficult interpretation. A 54-year-old woman was admitted to our hospital with severe pelvic and anal pain, constipation, and oliguria. Her body mass index was 29. Her personal history included menarche at age 12, with irregular menstrual cycles and dysmenorrhea. She had been pregnant three times, with two spontaneous abortions and one successful pregnancy with cesarean delivery. At the age of 43, she underwent laparotomic hysterectomy and bilateral salpingo-oophorectomy for leiomyomatosis of the uterus. Hormone replacement therapy was not prescribed after surgery. Histologic examination of the resected specimen showed multiple intramural leiomyoma of the uterus, minute borderline cystadenoma, and cyst of the right ovary. At the time of hospitalization, she denied any history of urinary symptoms, and rectal digital examination revealed a palpable, painful, hard, and fixed mass of the pelvis infiltrating the rectal wall. The serum concentrations of carbohydrate antigen 125 (CA 125) and carbohydrate antigen 15.3 (CA 15.3) were 134.4 and 44 .3 U/ml , respec t ive ly. Carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) levels were normal. Endoscopic examination revealed the presence of a pelvic mass compressing the walls of the rectum without mucosa infiltration at 8 cm from the anal verge and a large (>5 cm) villous polypoid lesion of the posterior wall of the rectum. Histology on the rectal biopsies from the polyp documented a villous V. Andriola :M. Battaglia : P. Ditonno :M. G. Fiore :M. De Fazio : R. Memeo :D. F. Altomare Department of Emergency and Organ Transplantation, University BAldo Moro^ of Bari, Bari, Italy

The optimal treatment for large colorectal polyps (LCPs) is still a controversial issue. The aim of this study was to evaluate the safety and effectiveness of endoscopic polypectomy (EP) of colorectal polyps ≥2 cm in size. One hundred fifty-one EP LCPs were performed over a period of 7 years. Diathermal snare was used for pedunculated and pseudopedunculated polyps and endoscopic mucosal resection (EMR) or biopsy forceps polypectomy for sessile and flat polyps. The resected polyps were recovered and collected for histology. At scheduled follow-up visits 1, 3, 6, and 12 months after polypectomy, complications and recurrences were recorded in all patients. Fifteen polyps were located in the rectum, 84 in the sigmoid colon, 11 in the descending colon, four in the splenic flexure, 11 in the transverse colon, 11 in the hepatic flexure, seven in the ascending colon and eight in the cecum. Fifty-six polyps were sessile, 54 pedunculated, 25 pseudopedunculated, and 16 flat. At histology, most of polyps (131) were adenomas (nine with adenocarcinoma in situ). Five were invasive polypoid carcinomas and required colonic resection. Immediate bleeding occurred in ten patients (7.6%) and it was stopped by endoscopic hemoclips (7), epinephrine injection (1), or surgery (2). There were three perforations (2.3%; all polypoid carcinomas), managed endoscopically (1) or surgically (2). Delayed bleeding occurred in two patients (1.5%) and was treated by endoscopic diathermy and hemoclips (1) or surgery (1). During follow-up, six (4.6%) incompletely excised polyps and three (2.3%) relapses in the site of previous EP were detected and endoscopically removed. EP is relatively safe and effective for benign-appearing LCPs.

The purpose of this study was to explore the potential role of deranged fecal microRNA (miRNA) pattern as a reliable warning signal of colorectal cancer (CRC), a subset of fecal CRC-related miRNAs was evaluated in CRC patients, before and after surgery, and in healthy controls. Twenty CRC patients and 20 age/sex-matched healthy volunteers with negative colonoscopy entered the study. Cancer biopsy, colonic mucosa from the resected specimens, and fecal samples from patients and controls were screened for 13 miRNAs involved in CRC onset and progressions by reverse transcription quantitative PCR (RT-qPCR). Postoperative evaluation of fecal miRNAs was carried out after a median follow-up of 18 months (range 12–30). Two out 13 miRNAs (RNU6B, miR-16-3p) were used as internal controls leaving 11 available for analysis. Cancer tissue contained significantly higher expression of all miRNAs, compared to normal mucosa (p

The anorectal angle (ARA) is believed to provide one of the most important contributions to anal continence. The normal resting angle is approx. 90 degrees, but the erect position may modify the ARA and other parameters usually considered in a proctometrogram. We compared the proctometrogram in different postures to elucidate the role of changes in the ARA in maintaining fecal continence. Sixty-three patients with constipation underwent static proctography. Variations in the ARA, perineal descent, puborectalis muscle length, and pubococcygeal distance were determined during resting, squeezing, and pushing with the patient in the Sims' position (SP); further evaluations used radiographs in resting position but with straight legs, in erect and sitting positions. The resting mean ARA was 95.3 +/- 15 degrees in SP and 79.8 +/- 14 degrees standing erect; the latter value was also significantly less during squeezing (84 +/- 11 degrees). The mean ARA during pushing was 118 +/- 16 degrees. A systematic and statistically significant difference in the mean resting ARA was demonstrated using the baseline of the rectal shape instead of the major rectal axis when measuring the anorectal angle. When sitting on a toilet, the mean resting ARA was significantly wider than in SP. The length of the puborectalis sling at rest did not change but was significantly reduced during squeezing and increased during pushing. The descent of the perineum at rest was near to 0 (-0.089 +/- 1.76 cm) in SP and significantly less when standing (-0.65 +/- 1.9 cm) and during squeezing (-0.97 +/- 1.7 cm). Perineal descent during pushing was +2.94 +/- 2.2 cm. The mean pubococcygeal distance did not change significantly in SP and in the erect position. The erect position thus contributes significantly to the maintenance of fecal continence by sharpening the ARA. This effect is stronger than any active contraction of the puborectalis muscle and is not related to shortening of the puborectalis sling but is secondary to lifting of the pelvic floor.

Dear Editor: Desmoid tumors are rare, non-metastatic soft tissue tumors caused by an abnormal clonal proliferation of fibroblastlike cells with a huge amount of extracellular matrix. Although they can occur sporadically, particularly in the extremities, they typically develop in about 20% of patients with a family history of adenomatous polyposis, in this case, Gardner's syndrome. Desmoid tumors are, in fact, the first cause of death in patients submitted to total proctocolectomy for familial adenomatous polyposis because despite their benign nature, their uncontrolled intra-abdominal growth with mesenteric infiltration usually makes surgical removal impossible. Multiorgan transplantation is usually the final lifesaving option, although the high peri-operative mortality and the risk of further recurrence of the desmoids are grave drawbacks. If feasible, surgical removal is still the most common approach, although the high reported rate of recurrence, up to 30–40%, should discourage this option in favor of other, more conservative treatments. However, this type of tumor usually responds poorly to traditional adjuvant therapy, including radiotherapy and chemotherapy, probably because of the low cellular density. Several other treatments based on non-steroidal antiinflammatory drugs, interferon, imatinib, radio-, and chemotherapy have all been tried with variable success. Recently, increasing attention has been paid to the effect of different anti-estrogen therapies on desmoids, even if the estrogen receptors (ERα and Erβ) issue is controversial. A 32-year-old Caucasian woman underwent total colectomy and ileorectal anastomosis for diffuse colonic polyposis in 1998. The rectum was spared because the polyps, although large, were few and endoscopically removed and in view of the young age of the patient and her desire for future maternity. Histology of the resected specimen revealed multiple adenomatous polyps, some with early cancer foci invading the submucosa. Her family history included several cases with phenotypical evidence of familiar adenomatous polyposis (FAP). Her father died of cancer of the sigmoid colon; one of her sisters died of cerebellar cancer at the age of 8 years (Turcot's syndrome), and another sister was diagnosed with a Gardner's variant of FAP, featuring non-resectable intraabdominal desmoids, at the age of 38 years, and treated with bowel transplantation in 1999. The outcome was very poor, featuring several other operations for desmoids recurrence and death 1 year later. Two other members of the same family (paternal uncles) also died of colonic cancer. Genetic testing revealed a deletion of 5 bp in position 3183 in the APC gene in most of the members of this family, including our patient. One year after the endoscopic removal of the polyps, an abdominal computerized tomography (CT) scan revealed a solid mass in her right iliac fossa measuring 8.5 cm in diameter. Another smaller mass, measuring 6.5 cm, was evident medially, with the same characteristics. Three months There are no sources of support for this article.

Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results.Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8-84) and 52.5 (12-156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score.Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45-76.6), indicating a good stoma function in 95% of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15-120); Wexner, 13 (2-19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0-4); coping/behaviour, 1.3 (0-3.5); depression, 2.1 (0-5.2); embarrassment, 2 (0-4.6)] and 11 complained of obstructed defecation [7.5 (3-16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2-80.3)].QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL.

A retrospective study of 87 patients, subjected to colostomy closure between 1976 and 1987, was conducted in order to evaluate the role of 8 potential risk factors on morbidity and mortality. Possible risk factors were age greater than 65 years, presence of hypoalbuminaemia (less than 3.0 gr%), anaemia (Hb less than 10 gr%), operative technique, duration of colostomy, site of colostomy, underlying disease and presence of subcutaneous drainage. Apart from hypoalbuminaemia, no clear risk factor was identified, although an interval of more than 90 days between construction and closure of colostomy appears to be safer than shorter intervals. A comparison was also made between two different periods from 1976 to 1982 and from 1983 to 1987 which resulted in important changes in patient management in the second period including: type of antibiotic prophylaxis, type of anastomosis and suture material, site of colostomy and mean duration of colostomy. Four post-operative deaths (4.6%) (two for myocardial insufficiency and two for sepsis), 11 major (13%) and 25 (29%) minor complications were recorded. The analysis of the two different periods showed a strong reduction in both mortality and morbidity in the second period, which could be related to a better management of this type of patient. In conclusion, the incidence of mortality and morbidity in colostomy closure cannot be underestimated and therefore the same skill and meticulous approach are required for this operation as for any major surgical procedure on the colon.

Sacral nerve modulation (SNM) using an implantable pulse generator is gaining increasing acceptance in the treatment of several functional disturbances of the urinary and intestinal tract. This new therapeutic approach offers new possibilities in the treatment of fecal incontinence (FI) by means of its possible effects on anorectal physiology.Fourteen patients with FI, six of whom had associated urinary disturbances, underwent permanent SNM after successful peripheral nerve evaluation tests. All had a clinical evaluation including FI grading systems (American Medical systems, AMS; Continence Grading System, CGS) and quality of life questionnaires (Fecal Incontinence Quality of Life, FIQL), and anorectal physiology tests performed before and during electrostimulation. Two patients had a lead displacement which was repositioned. Median follow-up was 14 months (range 6-48 months).AMS scores decreased significantly from 101 to 67 after 24 months CGS scores from 15 to 2 after 2 months. The median number of episodes of major incontinence per 2 weeks decreased from 14 to 1 after 24 months. FIQL scores improved significantly in the nine patients tested from an overall score of 1.59 to 3.3, with improvement in all areas of the FIQL. Four of the six patients with associated urinary disturbances had a significant improvement in their symptoms. Anal resting and squeezing tone did not change significantly, nor did rectal volumetry, compliance, rectoanal inhibitory reflex, or length of the anal high-pressure zone, while 24-h rectal manometry showed inhibition of the spontaneous rectal motility complexes after meal and on awakening in the only two patients undergoing this investigation.Although the mechanism of action of SMN is still unclear and requires further investigations, clinical results are very encouraging, confirming the role of this new and safe procedure in the treatment of FI and associated urinary disturbances.

The possibility of converting an easily fatiguable muscle like the gracilis muscle into a fatigue-resistant one using chronic electrostimulation has renewed interest in Pickrell's procedure. Between July 1991 and June 1996, 9 patients (2 M; 7 F) mean age = 45 y (range 14-72) underwent dynamic graciloplasty using Medtronic electrostimulators. Five patients had faecal incontinence (2 congenitally anomaly, 1 neurological, 2 post-operative) and 4 had a perineal colostomy performed either simultaneously (two cases) or at 3 to 4 years after abdominoperineal excision of the rectum. Early post-operative complications included distal tendon necrosis [1], perineal colostomy breakdown [1], detachment of the gracilis tendon [2] and seroma in the thigh [1]. Long-term complications included rectocele with faecal impaction in one patient with imperforate anus, anal stricture in one patient who had refashioning of a perineal colostomy, and displacement of the lead from the main nerve in 3 with external expulsion in 2. The patient with anal stricture was successfully treated with anoplasty but subsequently returned to an abdominal colostomy due to stricture recurrence 2 years later. The rectocele was successfully treated using a transvaginal approach. Electrical conversion of the muscle was completed in all patients but long term functional results are available for only 5 cases. Manometry revealed a significant improvement in anal pressure under electro-stimulation and the continence grading scale score significantly improved in 4 patients. The technique is applicable to a very selected group of patients with no other options but is still in the experimental phase and should not be performed outside controlled trials. Repeated hospitalisation and reoperations are often required although the complication rate may diminish and improve with experience.

A 35 years old woman developed obstructed defecation due to a large (6 cm) non-emptying rectocele one year after successful electrostimulated gracilis neosphincter operation for correction of fecal incontinence after surgery for imperforate anus. Surgical correction of the rectocele was performed by a trans-vaginal approach due to the poor elasticity of the neoanus and avoidance of possible damage to the neosphincter. After physiological investigations, including defecography, the patient had a resection of the posterior vaginal mucosal wall, a double layer plication of the muscular wall with non-absorbable suture and a longitudinal mucosal suture. The postoperative course was uneventful. Defecography, performed 3 and 6 months later, showed a marked reduction of the rectocele (2 cm) which corresponded to clinical improvement. Occurrence of disabling rectocele can be considered a possible long term complication after successful electrostimulated neosphincter procedure in patients at risk for developing a rectocele; a successful repair can be obtained using trans-vaginal approach without the risk of neosphincter damage. Transvaginal repair of rectocele in similar clinical situations may be recommended.