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e174
Abstracts of the 22
nd
National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231
of piecemeal endoscopic mucosal resection + APC and in the other
with hot snare polipectomy + APC). In the remaining 10 patients,
after a mean follow-up of 26.5±10.3 months, we had no evidence of
RCP at the site of endoscopic intervention.
Conclusions:
ESD is an efficient technique as salvage treatment of
RCP in alternative to surgery. Long term observation revealed low
rates of recurrence even when radical resection was not achieved.
P.09.7
PROGNOSTIC SIGNIFICANCE OF CLINICALLY METASTATIC
MESORECTAL LYMPH NODES IN LOCALLY ADVANCED RECTAL
CANCER TREATED BY NEOADJUVANT CHEMORADIATION:
IMPLICATIONS FOR SURGICAL STRATEGIES IN RELATION TO
PATHOLOGICAL RESPONSE
Belluco C.*, De Paoli A., Forlin M., Buonadonna A., Cannizzaro R.,
Canzonieri V., Fornasarig M., Maiero S., Olivieri M., Bertola G.
Cro - Aviano, Aviano, Italy
Background and aim:
Neoadjuvant chemoradiation therapy (CRT)
and radical surgery including total mesorectal excision (TME)
reduces the risk of local recurrence, and is considered the standard
of care for patients with locally advanced (T3-4 or any N1-2) mid-
distal rectal cancer (LARC). Organ preserving strategies have been
considered in LARC patients achieving complete pathological
response (pCR) after neoadjuvant CRT. Our aim was to explore the
value of this approach in cN+ patients.
Material and methods:
Data were retrieved from our Institutional
prospective rectal cancer data-base. Tumors with mesorectal lymph
nodes >5mm by pelvic MRI and/or endorectal US were staged as cN+.
Results:
Study population comprised 226 patients (142 men, 84
women; median age 64 yrs, range 25-87) with LARC and no distant
metastasis treated by CRT followed by surgery including TME (n.
179), and by full thickness local excision (LE) (n. 47) between 1996
and 2013. At staging 123 (54.4%) patients were cN+. At pathology,
pCR in the primary tumor was observed in 65 (28.7%) cases. Median
number of examined lymph nodes was 12 (range, 2-37). Metastatic
mesorectal lymph nodes (ypN+) were detected in 45 (42.2%) out
of 107 cN+ patients compared to 2 (2.7%) out of 72 cN- patients
(p<0.01). In cN+ tumors 4 (16.0%) out of 25 cases with pCR were ypN+
compared to 43 (51.8%) out of 83 cases with no-pCR (p<0.01). During
a median follow-up of 48 months 30.5% patients had recurrent
disease, and 16.3% died of disease. In cN+ patients who underwent
TME surgery 5-year DSS and DFS were 100% and 91.6% in pCR
patients compared to 71.2% and 58.0% in no-pCR patients (p=0.01).
In ypN+ patients with metastatic lymph nodes at pathology 5-year
DSS and DFS were both 100% in pCR cases compared to 59.1% and
43.3% in no-pCR patients (p=n.s.). In cN+ patients and pCR 5-year
DSS and DFS were 100% and 85.7% in TME patients and 100% and
91.6% in LE patients (p=n.s.). At multivariate analysis pCR was the
only independent prognostic factor.
Conclusions:
Our findings indicate that in patients with LARC
achieving pCR after CRT organ preserving strategies are safe in cN-
cases, while the favorable long-term outcome of pCR tumors should
be balanced with the risk of metastatic mesorectal lymph nodes in
cN+ cases.
P.09.8
BIOFEEDBACK BENEFITS PATIENTS WITH DYSSYNERGIC
DEFECATION WITH OR WITHOUT ELECTRICAL STIMULATION
Cossignani M.*, Cipolla R., Fenderico P., Nasoni S., Petrolati A., Forlini G.
Ospedale Regina Apostolorum, Albano Laziale (RM), Italy
Background and aim:
Constipation is a common disorder but its
treatment remains unsatisfactory. A large part of patients affected
by constipation suffers of dyssinergic defecation. Pelvic floor
retraining is useful to improve defecatory disorders symptoms but
the exercises are not standardized. In particular is not established
the utility of functional electrical stimulation (SEF), especially used
for urological disorders, in dyssynergic defecation to improve rectal
sensation. The aim of the study is to compare biofeedback-guided
pelvic floor (BFB) exercise therapy with and without SEF in the
treatment of obstructive defecation.
Material and methods:
A total of 39 subjects affected by obstructive
defecation, diagnosed by clinical history, ano-rectal manometric
results and baloon expulsion test, were assigned to BFB (19 pts) and
BFB+SEF (20 pts). BFB consists of improving the abdominal push
effort together with pelvic floor relaxation followed by simulated
defecation training. SEF involves the electrical stimulation of pelvic
floor muscles using a probe wired to a device for controlling the
electrical stimulation. The Wexner constipation score system (that
evaluates frequency of bowel movements, difficult evacuation,
digitation necessity, incomplete emptying sensation, laxative
dependence, unsuccessful attempts at evacuation, minutes in
lavatory per attempt, abdominal pain) was assessed at the beginning
and at the end of pelvic floor retrainig.
Results:
At the end of pelvic floor retraining the symptoms improved
in 11/20 pts treated with BFB+SEF and in 11/19 pts with BFB, did
not change in 8/20 pts with BFB+SEF and in 8/19 with BFB and
worsened in 1/19 pts with BFB+SEF. Patients in both groups referred
improvement of incomplete emptying sensation, more of the other
symptoms (8 in BFB+SEF and 9 in BFB group). About the efficacy of
pelvic floor retraining we showed no differences in patients treated
with BFB alone or with SEF.
Conclusions:
The pelvic floor retrainig is useful for obstructive
defecation but electrical stimulation dose not give additional effect
in this patient group.
P.09.9
AN APPROACH TO CHRONIC CONSTIPATION BY DIGITAL
EXAMINATION + BALLOON EXPULSION TEST IS FEASIBLE IN
DAILY CLINICAL PRACTICE AND DECREASES FURTHER ANO-
RECTAL INVESTIGATION
Calcara C.*
2
, Appiani B.
2
, Fornara R.
2
, Longoni M.
2
, Balzarini M.
2
,
Natale G., Broglia L.
2
, Kozel D.
2
1
Ospedale Maggiore, Novara, Italy,
2
Ospedale SS Trinità, Borgomanero, Italy
Background and aim:
Patients (Pts) affected by chronic
constipation are evaluated by general practitioners and, if necessary,
by gastroenterologists usually located in primary centers. Both
often prescribe many types of laxatives but rarely perform digital
examination (DE) focused on motility disorders and/or balloon
expulsion test (BET). Only Pts refractory to laxatives are extensively
evaluated in tertiary centers. This approach could delay a diagnosis
of obstructed defecation syndrome (ODS) and could affect the
real prevalence of ODS due to possible selection bias. However it’s
unclear if an approach to chronic constipation by DE +BET is feasible
in daily clinical practice.
In our GE unit we started an open-access medical office focused
on chronic constipation. If the patient agrees, we perform DE+BET
during the first evaluation. If both tests are negatives we exclude
ODS and avoid further ano-rectal tests. If both tests are positives
we make a diagnosis of ODS and prescribe a biofeedback therapy
or perform AR-manometry (ARM) or defecography (DEF) guided
by clinical judgment. If DE+ BET are discordant we prescribe ARM
and/or DEF to confirm or not ODS. Obviously we prescribe others
investigations (eg. colonoscopy, Rx transit time) if necessary.
Our aim was to show that this approach is feasible in daily clinical
practice and is able to confirm or exclude ODS, decreasing utilization
of others ano-rectal tests.