The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Identification of a new syndrome: ASS-SSA or anal sphincter syndrome.

AIM: The author proposes a new, original Syndrome, observing the relationship between some of the most frequent anal pathologies, apparently different from each other in terms of morphological aspect and symptomatologic expression, but united by the same pathogenic cause, represented by the hypertonicity of the anal sphincter apparatus. There are already descriptions of other "syndromes" of the pelvic floor, inaccurate and subject to different interpretations. The proposed syndrome, instead, called Anal Sphincter Syndrome - ASS (in Italian SSA - Sindrome dello Sfintere Anale) presents clarity on the determining cause (sphincter hypertonicity) and descriptive simplicity, including only two welldefined pathological conditions: anal fissure and anal thrombosis; other ancillary conditions or symptoms are inconstantly possible, but not decisive. The author will present, as soon as possible, in subsequent works, a retrospective study (still to be completed) on a wide personal case history, dating back to the 1990s. KEY WORDS: Anal sphincter hypertonia, Anal thrombosis, Anal fissure, Syndrome, Proctology, Somatization.

[Starr0ne: transanal procedure for rectal resection with only one stapler. Case report]. / Starr0ne: procedura di resezione transanale del retto con unica suturatrice circolare. Caso clinico.

AIM: Stapled Trans-Anal Rectal Resection methods (STARR double-PPHO1 J&J and Transtar CCS30 J&J) designed and proposed by Antonio Longo, widley used, present some problems and difficulties. Many Authors have sought alternatives able to optimize the results, to limit the risk of complications, to facilitate the operations, to reduce the operating times, to lower the economic costs. Resection whit single stapler of prolapse and rectocele only on anterior rectal wall, have been proposed: they often have caused asymmetry and bad functional results: they have not received acknowledge. MATERIAL OF STUDY: On the bases of personal experience (1398 stapled anopexys + 239 STARR/Transtar) the author propose the technique of trans-anal resection using single stapler (8 cases performed) defined StarrOne (Stapled TransAnal Rectal Resection only-One Stapler). The main times of the technique are briefly described, pointing out the characteristics of the device (stapler CPH 34-32 Chex-Healtcare) and the benefits that this entails. RESULTS: A significant case is reported, particularly complex, with operation performed in patient already treated, some years before, with Sarles technique, unsuccessfully. CONCLUSIONS: Only further experiences and careful evaluation of results will can indicate the validity of the method.