Acute supralevator abscess: the little we know.

INTRODUCTION: Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula formation. A comprehensive review of the literature was conducted to determine the incidence of SLA and the surgical outcome with particular reference to the direction of drainage. METHODS: A search of Medline, PubMed and the Cochrane Library was performed to identify all studies reporting surgical drainage of SLA. FINDINGS: A total of 19 studies were identified, including 563 patients. The only two prospective studies reported an incidence of SLA of 10% and 3% in 68 and 100 patients, respectively, with anorectal sepsis. In 17 retrospective studies, the incidence ranged from 0% to 28%. Magnetic resonance imaging (MRI) was performed routinely in only one study. The surgical anatomical classification of the abscess was described in six studies diagnosed at surgery. The direction of surgical drainage whether 'inwards' (into the lumen) or 'outwards' (into the ischioanal fossa) was stated in only six studies. In two of these, the direction of drainage was contradictory to the recommendation made by Parks et al. Recurrent sepsis was reported in eight studies and ranged from 0% to 53%. CONCLUSIONS: Detailed and prospective data on acute SLA are lacking. Its real incidence is unclear and it is not possible to analyse surgical outcomes conclusively according to different direction of drainage. The routine use of MRI in complicated anorectal sepsis would specify the surgical anatomy of SLA before any drainage is carried out.

The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review.

BACKGROUND: The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS: We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS: The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Correction to: Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication. The complete correct affiliation should read as follows.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer.

The T3 category of the TNM classification includes over 60% of all rectal tumours and encompasses the greatest variance in cancer-specific end-points than any other T category. The most recent edition of the cancer staging handbook of the American Joint Committee on Cancer (AJCC) dated 2010 does not divide T3 tumours into subgroups which reflect cancer-specific outcome more sensitively. The original aim of the present study was to review the literature to assess the influence of the degree of extramural extent of T3 rectal cancer on local recurrence and survival. An article written by the authors was accepted for publication but was withdrawn immediately after they became aware of the publication of the 4th edition of the TNM Supplement by the Union for International Cancer Control dated 2012, which was not accessible by the search system used. This article dealt with the subdivision of the T3 category although this was not included in the most up-to-date AJCC guidelines and was stated to be 'entirely optional'. Medline, PubMed and Cochrane Library searches were performed to identify all studies that investigated the degree of extramural spread and its relationship to survival and local recurrence. Twenty-two studies were identified of which 12 assessed the degree of histopathological extramural spread measured in millimetres. In 18 of the 22 studies the degree of extramural spread was a statistically significant prognostic factor for survival and local recurrence. Analysis of the studies indicated that the subdivision of category T3 rectal cancer into two subgroups of extramural spread ≤ 5 mm or more than 5 mm resulted in markedly different survival and local recurrence rates. The data were insufficient to allow validation of any greater subdivision. Measurement of the extent of extramural spread by MRI before any treatment agreed with the histopathological measurement in the surgical specimen to within 1 mm. The extent of extramural spread in T3 rectal cancer measured in millimetres is a powerful prognostic factor. A subdivision of T3 into T3a and T3b of less than or equal to or more than 5 mm appears to give the greatest discrimination of local recurrence and survival. Preoperative T3 subdivision by MRI has the same sensitivity as histopathological examination of the resected specimen. Given the clinical need for the pretreatment classification of the T3 category for oncological management planning, the evidence strongly indicates that the subdivision of the T3 category by MRI should be formally considered as part of the TNM staging system for rectal cancer.

The degree of extramural spread of T3 rectal cancer: a plea to the UICC and AJCC.

The above article, published online on 15 July 2016 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor-in-Chief, Neil Mortensen, and John Wiley & Sons Limited. After acceptance the authors were made aware of a contribution to a prior publication of the UICC, TNM Supplement: A commentary on uniform use, 4th Edition, ed. C. Wittekind (Wiley, 2012), p. 195, which renders the central argument of their article invalid. They have therefore asked for it to be withdrawn. A modified version of the paper was published in the January 2017 issue (volume 19; issue 1) with the title "The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer".

Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re-examined.

AIM: Haemorrhoidectomy and removal of anal skin tags in inflammatory bowel disease (IBD) have been considered to be potentially harmful, but the evidence for this is poor. A review of the literature was undertaken to determine the complications rate after haemorrhoidectomy in patients with IBD. METHOD: A Medline, PubMed and Cochrane Library search was performed to retrieve studies reporting the surgical treatment of haemorrhoids in patients with IBD. All studies that investigated the complications of haemorrhoidectomy and skin tag removal in patients with IBD were included. Complications included local sepsis, fissure, ulcer, stenosis, faecal incontinence and the direct need for proctectomy or a stoma. RESULTS: Eleven retrospective studies including 135 patients were identified. Most series were small and lacked information on the interval between surgery and the onset of complications. The range of complications ranged from 0% to 100%. Taking the studies together, complications occurred more frequently in Crohn's disease (CD) (17.1%) than in ulcerative colitis (UC) (5.5%). The risk of complication was much higher in patients with unknown than in those with known diagnosis of IBD (50% vs 9.8% in CD; 9.1% vs 4% in UC). CONCLUSION: There is great variation in the incidence of complications reported after haemorrhoidectomy or removal of skin tags in patients with IBD and it is not possible to draw a firm conclusion. Nevertheless the incidence of complications is high in patients with CD.