Temporal trends and treatment patterns in anal fissure management: insights from a multicenter study in Italy.

INTRODUCTION: Anal fissure (AF) poses a common challenge in clinical practice, prompting various treatment approaches. This multicenter study, conducted by the Italian Society of Colorectal Surgery, aimed to assess treatment trends in AF over a 10 year period. METHODS: A survey of proctologists and retrospective analysis of patient records were conducted to evaluate treatment modalities and outcomes across six different clinical scenarios based on AF presentation (acute/chronic) stratified by sphincter function (normal/hypertonic/hypotonic). RESULTS: Analysis of data from 17 principal investigators and 22,016 patients revealed significant variability in treatment approaches, influenced by factors such as symptom duration, anal tone, and surgeon preference. Conservative treatments were commonly utilized, while surgical interventions were reserved for refractory cases. Specifically, pharmaceutical treatment was administered to 66-75% of patients in cases of acute AF and 63-67% for chronic AF, while 10-15% underwent anal dilation, and < 2% received botulinum toxin injection. Among medical treatments, nifedipine with lidocaine and glycerin film-forming ointments were the most utilized. The most performed surgical techniques were fissurectomy and anoplasty, except for patients with chronic AF and hypertonic sphincter where sphincterotomy prevailed. Trends in treatment utilization varied depending on the clinical scenario, with notable shifts observed over time. CONCLUSIONS: This study provides insights into the evolving landscape of AF management, highlighting the need for further research to elucidate optimal treatment strategies and improve patient outcomes.

Suture reinforcement using a modified cyanoacrylate glue to prevent anastomotic leak in colorectal surgery: a prospective multicentre randomized trial : The Rectal Anastomotic seaL (ReAL) trial.

BACKGROUND: Anastomotic leakage (AL) is the most frequent life-threating complication following colorectal surgery. Several attempts have been made to prevent AL. This prospective, randomized, multicentre trial aimed to evaluate the safety and efficacy of nebulised modified cyanoacrylate in preventing AL after rectal surgery. METHODS: Patients submitted to colorectal surgery for carcinoma of the high-medium rectum across five high-volume centres between June 2021 and January 2023 entered the study and were randomized into group A (anastomotic reinforcement with cyanoacrylate) and group B (no reinforcement) and followed up for 30 days. Anastomotic reinforcement was performed via nebulisation of 1 mL of a modified cyanoacrylate glue. Preoperative features and intraoperative and postoperative results were recorded and compared. The study was registered at ClinicalTrials.gov (ID number NCT03941938). RESULTS: Out of 152 patients, 133 (control group, n = 72; cyanoacrylate group, n = 61) completed the follow-up. ALs were detected in nine patients (12.5%) in the control group (four grade B and five grade C) and in four patients (6.6%), in the cyanoacrylate group (three grade B and one grade C); however, despite this trend, the differences were not statistically significant (p = 0.36). However, Clavien-Dindo complications grade > 2 were significantly higher in the control group (12.5% vs. 3.3%, p = 0.04). No adverse effects related to the glue application were reported. CONCLUSION: The role of modified cyanoacrylate application in AL prevention remains unclear. However its use to seal colorectal anastomoses is safe and could help to reduce severe postoperative complications.

Synchronous "skip" facial metastases from colorectal adenocarcinoma: a case report and review of literature.

BACKGROUND: Skin metastases from colorectal adenocarcinoma are rare conditions that are metachronous in most of cases and may represent the first sign of a recurrence. These lesions are usually located to the abdominal wall on postoperative scars, perineum and chest due to direct spread from the tumor or to the lymphatic and venous dissemination. We describe a rare case of synchronous skin metastases in a patient affected by sigmoid adenocarcinoma with no sign of liver and lung repetitive lesions. CASE PRESENTATION: We admitted a 59 years old male, with no relevant medical history. He was evaluated by our tertiary center of colorectal surgery complaining diarrhoea and abdominal pain. The physical examination revealed a palpable mass in left flank of the abdomen. The colonoscopy showed a sub-stenosis of the sigmoid colon (G2 adenocarcinoma). No repetitive lesions were detected by the preoperative CT scan. The patient reported a rapid grow of a soft supralabial and chin nodules in the last 2 months, which he believed to be related to the use of the mask due to COVID-19 pandemic. A laparoscopic left hemicolectomy with complete mesocolic excision and a local excision of both facial nodules were performed. The histological examination revealed a poorly differentiated signet ring cell colorectal adenocarcinoma with metastases in seven pericolic lymphonodes. The excisional biopsy of the skin nodules revealed a subcutaneous metastases from primary colorectal tumour. CONCLUSIONS: As far as we know, synchronous facial metastases from colorectal cancer in the absence of any other metastases has never been described before. The onset of new skin nodules in patients affected by colorectal cancer should raise-up the clinical suspicion of metastatic lesions even when repetitive lesions are not detected in the liver or lungs.

Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR).

BACKGROUND: Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers. METHODS: Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient's anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario. RESULTS: Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10-20 (54%) to 21-50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function. CONCLUSIONS: The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.

Effects of temporary sacral nerve stimulation on gastrointestinal motility and function in patients with chronic refractory slow-transit constipation.

BACKGROUND: The efficacy of sacral nerve stimulation (SNS) on patients with chronic refractory slow-transit constipation is controversial and its mechanism of action on gastrointestinal motility and transit is not fully understood. The aim of this study was to document the effects of temporary SNS on the gastrointestinal and biliary tract motility and on gastrointestinal transit in patients with refractory slow-transit constipation. METHODS: This was a prospective interventional study. Patients with slow-transit chronic constipation, unresponsive to any conservative treatment, were enrolled between January 2013 and December 2018. Patients' quality of life [patient assessment of constipation quality of life (PAC-QOL) questionnaire], constipation scores (Cleveland Clinic Constipation Score) colonic transit time (CTT), orocecal transit time (OCTT), gastric and gallbladder kinetics, together with the assessment of the autonomic nerve function were evaluated before and during temporary SNS. RESULTS: 14 patients (12 females, median age 38 years, range 24-42 years) had temporary SNS. The Cleveland Clinic Constipation Score did not change compared to baseline (23 ± 3 vs 21.4; p = 070). The PAC-QOL did not improve significantly during the stimulation period. Gallbladder/stomach motility (half-emptying time) did not change significantly before and after SNS. OCTT was delayed at baseline, as compared to standard internal normal values, and did not change during SNS. CTT did not improve significantly, although in two patients it decreased substantially from 97 to 53 h, and from 100 to 65 h. CONCLUSIONS: Temporary SNS did not have any effect on upper/lower gastrointestinal motility and transit in patients with severe constipation.

The REALISE score: a new statistically validated scoring system to assess the severity of anal fissures.

BACKGROUND: Anal fissure (AF) is a common, painful disease that strongly affects patients' quality of life, however, no scoring system to assess the severity of AF is available in the literature. The aim of this study was to set up and validate a reliable scoring system to quantify the severity of AF, to be used in prospective trials comparing the efficacy and the outcomes of surgical or medical treatments. METHODS: The study was conducted on patients with acute or chronic AF and a control group in a tertiary centre for coloproctology in June 2020-September 2020. Two researchers independently carried out a structured interviewer-led questionnaire at two different time points (T1/T2). The questionnaire consisted of five items selected according to the most commonly reported symptoms for AF: the item pain, was scored from 0 to 10 using a visual analogue scale, and quality of life, duration of pain, use of painkillers, and bleeding were scored from 1 to 5 using Likert-scale questions. The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points. Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study. Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability. RESULTS: One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled. A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99). The coefficient of repeatability was 1.45 in T1 and 1.18 in T2. CONCLUSIONS: The REALISE score may have an important role in the assessment and management of AF, in grading the severity of AF and comparing results of different treatments.

European Society of ColoProctology: guideline for haemorrhoidal disease.

AIM: The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS: The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS: There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION: This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation.

AIM: To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation. METHODS: A retrospective study (June 2012-December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark's and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients' satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry. RESULTS: Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0 cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6). CONCLUSION: Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

Pelvic floor rehabilitation for defecation disorders.

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years.

AIM: The management of haemorrhoids has changed significantly in the last two decades as a result of new insights into their pathophysiology and the availability of new surgical devices. The aim of this survey was to evaluate changes in the management of haemorrhoids in Italy over the last 17 years. METHOD: An electronic database which recorded details of management relating to the severity of haemorrhoids between 2000 and 2016 was obtained from 18 of 34 colorectal surgeons who were invited to participate. RESULTS: A total of 32 458 patients were treated for haemorrhoids by 18 expert coloproctologists during a 17-year period. Patients were classified as Grade II (7542, 23.2%), Grade III(15 360, 47.3%) and Grade IV (9556, 29.4%). Grade II haemorrhoids were treated with rubber band ligation in over 90% of the cases, and patients with Grade IV had a Milligan-Morgan (MM) haemorrhoidectomy in over 90% of the cases. In Grade III, the use of stapled haemorrhoidopexy progressively decreased from 30% to 35% (between 2000 and 2007) to 5% of the cases. Meanwhile, commencing from 2006 the use of Doppler-guided haemorrhoid artery ligation (DGHAL) with mucopexy increased progressively from 6% to 24%. Over the years, the percentage of MM haemorrhoidectomy remained consistent at between 65% and 70% of the cases. CONCLUSION: Relevant changes in the surgical choice of haemorrhoid treatment have occurred in Italy over the last 17 years. MM haemorrhoidectomy remains the most frequently performed procedure for Grade III haemorrhoids. Stapled haemorrhoidopexy has become much less popular in contrast to DGHAL with mucopexy which is being performed much more frequently.

Pelvic floor function following ventral rectopexy versus STARR in the treatment of obstructed defecation.

BACKGROUND: Obstructed defecation syndrome (ODS), most commonly found in females, can be treated by a transanal or abdominal approach with good success rate. Nevertheless, patients may experience de novo or persisting pelvic floor dysfunctions after surgery. The aim of this study was to compare the functional outcome of stapled transanal rectal resection (STARR) and ventral rectopexy (VRP) in a series of ODS patients. METHODS: Forty-nine female patients who had surgery for ODS between 2006 and 2016 were retrospectively evaluated: 28 (median age 60 years, IQR 54-69 years) had VRP and 21 (median age 58 years, IQR 51-66 years) had STARR. ODS was scored with the ODS score while the overall pelvic floor function was assessed with the three axial perineal evaluation (TAPE) score. Quality-of-life was evaluated by the patient assessment of constipation quality-of-life (PAC-Qol) questionnaire administered preoperatively and after 1 year of follow-up. RESULTS: The preoperative median ODS score and TAPE score were comparable in both groups. After a median follow-up of 12 months (range 12-18 months), the median ODS score was 12 (range 10-20) in the STARR group and 9 (range 3-15) in the VRP one (p = 0.02), while the median TAPE score was 70.5 (IQR 60.6-77.3) in the former and 76.8 (IQR 70.2-89.7) in the latter (p = 0.01). Postoperatively the physical domain of the PAC-QoL score had a median value of 2.74 (IQR 1.7-3.75) in the STARR group compared to 1.5 (IQR 1-2.5) in the VRP group (p = 0.03). No major complications were recorded in either group. CONCLUSIONS: VRP and STARR can improve defecation in patients with ODS with minimal complications, but the overall pelvic wellness evaluated by the TAPE score improves significantly only after VRP, suggesting a better performance of VRP than STARR when overall pelvic floor function is concerned.

Short-term outcome of percutaneous tibial nerve stimulation for low anterior resection syndrome: results of a pilot study.

AIM: Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive procedure which has been demonstrated to be effective in faecal/urinary incontinence but has never been tested in low anterior resection syndrome (LARS). The severity of LARS may be evaluated by the LARS score, but rectal cancer treatments may also affect urinary and sexual function, which are not explored by the LARS score. The Three Axial Perineal Evaluation (TAPE) score is a new validated index addressing the overall pelvic floor functions. This study aims to assess the efficacy of PTNS in LARS patients and to evaluate the results by the LARS and TAPE scores. METHODS: Twenty-one patients operated on for rectal cancer between 2009 and 2014 complaining of LARS underwent PTNS (12 sessions of 30 min each). Six patients reported urinary incontinence and all except two (men) were sexually inactive. The LARS score and the TAPE score questionnaires were administered at baseline and after 6 months of follow-up. RESULTS: At 6 months' follow-up, nine patients reported a significant improvement of faecal incontinence and 3/6 an improvement of urinary incontinence after PTNS. Median LARS score significantly decreased from 32 to 27 (P = 0.009), while the median TAPE score improved significantly from 55 to 58 (P = 0.004). CONCLUSIONS: PTNS may be a further option in the treatment of selected patients with LARS and in addition may improve associated urinary incontinence. The severity of LARS can be detected by the LARS score; however, the adoption of the TAPE score is preferred in the case of concomitant urinary and/or sexual problems not explored by the LARS score.

Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long-term outcome of a randomized controlled trial.

AIM: The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy. METHOD: In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria. RESULTS: Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021). CONCLUSION: The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH.

T1 colon cancer in the era of screening: risk factors and treatment.

BACKGROUND: The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit. METHODS: The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases. RESULTS: Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN. CONCLUSIONS: Some factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.

Multicentre observational study of the Gatekeeper for faecal incontinence.

BACKGROUND: A variety of therapeutic approaches are available for faecal incontinence. Implantation of Gatekeeper prostheses is a new promising option. The primary endpoint of this prospective observational multicentre study was to assess the clinical efficacy of Gatekeeper implantation in patients with faecal incontinence. Secondary endpoints included the assessment of patients' quality of life, and the feasibility and safety of implantation. METHODS: Patients with faecal incontinence, with either intact sphincters or internal anal sphincter lesions extending for less than 60° of the anal circumference, were selected. Intersphincteric implantation of six prostheses was performed. At baseline, and 1, 3 and 12 months after implantation, the number of faecal incontinence episodes, Cleveland Clinic Faecal Incontinence, Vaizey and American Medical Systems, Faecal Incontinence Quality of Life Scale and Short Form 36 Health Survey scores were recorded. Endoanal ultrasonography was performed at baseline and follow-up. RESULTS: Fifty-four patients were implanted. After Gatekeeper implantation, incontinence to gas, liquid and solid stool improved significantly, soiling was reduced, and ability to defer defaecation enhanced. All faecal incontinence severity scores were significantly reduced, and patients' quality of life improved. At 12 months, 30 patients (56 per cent) showed at least 75 per cent improvement in all faecal incontinence parameters, and seven (13 per cent) became fully continent. In three patients a single prosthesis was extruded during surgery, but was replaced immediately. After implantation, prosthesis dislodgement occurred in three patients; no replacement was required. CONCLUSION: Anal implantation of the Gatekeeper in patients with faecal incontinence was effective and safe. Clinical benefits were sustained at 1-year follow-up.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Volatile organic compounds as new biomarkers for colorectal cancer: a review.

Analysis of the volatile part of the metabolome (volatile organic compounds, VOC) present in the gas phase of excreted materials is a promising new screening tool for several cancers, including colorectal cancer (CRC). The VOC signature can reflect health status, like a 'fingerprint', and can be modified in several diseases. Technical difficulties still limit the widespread use of VOC analysis in the clinical setting, but this approach has already been applied successfully in the diagnosis of CRC. The present study reviews the available data on VOC present in the headspace (the gaseous constituents of a closed space above a liquid or solid) of blood, urine, faeces and breath as a potential screening tool for CRC. A systematic electronic literature search was conducted in PubMed, Scirus and Google using the following keywords: Metabolomic, Volatile Organic Compounds (VOC), Electronic-nose and Colorectal Cancer. Only articles published in English between 2000 and 2015 were selected and these were independently checked by two of the authors. Ten papers describing the reliability of VOC analysis in breath and faeces, blood and urine were selected; all indicated good reliability in detecting CRC. The use of different substrates and different analytical platforms has led to the identification of different patterns of VOC. The reliability of a metabolomic approach as a noninvasive biomarker for use in CRC screening is supported by this review despite several limitations due to the number of patients included in each study, the different analytical platforms and biological materials used and different VOC identified.