Experience with a new device for pathological assessment of colonic endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is gaining popularity worldwide in the treatment of neoplastic lesions of the gastrointestinal tract. However, the experience in Western countries is quite limited and restricted to large or academic centers. Besides, this approach requires an optimal pathological assessment. The aim of this study was to report our experience with colonic ESD using a new device that allows complete handling of the resected specimens and especially of lateral margins, for pathological analysis. In a 1-year period, 14 patients (6 men, 8 women, age range 50-82 years) underwent colonic ESD in a non-academic hospital. The endoscopic procedure was carried out successfully en bloc in more than 90 % of cases. Perforation requiring surgery occurred in one patient (7 %). Pathological assessment with the new device allowed entire and complete examination of both the deep and lateral margins of the excised specimens. Colonic ESD is a viable option for non-surgical treatment of large bowel lesions even in relatively small centers and in non-academic settings. The new device allows good handling of the specimens, and it seems to be useful for the entire examination of the resection margins.

A proposal for an evidence-based model of the screening for the colorectal carcinoma in an Italian setting.

INTRODUCTION: The aim of this paper is to improve the feasibility perception of policymakers, health care workers and target population about the cost-effectiveness of the implementation of colorectal screening as Public Health strategy. METHODS: Retrospective study by application of a three-step model designed for a local setting in Sicily (Palermo and its Province) in order to distribute Fecal Occult Blood Tests (FOBTs), offer colonoscopy and surgery, by district allocation of pharmacies, public digestive endoscopic centres and oncologic and general surgery units. Mean adherence to consolidated colorectal screening programs in Italy was applied in order to evaluate the feasibility of an operative model in our area. RESULTS: Applying the model to the target population (269,368 individuals of both sexes), it can be expected a mean percentage of 79% delivered invitation and a mean participation rate of 46.3% accounting for a total of 213,070 invited individuals and 98,651 participating in the first round of the program. Furthermore, considering the national mean of 6% positive FOBT, 82% of colonscopy adhesion and 7% CRC detection rate, it can be scheduled a burden for health care structures involved in the program accounting for 49,325 FOBTs, 2,338 colonscopies and 141 surgeries for each year. DISCUSSION: This work demonstrates the feasibility of a colorectal screening project in our area, showing a sustainable impact for local health care involved structures. Furthermore, this program may be spread as an applicative model to other areas, adapting the project to the needs of the local setting in which the colorectal screening will be organized.

Evolution of the transfixed stitches technique hemorrhoidectomy.

AIM: To date, the types of surgical hemorrhoidal treatments available for a surgeon are manifold. The authors, beginning from an original interpretation of the indications for a surgical treatment of hemorrhoids, based on the new disease classification defined PATE 2006, hereby present the results related to the evolution in performing hemorrhoidectomy with the transfixed stitches technique (TPT). METHODS: A total of 50 patients, 30 males and 20 females, with diagnosis of hemorrhoids of grade III-IV underwent hemorrhoidectomy with the TPT, which consisted in using two suture threads (Monofil) for each nodule. Patients' follow-up was prolonged for six months after the surgical intervention. RESULTS: The mean score, according to the PATE 2006 classification, after the intervention was significantly lower in all patients in comparison to the initial mean score (23.7 versus 7.2, P<0.01). The mean score value of the early stage complications was 4.8 while that of the late stage complications was 2.2. We found a reduction in the score related to the recorded pain after 24 and 96 hours from the intervention (3 versus 1.4, P=0.05). Only 26% of the patients who underwent hemorrhoidectomy with the new TPT were administered non-steroidal anti-inflammatory drugs. The relapse rate was only of 2%. CONCLUSIONS: The TPT, performed with the new technique, allows to reach best results in comparison to the previous surgical options, by reducing the incidence of disease relapse and the infectious events during the postoperative period, thus reducing the needed time for return to working activity.

[Overnight surgery in proctology and anesthesia type: our experience on 320 patients]. / Overnight surgery in proctologia e tipo di anestesia: nostra esperienza su 320 pazienti.

BACKGROUND: Several evidences demonstrated that general anaesthetics associated with local anaesthesia show more advantages in comparison to spinal anaesthesia in proctological surgery. Aim of this study was to verify the efficacy of deep general anaesthesia associated with a loco-regional anesthesiological technique, in a grade population of 320 patients affected by haemorrhoidal disease and anal fissure. PATIENTS AND METHODS: Patients with III-IV grade haemorrhoids and chronic posterior anal fissures has been eligible for this study while were excluded patients with history of allergic reaction or pharmacological hypersensibility to naropine, propofol o similar drugs. All patients (group A) were submitted to general anaesthesia associated with loco-regional anaesthesia, Control patients (group B) underwent spinal anaesthesia. At the end of all surgery procedure, it has been evaluated the presence of early and late complications according to our classification recently proposed. RESULTS: A total of 320 patients were included, 240 submitted to haemorrhoidectomy for prolapse and 80 surgically treated for anal fissures. Anesthesia obtained has been satisfactory in the all treated patients and has not been observed permanent side-effects. Among the early post-operative complications it has been observed urinary retention in 9% of patients and pain in 30%. Among late post-operative complications it has been observed pain in 8% and urinary retention in 1% of patients. In two patients has been observed the development of abscess in correspondence of anaesthetic infiltration area. The local anaesthetical effect was present for a mean period of 4-8 hours. CONCLUSIONS: Loco-regional anesthesiological technique with posterior block, associated to general anaesthesia, has been demonstrated efficacious for the treatment of the most frequent proctological pathologies. This method allowed a low incidence of early and late complications and a more fast resolution of clinical sequelae of the surgery.

The impact of experience on short- and long-term outcomes on gastric ESD: a western series.

Endoscopic submucosal dissection (ESD) represents the standard of care for early gastric cancer in Eastern countries. Nevertheless, in the West, this procedure is not widespread. Aim of the study was to confirm the feasibility and the efficacy of ESD in the West. A total of 60 ESD were performed between January 2005 and December 2014 by two expert endoscopists. The analysis, based on a retrospective collected database, was conducted by dividing the study period in three subgroups. Clinical and technical outcomes have been compared. Rates of complete, curative and en bloc resection did not significantly change among the study periods. Three cases of perforation occurred (5%), one in each period. The operation time significantly decreased from the second to the third period (p < 0.001). When adjusting for gender, tumor size and site in multivariable analysis, operation time decreased by nearly 90 min from the first to the second period, and by more than 3 h from the first to the last period. The median follow-up was 33 months. No cases of local or lymphnodal recurrence were detected during the study period. One patient presented a synchronous lesion, whilst four metachronous lesions have been discovered after a median follow-up of 11 months. Our experience supports the feasibility and safety of ESD in the West, if an adequate learning curve is accomplished. Long-term outcomes are comparable to the Eastern series.

The evolution of transfixed sequential suturing technique (TSST) in the treatment of rectocele: advantages and efficacy in 10 cases.

AIM: Rectocele, or posterior vaginal prolapse, is considered a herniation of the anterior rectal and posterior vaginal wall into the lumen of the vagina, which arises from either a tear or an attenuation of the rectovaginal (Denonvilliers') fascia. To date, all the surgical techniques proposed both through the anus and through the vagina have not demonstrated a real clinical efficacy in terms of a complete solution of this anatomic disorder. The authors of the present study have improved the surgical treatment outcome of rectocele introducing a new technique called transfix sequential suturing technique (TSST). Hereby its evolution is described, using a new suture called Monofil (Assut Europe s.p.a., Magliano dei Marsi, L'Aquila, Italy) and a new single-use operating kit. METHODS: Ten consecutive female outpatients were treated surgically, after diagnosis of rectocele has been made both clinically and by imaging. Seven patients were found at stage 2 and three at stage 3 rectocele. The surgical technique performed was the same in all patients, and consisted in fixing sutures sequentially into the rectum until a complete closure of the rectocele pouch was obtained. All patients underwent a gloved finger examination of the rectum, anoscopy with the sphere-test, a defecagram and a total colonoscopy. Each patient was asked to fill a Quality of Life questionnaire (Agachan-Wexner Score) before surgery, and after three and six months of follow-up. RESULTS: In our series, no serious postoperative complication was registered. The Quality of Life average score before treatment was 25, after three months of follow-up it decreased to 14, and to 12 after six months. The difference was found statistically significant (P<0.05). CONCLUSIONS: The introduction of Monofil and that of a single-use operating kit demonstrated to be more efficacious in treating rectocele compared to TSST performed with an interrupted running suture and compared to other surgical techniques. Patients' quality of life improved significantly and a lower incidence of postoperative discomfort was found.

[Haemorrhoid disease during pregnancy: focus on delivery unit]. / La malattia emorroidaria durante la gestazione: focus sulle sale parto.

OBJECTIVE: Hemorrhoidal disease (HD) is most frequent during and after the pregnancy, always resulting disabling and not without the occurrence of complications that make necessary a surgical therapy. In these cases the HD could be underestimated by obstetricians, precluding the patient's access to possible medical and surgical or rehabilitative treatments to correct eventual dysfunction related to the delivery. MATERIALS AND METHODS: For this purpose the Authors have administered a questionnaire at 165 obstetricians regarding the occurrence of HD symptoms according to our experience, the prevalence and the modalities of treatment of HD and the knowledge of specialists and methods to cure HD. RESULTS: The interviewed obstetricians in a proportion of 95% referred the presence of HD symptoms during pregnancy in particular in three-fourths of patients who have a natural (57%) or a vaginal operative delivery (41%). It was resulted that only the 42% of obstetricians refer to the specialist for HD and approximatively the half of them not known the role of perineologist or the pelvic rehabilitative methods. CONCLUSIONS: Our study seems to confirm that the management of HD during pregnancy is inadequate due to the lack of collaboration between obstetrician, gynaecologist and the specialist of anal and pelvic pathologies.

[Scientific background and clinical implementation: three new proposals in coloproctology]. / Ideazione scientifica e sperimentazione clinica: tre moderne proposte in colonproctologia.

OBJECTIVE: The Authors underline three clinical problems in coloproctology: the surgical access to the anal canal, the lacking aspects of the actual classification of hemorrhoids, the difficult choice of the surgical treatment in case of coexisting III degrees and IV degrees degree of hemorrhoids. They propose a new anal retractor which enables the surgeon to better calibrate all the surgical procedures inside the anal canal and to operate alone without the help of another operator. A new computerized software is able to rapidly guarantee a numeric score for hemorrhoids which is repetable before and after treatment of the disease. The Authors present a new surgical technique defined of transfixed stichtes for the resolution of the most advanced stage of hemorrhoids. PATIENTS AND METHODS: The new anal retractor was used in fifthy consecutive patients operated on for proctological problems. A quickly computerized score coming from the new classification PATE 2000 Sorrento was evaluated in one hundred patients, while the surgical technique of transfixed stichtes was utilized in fifthy. RESULTS: All the surgical procedures performed with the new device were concluded without complications. The highest values of the score from PATE 2000 Sorrento always fit with the surgical treatment of the disease, while transfixed stitches gave dysuria in five patients, but a better quality of life was referred by 38 over 50 patients treated. CONCLUSIONS: The Authors underline in this paper the results of the clinical implementation of these three new solutions in colon-proctology.

[Incidental diagnosis of caecum adenocarcinoma due to retention of endoscopic videocapsule: a clinical case]. / Diagnosi incidentale di adenocarcinoma del cieco dovuto a ritenzione della videocapsula endoscopica: un caso clinico.

Capsule endoscopy is a new technique for the study of small intestine particularly in cases of obscure gastro-intestinal bleeding or chronic iron-deficiency anemia. In our study we present a case of 62 years-old man with a chronic iron-deficiency anaemia developed at least six months before and refractory to iron therapy. The patient was submitted to upper gastro-intestinal endoscopy and to partial colonscopy due to abdominal adhesions for previous abdominal surgery. A capsule endoscopy was indicated to achieve a definitive diagnosis. Wich discosed an intestinal obstruction. So far a surgical resolution was indicated. The surgery revealed a stricturing neoplasia of the cecum in which the capsule endoscopy was retained.

[Surgical management of incidental Meckel's diverticulum: the necessity to obtain the informed consent]. / Il trattamento chirurgico del diverticolo di Meckel riscontrato incidentalmente: la necessità di acquisire il consenso informato.

Surgical approach to the incidentally found Meckel's diverticulum (MD) is still source of debate: some support the systematic search and the surgical resection, others suggest to leave in situ the asymptomatic diverticulum. A wide literature review and some claims for malpractice referred to resection of diverticular formations (2 cases are described herein) allow us to deem that the removal of an asymptomatic MD may be an excess of surgical indication regarding an entity that cannot be defined as pathological for itself; anyway, the informed consent must be obtained before the incidental resection. The consent to the removal of MD must always be requested for laparotomies in which the surgeon forecasts the possibility to remove a diverticulum eventually found. Finally, an easy informed consent form about an incidentally found MD to be submitted to the patient is proposed.

[Constipation following hysterectomy. Retrospective study based on 105 cases]. / Stipsi post isterectomia. Studio retrospettivo su 105 casi.

Constipation after surgery is considered as a subgroup of patients in whom the disorder begins after pelvic surgery. A group of patients (median age 52 years with a range of 34-65 years) who had a hysterectomy underwent a retrospective study with the aid of a questionnaire and clinical records, to evaluate the incidence of constipation before and after the operation. Forty patients were operated on for benign pathology and 65 for malignant pathology. Forty-two patients underwent a Wertheim-Meigs, 39 had laparohysterectomy, 20 had a colpohysterectomy and 4 had a Schauta. The incidence of constipation increased from 25% preoperatively to 38% postoperatively (p < 0.05). There is no difference in the incidence of postoperative constipation among the various operations. Constipation after hysterectomy is associated with urinary disorders. These data confirm previous studies on the effect of hysterectomy on urinary and defaecatory functions and they show how a simple colpohisterectomy can cause constipation.

The new classification of hemorrhoids: PATE 2000-Sorrento. History of the scientific debate.

BACKGROUND: The history of our proposal for a new classification of hemorrhoids is very old: 7 years of scientific debate had a big impact for the study and the definition of hemorrhoids. METHODS: Nowadays many things have changed mainly in the field of treatment of hemorrhoids. New medical and surgical tools are available for the modern proctologist. RESULTS: The new classification of the disease seems to fit the necessity of introducing these modern opportunities. Many authors recognize the fundamental role and claim for the routine use of a new classification, named PATE 2000 Sorrento. Nevertheless many problems are on debate. Their resolution needs the cooperation of all the experts in order to choose the best version of the classification. CONCLUSIONS: For these reasons the authors analyse all the work carried out till now in order to see what we still need to introduce a new classification of the disease.

[Towards a new classification of hemorrhoidal disease]. / Verso una nuova classificazione della malattia emorroidaria.

The generally accepted classification of hemorrhoids presents some rather wide gaps which may either be due to expressions of intrinsic limits or recent moves of the Colonproctology field. The authors of this paper would like to present their proposal for a new classification that considers the results of the National Multicentric Study that was performed in collaboration with nineteen centres and a total of 1,494 patients. In addition, a comparative study was conducted on the two forms of classification. Nineteen patients (1.28%) were considered unclassifiable with the new classification system while 49 were (3.29%) with the presently used one. These results were found significant with the MacNemar Chi-Square test. The description of type 2 and 3 in the new classification system was found useful in 69% of 2nd degree, 77% of 3rd degree and 28% of 4th degree using the present system. Acute events (type 5,6 and 7) proposed with the new classification were found in the present system with several different rates. We have also included the data taken from a national and international survey we conducted on the usefulness of the new classification that provoked intense debate within two of the most important national institutes. The result was the elaboration of a design on the new classification.