A step-by-step approach to endorectal proctopexy (ERPP): how we do it.

There are many surgical treatments aimed at correcting internal mucosal prolapse and rectocele associated with obstructed defecation syndrome (ODS). Perineal procedures can be considered as first options in young men in whom an abdominal approach poses risks of sexual dysfunction and in selected women with isolated posterior compartment prolapse who failed conservative treatment. About 20 years ago, we described endorectal proctopexy (ERPP) also known as internal Delorme procedure. The aim of the present study was to describe, with attention to technical details and the aid of a video, the different steps of ERPP for the treatment of ODS. A retrospective analysis of our last 100 cases confirms our initial good results. Complications included suture line dehiscence with consequent stricture in four patients (4%). Bleeding occurred in four (4%) patients and was conservatively treated. Transient anal continence impairment consisting of urgency and soiling occurred in 12 (12%) and 6 (6%) patients, respectively. At 6-month follow-up the Cleveland Clinic Constipation Score and ODS score improved from a median preoperative value of 18.9 and 18.5 to 5 and 5, respectively (p < 0.0001). The mean follow-up was 36.05 ± 13.3 (range 12-58) months and anatomical recurrence rate was 6 (%). Due to its excellent safety profile and the ability to tailor the procedure to different disease presentations, we think that ERPP should be part of the basic armamentarium of all colorectal surgeons operating on the pelvic floor.

A tailored rhomboid mucocutaneous advancement flap to treat anal stenosis.

AIM: Anal stenosis (AS) is a rare but disabling disorder that often represents a complication of anorectal surgery. The aim of our study was to assess the safety and functional outcome of a modified rhomboid flap (MRF) in the treatment of moderate and severe AS. METHODS: Between January 2002 and September 2017, 50 consecutive patients with moderate and severe AS who underwent an MRF were retrospectively included. Anal continence (Cleveland Clinic Incontinence Score) and symptoms (Obstructed Defaecation Syndrome Score) were assessed preoperatively and postoperatively at 12 months. Furthermore, anal calibre was measured both preoperatively and postoperatively at 1, 6 and 12 months. RESULTS: The mean follow-up period was 97 ± 48.3 (33-180) months. The main aetiology was a previous excisional haemorrhoidectomy (N = 23; 46%). The mean preoperative anal calibre was 9.96 ± 2.68 (5-15) mm and there was a statistically significant improvement in all three periods (P < 0.0001) of postoperative evaluation (1, 6 and 12 months) with a mean difference, obtained comparing preoperative and 12 months anal calibre, of 14.1 ± 2.72 (P < 0.0001). Statistically significant improvement in both Cleveland Clinic Incontinence Score and Obstructed Defaecation Syndrome Score was observed in all patients at 12 months. The overall success rate was 96% (48/50 patients). CONCLUSION: The use of an MRF is a safe and suitable option for the treatment of moderate and severe AS. The possibility of tailoring the flap, based on the degree as well as the level of AS, is the key.

Correction to: Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

An amendment to this paper has been published and can be accessed via the original article.

Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

BACKGROUND: Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). METHODS: This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. RESULTS: In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). CONCLUSIONS: The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698-Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease.

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Use of the Martius advancement flap for low rectovaginal fistulas.

AIM: The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short- and long-term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues. METHOD: Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien-Dindo classification. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre- and postoperatively. RESULTS: The mean follow-up was 42 ± 29 months (range 3-101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45-70 min), and the median hospital stay was 3.5 days (range 3-5 days). No major complications occurred. Pre- and postoperative CCIS did not differ [1 (range 0-3.5)]. The postoperative SF-12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001). CONCLUSION: The Martius procedure should be considered as the first-line method of treatment in carefully selected cases of LRVF.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement.

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Transperineal repair with bulbocavernosus muscle interposition for recto-urethral fistula.

AIM: The results of repair of recto-urethral fistulae (RUF) are presented using a bulbocavernosus muscle graft. METHOD: Prospectively collected data were reviewed on 11 patients with RUF operated on between 2003 and 2011. Of these, six were treated by a bulbocavernosus flap. Two RUF had occurred after prostatectomy, three after prostatectomy and radiotherapy and one after perineal trauma; all had a urinary diversion. RESULTS: Closure of the fistula was achieved in all patients and was maintained for the duration of the period of follow up (mean ± SD = 43.5 ± 24.7 months; range, 8-80 months) There were no complications. CONCLUSION: This new technique for the repair of RUF is safe and effective, especially in patients with complex postradiation RUF.

Internal Delorme's procedure for rectal outlet obstruction.

AIM: The outcome of the internal Delorme's procedure (IDP) for obstructed defaecation was assessed. METHOD: From October 2001 to March 2009, 167 patients with obstructed defaecation associated with rectal intussusception were operated on. Patients were selected on the basis of validated constipation and continence scores, clinical examination and defaecography. Seventy-six patients were treated by the IDP alone and 91 patients were treated by the IDP with a levatorplasty. Before surgery and after a mean ± SD follow up of 3.0 ± 1.5 years, patients were assessed using the Cleveland Clinic Incontinence and Constipation Score (CCIS and CCCS), the Obstructed Defecation Score (ODS), faecal urgency and the Patient Assessment of Constipation Quality of Life (PAC-QoL) questionnaire. RESULTS: Seventeen (10.2%) patients developed a postoperative complication including fissure-in-ano (4.2%), proctalgia (3.0%), suture-line dehiscence with stenosis (1.8%) and Clostridium difficile colitis (1.2%). Faecal urgency changed from 22% to 17.6% (P = 0.754). Tenesmus fell from 53.9% to 17.1% (P < 0.001). The CCCS and the ODS fell by 50% or more in 82.6% and 73.7% of the patients, respectively. The CCIS did not worsen significantly in patients who remained incontinent, and 45.7% of the previously incontinent patients regained normal continence. The CCCS decreased from 11 to 3 (P < 0.001) in the patients treated by the IDP and from 12 to 3 (P < 0.001) in the patients treated by the IDP with levatorplasty. The overall recurrence rate was 5.4%. The PAC-QoL showed a reduction of anxiety/depression and of physical and psychological discomfort (P < 0.001). CONCLUSION: The IDP is an effective and safe option for rectal outlet obstruction caused by rectal intussusception with excellent function and patient satisfaction.

Multicentre observational study of the natural history of left-sided acute diverticulitis.

BACKGROUND: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. METHODS: The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. RESULTS: Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. CONCLUSION: Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.