Rivaroxaban vs placebo for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer.

The clinical benefit of extended prophylaxis for venous thromboembolism (VTE) after laparoscopic surgery for cancer is unclear. The efficacy and safety of direct oral anticoagulants for this indication are unexplored. PROphylaxis of venous thromboembolism after LAParoscopic Surgery for colorectal cancer Study II (PROLAPS II) was a randomized, double-blind, placebo-controlled, investigator-initiated, superiority study aimed at assessing the efficacy and safety of extended prophylaxis with rivaroxaban after laparoscopic surgery for colorectal cancer. Consecutive patients who had laparoscopic surgery for colorectal cancer were randomized to receive rivaroxaban (10 mg once daily) or a placebo to be started at 7 ± 2 days after surgery and given for the subsequent 3 weeks. All patients received antithrombotic prophylaxis with low-molecular-weight heparin from surgery to randomization. The primary study outcome was the composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected deep vein thrombosis (DVT), or VTE-related death at 28 ± 2 days after surgery. The primary safety outcome was major bleeding. Patient recruitment was prematurely closed due to study drug expiry after the inclusion of 582 of the 646 planned patients. A primary study outcome event occurred in 11 of 282 patients in the placebo group compared with 3 of 287 in the rivaroxaban group (3.9 vs 1.0%; odds ratio, 0.26; 95% confidence interval [CI], 0.07-0.94; log-rank P = .032). Major bleeding occurred in none of the patients in the placebo group and 2 patients in the rivaroxaban group (incidence rate 0.7%; 95% CI, 0-1.0). Oral rivaroxaban was more effective than placebo for extended prevention of VTE after laparoscopic surgery for colorectal cancer without an increase in major bleeding. This trial was registered at www.clinicaltrials.gov as #NCT03055026.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery.

PURPOSE: Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery. METHODS: A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time. RESULTS: Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001). CONCLUSION: SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer.

AIM: Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. METHODS: All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. RESULTS: During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. CONCLUSION: The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users.

BACKGROUND: Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. METHODS: We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. RESULTS: The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. CONCLUSION: Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Low anterior resection syndrome: can it be prevented?

Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.

Management guidelines for low anterior resection syndrome - the MANUEL project.

AIM: Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS. METHOD: The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project. RESULTS: The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts. CONCLUSIONS: The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

The Role of DAMPS in Burns and Hemorrhagic Shock Immune Response: Pathophysiology and Clinical Issues. Review.

Severe or major burns induce a pathophysiological, immune, and inflammatory response that can persist for a long time and affect morbidity and mortality. Severe burns are followed by a "hypermetabolic response", an inflammatory process that can be extensive and become uncontrolled, leading to a generalized catabolic state and delayed healing. Catabolism causes the upregulation of inflammatory cells and innate immune markers in various organs, which may lead to multiorgan failure and death. Burns activate immune cells and cytokine production regulated by damage-associated molecular patterns (DAMPs). Trauma has similar injury-related immune responses, whereby DAMPs are massively released in musculoskeletal injuries and elicit widespread systemic inflammation. Hemorrhagic shock is the main cause of death in trauma. It is hypovolemic, and the consequence of volume loss and the speed of blood loss manifest immediately after injury. In burns, the shock becomes evident within the first 24 h and is hypovolemic-distributive due to the severely compromised regulation of tissue perfusion and oxygen delivery caused by capillary leakage, whereby fluids shift from the intravascular to the interstitial space. In this review, we compare the pathophysiological responses to burns and trauma including their associated clinical patterns.

Middle-term Outcomes of Gatekeeper Implantation for Fecal Incontinence.

BACKGROUND: Intersphincteric injectable bulking agents are one of the current treatment options for fecal incontinence, failing behavioral and medical therapy. Gatekeeper showed promising short-term results, but long-term outcomes are unknown. OBJECTIVE: The purpose of this study was to clinically evaluate a prospective cohort of fecal incontinence patients up to 36 months after implantation of Gatekeeper. DESIGN: This was a prospective clinical study. SETTINGS: The study was conducted at a large university tertiary care hospital. PATIENTS: Consecutive female patients were eligible if fecal incontinence onset was ≥6 months before the first visit and symptoms were refractory to standard conservative measures. INTERVENTIONS: All of the patients underwent implantation of 4 or 6 Gatekeeper prostheses. Three-dimensional endoanal ultrasonography and high-resolution anorectal manometry were performed preoperatively and postoperatively at 2 and 3 months after implantation. MAIN OUTCOME MEASURES: The Cleveland Clinic Fecal Incontinence score was calculated at baseline and 1, 3, 12, 24, and 36 months postoperatively. RESULTS: Twenty patients (all women; median age, 59 y) were enrolled, and all implants were uneventful. Postoperative endoanal ultrasonography showed normal prosthesis localization in 16 patients (80%). At manometry, mean anal resting pressure significantly improved (57.8 ± 7.5 mm Hg; p = 0.0004). Mean preoperative Cleveland Clinic Fecal Incontinence score was 12.4 ± 1.8, with significant improvements initially documented at 3 months (4.9 ± 1.5; p < 0.0001) and sustained up to 36 months (4.9 ± 1.7; p < 0.0001). Patients receiving only 4 (compared with 6) prostheses and those experiencing pudendal neuropathy (compared with those who did not) showed significantly higher Cleveland Clinic Fecal Incontinence score values in the middle term. LIMITATIONS: The study was limited by its small sample size and absence of quality-of-life data. CONCLUSIONS: Initial improvements after Gatekeeper implantation for fecal incontinence are sustained in the middle term. Accurate preoperative evaluation of coexistent clinical conditions that may negatively affect outcomes is recommended for patient selection. See Video Abstract at http://links.lww.com/DCR/B109. RESULTADOS A MEDIANO PLAZO EN LA IMPLANTACIÓN DE GATEKEEPER PARA LA INCONTINENCIA FECAL: Los agentes de volumen inyectables interesfintéricos, son opciones actuales de tratamiento para la incontinencia fecal, ante fallas de terapias conductuales y médicas. Gatekeeper mostró resultados prometedores a corto plazo, pero resultados a largo plazo aún son desconocidos.Evaluar clínicamente una cohorte prospectiva de pacientes con incontinencia fecal, hasta 36 meses después de la implantación de Gatekeeper.Estudio clínico prospectivo.El estudio se realizó en un gran hospital universitario de atención terciaria.Fueron elegibles pacientes femeninas consecutivas, si el inicio de la incontinencia fecal, fue al menos 6 meses antes de la primera visita, y que los síntomas fueron refractarios a las medidas conservadoras estandarizadas.Todas las pacientes fueron sometidas a implantación de 4 o 6 prótesis Gatekeeper. Se realizó ecografía endoanal de 3D y manometría anorrectal de alta resolución, antes de la implantación y después a los 2 y 3 meses.Se calculó el puntaje de incontinencia fecal de la Cleveland Clinic al inicio, y a los 1, 3, 12, 24 y 36 meses después de la operación.Se inscribieron veinte pacientes (todas mujeres; con edad media de 59 años), y todos los implantes transcurrieron sin incidentes. La ecografía endoanal postoperatoria, mostró localización normal de la prótesis en 16 (80%) pacientes. A la manometría, la presión media de reposo anal, mejoró significativamente (57.8 ± 7.5 mmHg, p = 0.0004). La puntuación media preoperatoria de la incontinencia fecal de la Cleveland Clinic, fue de 12.35 ± 1.75, con mejoras significativas documentadas inicialmente a los 3 meses (4.9 ± 1.5, p <0.0001) y sostenidas hasta los 36 meses (4.9 ± 1.7, p <0.0001). Los pacientes que recibieron solo 4 prótesis (en comparación con 6) y que padecían neuropatía pudenda (en comparación con aquellas que no la padecían), mostraron valores de puntaje de Incontinencia Fecal de la Clínica Cleveland, significativamente más altos en el mediano plazo.El tamaño pequeño de la muestra y la ausencia de datos en calidad de vida.Las mejoras iniciales después de la implantación de Gatekeeper para la incontinencia fecal, se mantienen en el mediano plazo. Para la selección de pacientes, se recomienda una precisa evaluación preoperatoria de las condiciones clínicas coexistentes, que puedan afectar negativamente los resultados. Consulte Video Resumen en http://links.lww.com/DCR/B109.

Colonic splenic flexure carcinoma: is laparoscopic segmental resection a safe enough oncological approach?

BACKGROUND: The surgical approach to the colonic splenic flexure cancer (SFC) is yet to be technically standardized. The aim of this study has been to retrospectively evaluate the oncologic long-term results of our cases comparing our data with other authors' experiences. METHODS: Clinical data of patients with SFC operated on at our institute were retrospectively analyzed. The laparoscopic approach was used in the whole series, with limited resection distally and proximally to splenic flexure and the origin ligation of left colic artery and left branch of middle colic artery. Data on the oncological long-term safety were compared to our laparoscopic series of extended right colectomy for proximal two-third transverse colon cancer and high anterior resections for sigmoid-high rectal cancer and to the main evidences in the literature, found after a comprehensive review. RESULTS: From March 2008 to May 2018, we completed 53 laparoscopic splenic flexure resections (26 female and 27 male, age 71.5 ± 15.4 years). The conversion rate was 3.8%. Most of the cases were stage II (pT3 73.5%, the mean number of lymph nodes harvested was 19.1, with positivity for malignancy in 45.3%). During the FU (43.5 months), 2 patients dropped out. Out of the 51 residual cases, 37 were alive (72.5%) and 14 are deceased (27.5%). DISCUSSION: Compared to the literature, our survival rate does not show significant differences. The other oncological outcomes seem to be comparable with the data evaluated. CONCLUSIONS: More extended resections seem not to confer an increase of the overall survival rate.

Caiman Versus LigaSure Hemorrhoidectomy: Postoperative Pain, Early Complications, Long-Term Follow-up, and Costs.

Purpose. Recently, the use of radiofrequency for hemorrhoidectomy has minimized incidence of postoperative complications. Effectiveness of LigaSure is demonstrated, but it is quite expensive. This study aims to compare LigaSure with Caiman, a cheaper instrument that uses radiofrequency for hemorrhoidectomy. Methods. A total of 35 patients were enrolled in this study between January 2015 and December 2017: 35 (Group A: Caiman) patients were matched with 35 control patients (Group B) from our historical cohort, treated with LigaSure. They were checked at 1 week after operation, at 4 weeks, and then after 2, 6, and 12 months. We considered different factors: intraoperative (operative time, number of piles removed, necessity of stiches or ligation), immediate postoperative (pain, bleeding within 4 weeks, incontinence, soiling within 4 weeks, healing time of anal wounds, return to working activities), and with a long-term follow-up. Results. There were no statistically significant differences between the 2 groups in analyzed intraoperative data: operative time (Group A 35 minutes vs Group B 33 minutes; P = .198) and stitches used. Postoperative data were comparable too, in particular pain (Group A 1 day Visual Analog Score = 6.25 vs Group B = 5.4, P = .178; Group A 1 week Visual Analog Score = 2.7 vs Group B = 1.14, P = .22) and bleeding (Group A = 2 vs Group B = 4; P = .2). Conclusions. According our initial experience, Caiman can be a safe and cheaper alternative to LigaSure for hemorrhoidectomy.

Anatomical and Functional Features of the Internal Rectal Prolapse With Outlet Obstruction Determined With 3D Endorectal Ultrasonography and High-Resolution Anorectal Manometry: An Observational Case-Control Study.

OBJECTIVES: To investigate correlation between rectal wall thickness (RWT) and anorectal pressures, in obstructed defecation syndrome (ODS) patients caused by internal rectal prolapse. METHODS: ODS patients and healthy volunteers (HVs) underwent 3D endorectal ultrasound (3D-EUS) and high-resolution anorectal manometry (HRAM); RWT, total rectal wall volume (TRWV), pushing endorectal pressure (PEP), recto-anal gradient were determined RESULTS: We enrolled 35 ODS patients and 25 HVs. Patients showed markedly decreased TRWV, PEP, and recto-anal gradient. Linear correlation was found between markedly reduced TRWV and markedly hypotonic PEP. CONCLUSIONS: HRAM and 3D-EUS could be performed in ODS assessment, to better understand rectal function.

Flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) in the treatment of I-III degree hemorroidal disease: a double-blind multicenter prospective comparative study.

PURPOSE: We evaluated the efficacy of new flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from I-III degrees hemorrhoidal disease in the short and medium time. METHODS: One hundred fifty-four consecutive patients with hemorrhoidal disease recruited in four colorectal units were enrolled to the study. Exclusion criteria were allergy to the flavonoids, inflammatory bowel disease, obstructed defecation syndrome, pregnancy and puerperium, associated anal disease or hemorrhoidal thrombosis, proctologic surgical procedures within 1 year before recruitment, contemporary cancer or HIV, previous pelvic radiotherapy, patients receiving oral anticoagulant therapy, or contemporary administration of other therapy for hemorrhoids. Patients with inability to understand the study or mental disorders were also excluded. RESULTS: Seventy-eight were randomized to receive the mixture of diosmin, troxerutin, rutin, hesperidin, and quercetin (study group, SG), and 76 a mixture of diosmin in combination with hesperidin, diosmetin, isoroifolin, and linarin in purified micronized fraction (control group, CG). Bleeding, number of pathological piles, and Golligher's grade were assessed at each scheduled visit and compared using the Chi-square test. During the study period, bleeding improved after 1 and 6 months both in the SG (79.5 and 70.5%) and in the CG (80.2 and 75%) without significant differences between two groups. Satisfaction degree after 6 months was greater in the patients of the SG (4.05) towards the CG (3.25): this result was statistical significant (p 0.003). CONCLUSIONS: Use of flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) is a safe and effective mean of managing bleeding from hemorrhoidal disease and minimal adverse events are reported.

Long-term functional follow-up after anterior rectal resection for cancer.

PURPOSE: This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. METHOD: Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. RESULTS: A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. CONCLUSIONS: Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.

A long-term evaluation of the quality of life after laparoscopic Nissen-Rossetti anti-reflux surgery.

BACKGROUND: The quality of life (QoL) has been suggested to be the most relevant parameter to assess and monitor the long-term outcome in patients who underwent surgery for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: A retrospective evaluation was conducted on patients who underwent Laparoscopic Nissen-Rossetti Fundoplication for GERD between January 1998 and December 2010. To evaluate the long-term results a telephone interview was made using the VISICK score and the GERD-health-related QoL (HRQL) questionnaire at 1, 3, 5 years and at the end of the study. If the questionnaires resulted unsatisfactory, a complete diagnostic revaluation was performed. RESULTS: A total of 168 patients underwent laparoscopic surgery for GERD. When evaluated at the end of the study, the number of unsatisfied patients according to the VISICK score was significantly higher than the one obtained with the GERD-HRQL questionnaire. CONCLUSIONS: Many data suggest a possible recurrence of the symptoms after surgery in a long follow-up period. Our data seem to demonstrate a slight but significant trend in symptoms relapse after surgery. Considering the non-specific and specific nature of the two scores, VISICK and GERD HRQL, our result showed a significantly more relevant trend of symptoms relapse only for the non-specific ones. Such QoL scores seem to be important in selecting patients who need to be instrumentally examined. Consequently, our work proves that only a few patients out of the total number of followed up patients, are to be recalled to undergo instrumental examination.

Persistent anal and pelvic floor pain after PPH and STARR: surgical management of the fixed scar staple line.

BACKGROUND: Persistent anal pain (PAP) after stapled procedures, be it hemorrhoidopexy (PPH) or stapled transanal rectal resection (STARR) may be hardly resolved by medical therapy. The typical objective finding in these patients is the staple line characterized by fixed scar to underlying layers. METHODS: A total of 21 consecutive patients were operated for PAP after stapled procedure. The scarred staple line was excised and detached from layers below, the mucosal continuity reconstructed by single stitches. From January 2003 to December 2013 1500 patients underwent stapled procedure. Of these patients treated in our unit, 9 (0.6 %) were operated for chronic anal pain and 12 were referred to our center from other hospitals. RESULTS: Fifteen (71.4 %) patients resolved and do not take any drugs for pain; an overall of 85.7 % (18/21) improved their clinical status. Mean time between the beginning of symptoms and the operation was 4.27 months (range 1-18 months). We divided the patients into three groups: before 3 months, between 3 and 6 months and after 6 months from the beginning of symptoms to the operation. The best results were in the first group with 100 % pain relief and satisfactory functional results. CONCLUSIONS: The relief of PAP after stapled procedure, in which we recognize a scarred and fixed staple line, depends by the early recognition of this typical finding. The authors suggest the surgical treatment not later than 3-6 months after the onset of symptoms to achieve the best results.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results.

UNLABELLED: The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series. METHODS: Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study. RESULTS: Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %). CONCLUSIONS: The study confirms the oncological safety of laparoscopic TME in a long follow-up period.

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus.

OBJECTIVE: The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery. METHODS: All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded. RESULTS: From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred. CONCLUSIONS: The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.

Colonic electrical stimulation for the treatment of slow-transit constipation: a preliminary pilot study.

BACKGROUND: Electrical stimulation of the gastrointestinal tract is an attractive concept. In this article we report on a procedure for electrical colonic pacing due to intramuscular electrode placement for slow-transit constipation and some preliminary results. METHODS: From January 2011 to December 2012, all consecutive patients affected by constipation and evaluated in our Pelvic Floor Center were prospectively assessed. Patients who underwent colonic electrical stimulation were evaluated for the present study. RESULTS: In the study period, 256 patients were evaluated for constipation; 58% were identified as having obstructed defecation syndrome, 27.3% with irritable bowel syndrome or mixed forms, 4% with pelvic floor dyssynergia, and 10.5% (27 patients) as having slow-transit constipation. After failure of all the maximal conventional therapies, two patients, candidates for colectomy, agreed to undergo colonic electrical stimulation before a resective treatment. Both patients were females, aged 34 and 29 years, and were suffering from severe constipation since childhood. The follow-up was 19 and 6 months. The number of bowel movements per week increased from 0.3 to 3.5 in the first patient and from 0.5 to 2.5 in the second patient. Both patients no longer needed laxatives, enemas, or any other treatment. The hospital stay was 4 days, the mean operative time was 120 min, and no complications were reported. CONCLUSIONS: Colonic pacing seems to be feasible and shows positive results. Further studies are required with a larger number of patients and a longer follow-up period to confirm the role of this promising treatment for slow-transit constipation.

Correlation between outcome and instrumental findings after stapled transanal rectal resection for obstructed defecation syndrome.

OBJECTIVE: Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain symptomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders. PATIENTS AND METHODS: All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome. RESULTS: From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence. CONCLUSION: Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient's satisfaction often does not match the objective functional outcome.