Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm.

BACKGROUND: Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach. METHODS: This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested. RESULTS: A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001). CONCLUSIONS: Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.

Technical modifications for cost optimization in robot-assisted ventral mesh rectopexy: an initial experience.

BACKGROUND: Robot-assisted ventral mesh rectopexy is considered a valid option in the treatment of rectal prolapse. However, it involves higher costs than the laparoscopic approach. The aim of this study is to determine if less expensive robotic surgery for rectal prolapse can be safely performed. METHODS: This study was conducted on consecutive patients who underwent robot-assisted ventral mesh rectopexy at Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, from 7 November 2020 to 22 November 2021. The cost of hospitalization, surgical procedure, robotic materials, and operating room resources in patients undergoing robot-assisted ventral mesh rectopexy with the da Vinci Xi Surgical Systems was analyzed before and after technical modifications, including the reduction of robotic arms and instruments, and the execution of a double minimal peritoneal incision at the pouch of Douglas and sacral promontory (instead of the traditional inverted J incision). RESULTS: Twenty-two robot-assisted ventral mesh rectopexies were performed [21 females, 95.5%, median age 62.0 (54.8-70.0) years]. After an initial experience performing traditional robot-assisted ventral mesh rectopexy in four patients, we adopted technical modifications in other cases. No major complication or conversion to open surgery occurred. In total, mean cost of hospitalization, surgical procedure, robotic materials, and operating room resources was €6995.5 ± 1058.0, €5912.7 ± 877.0, €2797.6 ± 545.6, and €2608.3 ± 351.5, respectively. Technical modifications allowed a significant reduction in the overall cost of hospitalization (€6604.5 ± 589.5 versus €8755.0 ± 906.4, p = 0.001), number of robotic instruments (3.1 ± 0.2 versus 4.0 ± 0.8 units, p = 0.026), and operating room time (201 ± 26 versus 253 ± 16 min, p = 0.003). CONCLUSIONS: Considering our preliminary results, robot-assisted ventral mesh rectopexy with appropriate technical modifications can be cost-effective and safe.

Simple fistula-in-ano: is it all simple? A systematic review.

BACKGROUND: Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques. METHODS: A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies. RESULTS: The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction. CONCLUSIONS: Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Efficacy of Sphinkeeper™ implant in treating faecal incontinence.

The primary aim of this prospective study was to assess the efficacy of Sphinkeeper™ (SK) implantation in patients with faecal incontinence. Forty-two patients with faecal incontinence (14 with sphincter defects) underwent SK implantation and were followed up for a mean(s.d.) of 15·9(8·6) months. SK implantation was a safe and effective method that improved patients' quality of life. Implants and incontinence.

Internet and social media use among patients with colorectal diseases (ISMAEL): a nationwide survey.

AIM: Social media are used daily by both healthcare workers and patients. Online platforms have the potential to provide patients with useful information, increase their engagement and potentially revolutionize the patient-physician relationship. This survey aimed to evaluate the impact of the Internet and social media (I&SM) on patients affected by colorectal and proctological diseases to define a pathway to develop an evidence-based communications strategy. METHOD: A 31-item anonymous electronic questionnaire was designed. It consisted of different sections concerning demographics and education, reason for the visit, knowledge of the diseases, frequency of I&SM use and patients' opinions about physicians' websites. RESULTS: Over a 5-month period, 37 centres and 105 surgeons took part in the survey, and a total of 5800 patients enrolled. Approximately half of them reported using the Internet daily, and 74.6% of the study population used it at least once per week. There was a correlation (P < 0.001) between those who used the Internet for work and those who had knowledge of both symptoms and the likely diagnosis before consultation. Patients who used the Internet daily were more likely to request a consultation within 6 months of symptom onset (P < 0.0001). Patients with anorectal diseases were more likely to know about their disease and symptoms before the visit (P < 0.001). CONCLUSION: Colorectal patients use I&SM to look for health-related information mainly after their medical visit. Surgeons and hospital networks should plan a tailored strategy to increase patient engagement, delivering appropriate information on social media.

Implantation of SphinKeeper(TM): a new artificial anal sphincter.

INTRODUCTION: A new artificial anal sphincter, SphinKeeper(TM), was devised with the aim to treat fecal incontinence (FI) by implanting specifically designed self-expandable prostheses into the intersphincteric space. Preliminary data concerning the procedure feasibility and prosthesis localization at 3 months are presented. METHODS: SphinKeeper(TM) prostheses in the native state are dehydrated, thin, solid cylinder (length 29 mm, diameter 3 mm), changing their state (shorter--length 23 mm, thicker--diameter 7 mm--and softer, with shape memory) within 48 h of contact with fluids. In this study, 10 prostheses were implanted in each patient with FI under local anesthesia and under endoanal ultrasound (EAUS) guidance, into the upper-middle intersphincteric space of the anal canal by a specifically designed delivery system. EAUS was used postoperatively to assess prostheses dislocation. RESULTS: Ten patients (5 females; median age 58 years, range 20-75) were enrolled and treated with SphinKeeper(TM) implantation. Median duration of procedure (performed by endoanal ultrasound guidance) was 40 min (range 30-45). Neither intraoperative nor postoperative complications were reported after a 3-month follow-up. In one patient, a partial dislocation of a single prosthesis was documented by EAUS, causing anal discomfort which resolved after 1 week. CONCLUSION: SphinKeeper(TM) can be safely implanted in patients with FI of different etiology. Implantation was well tolerated with no dislodgment of implants at 3-month follow-up.

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization.

BACKGROUND: Arterial hyperflow to haemorrhoids has been implicated as a possible pathophysiological co-factor in haemorrhoidal disease. The purpose of this study was to investigate how transanal haemorrhoidal dearterialization (THD) can influence haemodynamic parameters at the level of the haemorrhoidal piles. METHODS: Patients with grade III haemorrhoids selected for THD between July and December 2018 were evaluated using endoanal ultrasonography and colour Doppler imaging at the level of internal haemorrhoids before and 1 year after the surgical procedure. Peak systolic velocity, pulsatility index, resistivity index, acceleration time, and end-diastolic velocity were measured, and preoperative and postoperative values compared. Symptom severity was measured using a symptom-based questionnaire (score range 0-20). RESULTS: Of 21 patients treated, 17 completed the study. Compared with preoperative values, postoperative peak systolic velocity (mean(s.d.) 18.7(1.1) versus 10.3(0.4) cm/s; P < 0.05), pulsatility index (5.5(0.3) versus 2.8(0.4); P < 0.050), and resistivity index (1.0(0.2) versus 0.8(0.5); P < 0.050) decreased significantly, whereas acceleration time increased significantly (65.6(3.6) versus 83.3(4.7) cm/s2; P < 0.050); end-diastolic velocity did not change (1.9(0.2) versus 2.0(0.4); P = 0.753). Symptoms disappeared or had improved significantly in all patients by 1 year after surgery. The mean(s.d.) total symptom severity score decreased from 15.8(1.1) to 1.2(1.6) (P < 0.001). CONCLUSION: THD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation.

PURPOSE: To evaluate long-term functional outcomes of Internal Delorme's Procedure (IDP) in patients refractory to conservative treatment for Obstructed Defecation Syndrome (ODS), and to compare those who received postoperative rehabilitation with those who did not. MATERIALS AND METHODS: All patients with ODS refractory to nonoperative therapy were identified across three regional pelvic floor referral hospitals, and IDP was performed. Postoperatively selected patients received biofeedback therapy. Functional outcomes were established using the Cleveland Clinic Constipation (CCC) score and obstructed defecation score (OD score) preoperatively at 12 months and at the last available follow-up. Patient satisfaction was assessed with a visual analogue score. RESULTS: From October 2006 to September 2013, IDP was performed in 170 patients: 77 received postoperative biofeedback and 93 did not. Mean follow-up was 6.3 years (range 1-8 years). CCC and OD scores improved significantly in both groups after 12 months and at the last follow-up (p > 0.05). When comparing two groups while there was no significant difference between CCC and OD scores at 12 months, score was significantly better in the group that received rehabilitation at the last follow-up (p = 0.001). Patient satisfaction was higher in the rehabilitation group (67%) compared with those without rehabilitation (55%). Clinical recurrence was recorded in nine patients who did not have postoperative rehabilitation. CONCLUSIONS: It has been demonstrated that IDP is associated with good long-term functional outcomes. Patients receiving rehabilitation had a better long-term follow-up, a higher overall satisfaction, and lower recurrence rate when compared with the patients who did not receive postoperative rehabilitation.