New Screening Strategy Combining Anal Papanicolaou and Human Papillomavirus Tests for Human Papillomavirus-Related Anal Cancer: A Prospective, Single-Center Study.

BACKGROUND: The objective of this study was to evaluate the performance of a combined approach of liquid-based anal cytology and human papillomavirus (HPV) testing in predicting patients who should undergo high-resolution anoscopy for the early detection of anal cancer and anal intraepithelial neoplasia (AIN)-2+. METHODS: We conducted a prospective single-center quality improvement study. We consecutively enrolled men who had sex with men (MSM) attending our sexually transmitted disease clinic to undergo anal Papanicolaou (Pap) and HPV tests. All patients with an abnormal anal Pap test result and/or positive HPV test result underwent high-resolution anoscopy. RESULTS: We enrolled 217 MSM, 80 HIV-positive patients, and 137 HIV-negative patients. Cytology showed a sensitivity of 100%, a specificity of 64.1%, an accuracy of 66.7%, a positive predictive value (PPV) of 15.7%, and a negative predictive value (NPV) of 100% for the detection of AIN-2+. The high-risk (HR)-HPV test showed sensitivity, specificity, accuracy, PPV, and NPV of 100%, 36.4%, 40%, 9.4%, and 100%, respectively. The combination of abnormal cytology with identification of infection by at least 1 HR-HPV strain on the HPV test had a sensitivity of 100%, a specificity of 73%, an accuracy of 74.6%, a PPV of 19.1%, and an NPV of 100%. CONCLUSION: Anal HR-HPV testing, complementary to cytology, improves the diagnostic accuracy of screening for anal cancer.

The impact of COVID-19 pandemic on a tertiary referral proctology center: no one should be left behind.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disrupted healthcare delivery. We aimed to describe a novel strategy to mitigate the impact of COVID-19 pandemic on a tertiary referral proctology center during the first wave of infection in Italy. METHODS: All patients booked appointments at the Proctology Unit between March 9th and May 4th, 2020 were identified. Patients booked for a first visit underwent a structured remote consultation. Patients with perianal or sacrococcygeal abscesses, major anorectal bleeding, incoercible anal pain and red flags for malignancy were labelled as "non-deferrable." A flowchart was designed to comply with adequate assistance of proctologic patients. Demographics, clinical data and outcomes of in-office procedures were collected. RESULTS: On a total of 548 booked visits, 198 (36.1%) were cancelled before remote consultation. Of the remaining 350, 112 (32.0%) attended a follow-up visit. Among 238 (68.0%) patients undergoing remote consultation, 88 (25.1%) were deemed "deferrable" and 148 (42.3%) "non-deferrable." Two (0.6%) were hospitalized for COVID-19 while waiting for an outpatient visit. Twenty-five of 88 (28.4%) deferrable patients cancelled their appointment as felt no longer necessary. A total of 45 of 148 (30.4%) non deferrable patients (mean age, 46 years; 31% females) underwent in-office procedures, most often related to anal abscess and/or fistula (48.9%). Final diagnosis of malignancy occurred in four cases. A 55% increase in the number of in-office procedures was noted compared to the previous year. None of the attending patients nor staff members resulted COVID-19 positive during the study period. CONCLUSIONS: Despite the uncertainties accompanying the use of remote consultations in proctology, the results of this study may inform the development of strategies for restructuring activities in response to future emergencies of this magnitude.

Deadlock of proctologic practice in Italy during COVID-19 pandemic: a national report from ProctoLock2020.

Proctology is one of the surgical specialties that suffered the most during COVID-19 pandemic. Using data from a cross-sectional worldwide web survey, we aimed to snapshot the current status of proctologic practice in Italy with differences between three macro areas (North, Centre, South). Specialists affiliated to renowned scientific societies with an interest in coloproctology were invited to join a 27-item survey. Predictive power of respondents' and hospitals' demographics on the change of status of surgical activities was calculated. The study was registered at ClinicalTrials.gov (NCT04392245). Of 299 respondents from Italy, 94 (40%) practiced in the North, 60 (25%) in the Centrer and 82 (35%) in the South and Islands. The majority were men (79%), at consultant level (70%), with a mean age of 46.5 years, practicing in academic hospitals (39%), where a dedicated proctologist was readily available (68%). Southern respondents were more at risk of infection compared to those from the Center (OR, 3.30; 95%CI 1.46; 7.47, P = 0.004), as were males (OR, 2.64; 95%CI 1.09; 6.37, P = 0.031) and those who routinely tested patients prior to surgery (OR, 3.02; 95%CI 1.39; 6.53, P = 0.005). The likelihood of ongoing surgical practice was higher in the South (OR 1.36, 95%CI 0.75; 2.46, P = 0.304) and in centers that were not fully dedicated to COVID-19 care (OR 4.00, 95%CI 1.88; 8.50, P < 0.001). The results of this survey highlight important factors contributing to the deadlock of proctologic practice in Italy and may inform the development of future management strategies.

Symptomatic pile tailored procedure. A new perspective for hemorrhoidal disease treatment.

AIM: Aim of the present paper was to evaluate the role of tailored different single pile treatment in the clinical outcome of hemorrhoids. MATERIAL OF STUDY: The surgical strategy considered to treat only pathological piles with different procedure according to each pathological Goligher's degree, presence of fibrous, inelastic redundant internal pile(F) and presence of external pathological pile (external pile congestion or subversion of dental line (E) and skin tag not tolerated from the patient (S)). We treated with Hemorrhoidopexy second and third degree pile without F or ES; with Hemorrhoidopexy and excision of external component every second and third degree pile with E or S and with complete semi-closed pile excision all third degree with F and IV degree piles. The number of post operative days of self administered analgesics was the primary end point and short/long term post operative complications, hospital stay, re-admission and recurrence were secondary end points. RESULTS: 157 patients were treated. No differences were noted in term of time of discharge between hemorrhoidopexy and complete or external excision. The painkiller assumption increases with the number of treated pile (r= 0.227, p=0.006). We observed 10.2% early complications (48h) all secondary to urinary retention and 7% late complications (2-15days) within only one reoperation for bleeding. After mean follow up of 16 months no patients required further treatments for hemorrhoids. DISCUSSIONS: A tailored approach showed to be effective in terms of short and long term complications and moreover to relapse. CONCLUSIONS: Single pile tailored treatment showed good results. KEY WORDS: Excision, Hemorrhoids, Hemorrhoidectomy, Hemorrhoidopexy, Pain, Tailored.

Preoperative radiochemotherapy in t3 operable low rectal cancers: a gold standard?

BACKGROUND: Preoperative chemoradiation followed by total mesorectal excision (TME) has become a standard treatment of preoperatively staged T3 low rectal cancers in many institutions; however, a direct comparison of generalized preoperative versus selective adjuvant chemoradiation has never been assessed in a clinical practice setting. PATIENTS: Over a 4-year period, 80 patients with T3 primary low adenocarcinoma of the rectum, judged operable at preoperative staging, were offered preoperative chemoradiation. Forty-seven patients (Group I) accepted the neoadjuvant treatment and 33 (Group II) preferred immediate surgery and postoperative chemoradiation if indicated. RESULTS: Major postoperative complications occurred in 21% of Group I versus in 11% of Group II (p = 0.3) patients. After a mean follow-up of 92 months, the local recurrence rate was 4 and 9% (p = 0.4), metastasis rate was 30 and 24% (p = 0.5), 5-year survival probability was 0.79 (95% CI = 0.49-0.92) and 0.82 (95% CI = 0.70-1.00) (log-rank test, p = 0.6) for Group I and Group II, respectively. CONCLUSIONS: In T3 operable low rectal cancers, selective postoperative radiochemotherapy yielded similar long-term results regarding recurrence rate and survival as extended preoperative chemoradiation.

Excision of the levator muscles with external sphincter preservation in the treatment of selected low T4 rectal cancers.

PURPOSE: The existence of an anatomic and functional separation between the puborectalis muscle and external anal sphincter permits the performance of an abdominoendoanal excision, instead of an abdominoperineal excision, of the rectum and levator muscles, with preservation of a functioning external sphincter, in selected patients with very low rectal cancer and limited infiltration of the levator muscles. METHODS: Seven patients (4 females; age, 48-69; mean, 60.7 +/- 7.8 years) with low posterior or posterolateral localized rectal cancers with infiltration of the puborectalis muscle (T4) were submitted to preoperative chemoradiation and excision of the rectum with the levator muscles, while the external sphincter and its innervation were preserved. A coloanal anastomosis was performed at the dentate line. RESULTS: At a median follow-up of 58 (range, 42-102) months, 6 patients (86 percent) were alive and disease free. No local recurrence was observed. Anorectal function, at three years from surgery was no worse than that of six patients of the same age and gender who had undergone more conventional coloanal anastomoses with preservation of the levator muscles. CONCLUSION: Selected patients with very low rectal cancers infiltrating the levator muscles (T4) and responding to preoperative chemoradiation therapy can still be treated with an advanced sphincter-sparing procedure, instead of an abdominoperineal excision. Oncologic and functional results seem to be satisfactory.