Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Correction to: Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication. The complete correct affiliation should read as follows.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Outcome and prognostic factors of local recurrent rectal cancer: a pooled analysis of 150 patients.

BACKGROUND: Surgery is the only curative treatment in patients with locally recurrent rectal cancer (LRRC). The aim of this study was to evaluate the outcome and the prognostic factors of tumour-free resection margin (R0) and overall survival (OS) in LRRC. METHODS: Consecutive LRRC patients observed between 1987 and 2005 in three Italian university hospitals were evaluated. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. In order to identify factors associated with both R0 resection and OS, a logistic regression analysis was performed in patients who underwent surgery with curative intent. RESULTS: Out of 150 patients with LRRC, 107 underwent surgery, but since 7 were found to have unresectable disease only 100 underwent surgical resection. Of them, 51 underwent radical and 49 extended resection. Sixty of the 107 patients underwent multimodality treatment. In 61 patients, R0 resection was achieved. Median OS after surgery was 43.4 months. In patients, who had surgery with curative intent, independent variables associated with R0 resection were: surgery for the primary tumour performed in other hospitals (p = 0.042) extended resection (p = 0.025) and use of positron emission tomography (PET) as a staging modality (p = 0.03). Independent variables associated with OS were: post-operative radiotherapy (p = 0.004), stage of the primary tumour (p = 0.004), R0 resection (p = 0.00001), and use of PET (0.02). CONCLUSIONS: Resection for LRRC results in improved survival. Other than the well-known prognostic factors R0 resection and OS, PET scan has an independent impact both on OS and R0 resection. It should therefore be included in routine clinical practice when staging LRRC.

Predictors of Venous Thromboembolism after Colorectal Surgery in a Single Unit.

BACKGROUND: Patients undergoing colorectal surgery are at risk of developing venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). Knowing predictors of VTE could help preventing this life-threatening complication. METHODS: We collected data of patients undergoing colorectal surgery at our Unit between 2009 and 2014. Baseline characteristics, type of surgery, and postoperative complications were gathered. A univariate regression analysis was performed with symptomatic VTE as outcome. Pre-, intra- and postoperative clinical factors were separately tested. All variables significantly associated with VTE occurring within three months from the discharge were entered in the final multivariate regression model. RESULTS: A total of 476 patients were included. Symptomatic VTE occurred in 13 patients (2.7%). Six (46.1%) occurred after hospital discharge. Preoperative variables associated with VTE were: advanced age at surgery (OR 2.3, 95%CI 1.8-5.6), smoking (OR 1.7, 95%CI 1.2-2.5), inflammatory bowel diseases (OR 2.1, 95%CI 1.5-4.3), advanced pelvic malignancies (OR 2.4, 95%CI 2.0-4.2), and obesity (OR 1.5, 95%CI 1.1-2.1). Prolonged pelvic manipulation (OR 1.8, 95%CI 1.1-4.3) and steep Trendelenburg position (OR 2.4, 95%CI 1.9-5.0) were intraoperative predictors of VTE, while stockings significantly reduced the risk (OR 0.8, 95%CI 0.4-0.9). Late mobilization (OR 2.5, 95%CI 2.0-4.6) and septic complications (OR 1.4, 95%CI 1.2-3.7) were postoperative predictors of VTE, whereas anticoagulants administered for at least 3 weeks after discharge were associated with lower VTE risk (OR 0.5, 95%CI 0.2-0.8). CONCLUSIONS: We observed several modifiable predictors of VTE. Patients with ≥2 risk factors undergoing colorectal surgery could benefit from a more intensive VTE preventive pathway.

Surgical treatment of recurrent prolapse after stapled haemorrhoidopexy.

BACKGROUND: Recurrent prolapse after stapled haemorrhoidopexy is a late complication of the procedure which can present with accompanying symptoms and may require surgery. We describe a technique for treating symptomatic patients, aimed at obtaining remission of symptoms and avoiding recurrences. METHODS: After excisional haemorrhoidectomy, a transverse incision is performed on the proximal part of the mucocutaneous bridge, above the plane of the internal sphincter. A flap of anal mucosa is gently raised. Haemorrhoidal tissue is not removed. LigaSure™ may be useful in focussing coagulation and reducing heat diffusion. Denudation of the internal sphincter allows the removal of potential retained staples. Then, stitches are placed between the proximal part of the flap and the proximal divided edge of the rectal mucosa. Excessive devascularisation of the flap must be avoided. RESULTS: From January 2007 to January 2011, we treated 11 patients. The procedures lasted a mean of 38.2 ± 11.1 min. One patient (9 %) suffered from bleeding during the night before being discharged, but this did not require surgery, and another (9 %) had urinary retention. No other perioperative complications were observed. The mean visual analogue scale score 1 day and 1 week after surgery was 4.7 ± 1.3 and 2.3 ± 0.5, respectively. At mean follow-up of 4 ± 1.8 years, neither symptomatic nor asymptomatic recurrences have been observed. Two out of three patients presenting with urgency reported regression of symptoms (66.7 %). In all patients suffering from pain after stapled haemorrhoidopexy, the procedure achieved pain relief (2/2, 100 %). No stenoses occurred. CONCLUSIONS: This technique is a promising alternative after failed stapled haemorrhoidopexy. Morbidity is low. The procedure may effectively treat associated symptoms.

Is omitting pouchography before ileostomy takedown safe after negative clinical examination in asymptomatic patients with pelvic ileal pouch? An observational study.

BACKGROUND: When restorative proctocolectomy (RPC) is performed, a temporary diverting loop ileostomy is often fashioned and usually closed 2-3 months later. Pouchography is used to assess pouch integrity, although its benefits have been questioned and no definitive data support its routine use. Our aim was to assess the utility of pouchography before ileostomy closure in patients with a negative clinical examination. METHODS: We retrospectively reviewed our database of patients who underwent ileostomy takedown between 1987 and 2010. Two hundred and thirty-two patients were identified who underwent RPC with a W- or J-pouch for ulcerative colitis or familial adenomatous polyposis. Twenty-one patients underwent RPC without diversion. Twenty-four symptomatic patients were excluded from the study. Only asymptomatic patients with a normal clinical examination were enrolled. One patient was lost at follow-up. Hence, 186 patients were considered suitable for evaluation. Patients undergoing ileostomy closure without any radiological examination were assigned to Group A (n = 132); those operated on after a preoperative pouchography to Group B (n = 54). RESULTS: Pouchography was normal in 49 (90.7%) Group B patients. None of the 5 (9.3%) Group B patients with an abnormal radiographic examination experienced complications. Negative pouchography did not exclude future problems. Patients of both groups experienced similar early functional impairments. Failure occurred in 3 (2.3%) Group A patients and in 2 (3.7%) patients of the pouchography group. CONCLUSIONS: Pouchography may be safely omitted before ileostomy takedown if there is no clinical or endoscopic evidence of pelvic sepsis or ileo-anal anastomotic complications, even in very young patients, provided clinical and endoscopic follow-up is carefully performed. All anomalies detected were already suspected clinically.

Infliximab in drug-naïve patients with failed ileorectal anastomosis for Crohn's disease: a new chance for sparing the rectum?

The aim of this intervention study is to determine whether long-term infliximab therapy can decrease the proctectomy rate in patients with failed total colectomy and ileorectal anastomosis (IRA) for Crohn's disease (CD). Twelve patients (5 females) - with a median age of 36.6 years (range 18-56 years), previously treated with IRA (5 in our institution and 7 referred) for colorectal and perianal CD (median Crohn's Disease Activity Index 334.5, range 220-426), with rectal disease recurrence requiring proctectomy, no responders to conventional therapy but infliximab-naïve - were treated with infliximab infusions (Remicade™ 5 mg/kg at 0, 2, 6 weeks and then every 8 weeks) to avoid proctectomy. The main outcome measures consisted of IRA preservation and bowel function at study end. Mortality and major adverse reactions have not been observed. At the time of the median follow-up (57.4 months, range 36-92), the rectum was preserved in 10 patients (83.3%). One patient underwent proctectomy 6 weeks after the beginning of the treatment for unresponsiveness to drugs and another after 26 weeks for rectal stenosis. Anorectal function (maximum tolerated volume: 239 ± 43 vs. 294 ± 36 ml) and quality of life (Inflammatory Bowel Disease Questionnaire score 89.2 ± 20.6 vs. 173.8 ± 31.9) improved, and the Wexner Continence score (4.4 ± 2.4 vs. 1.7 ± 1.0) and daily defecations (5.2 ± 1.03 vs. 2.7 ± 1.05) decreased in 10 patients. Our results, although preliminary, are encouraging and seem to justify a less aggressive approach in patients with rectal and perianal recurrence after IRA for CD.

Wireless capsule endoscopy years after Michelassi stricturoplasty for Crohn's disease.

The use of wireless capsule endoscopy in Crohn's disease has been a matter of debate. We report the case of a 27-year-old woman operated for Crohn's disease with a Michelassi stricturoplasty presenting with anaemia. We tested the patient with a patency capsule before undertaking a wireless capsule endoscopy. Although the absorbable capsule was successfully expelled, the wireless capsule was retained next to the distal edge of the Michelassi stricturoplasty, where it revealed an otherwise undetected stenotic recurrence. We successfully treated the recurrence with a Heineke-Mikulicz stricturoplasty on the stenotic outlet of the previous Michelassi, extracting the capsule. We found our treatment effective. We believe that capsule endoscopy can be performed in patients operated on for Crohn's disease, although further studies are needed to clarify its role in patients with long-stricturoplasties and to establish which examination could be the most effective in selecting patients.

Retrorectal epidermoid cyst--a rare entity: the effectiveness of a transperineal posterior approach.

BACKGROUND: Presacral cysts are rare presacral tumours. The ideal treatment is a matter of debate. METHODS: We report the case of a 39-year-old woman referred to our institution for a presacral mass, casually diagnosed during a pelvic ultrasound examination. Ano-rectal examination and MRI revealed the presence of a mass (53 x 52 x 54 mm) in the retrorectal space, located between the right pyriform muscle and the lateral rectal wall, without signs of invasion of the surrounding structures. We performed the intervention with a transperineal approach in the jack-knife position. RESULTS: Operating time was 20 minutes. During the postoperative period no complication was observed. The patient was discharged in good general condition. No complication occurred during 48 months follow-up. CONCLUSION: We chose this approach, because, although alternative approaches are described in the literature, they are based on a small number of patients, even if showing encouraging results. We found the posterior procedure safe, feasible and effective.

Vascular anomalies of the large bowel.

Vascular anomalies of the large bowel, commonly known as vascular malformations of the colon (VMC), constitute a rare but important condition, potentially causing significant morbidity and mortality. Our aim is to provide an up-to-date, practical summary evaluating this disease entity, focussing on pathogenesis, as well as diagnostic and therapeutic modalities. We reviewed available data in the literature, and discussed it in the form of a narrative, readily applicable review. Most VMC (over 70%) are detected in the caecum and ascending colon, and affect people aged over 50 years. VMC are almost always symptomatic, presenting with lower bleeding. Endoscopy is crucial to identify and locate VMC, and to treat the lesions. In patients who fail or do not fit endoscopic treatment, aggressive approaches (interventional angiology or surgery) are mandatory. Up to 40% of patients may have relapse in the long term. VMC are rare but potentially life-threatening. Advances in endoscopic imaging and therapy have improved the results of treatment. Long-term follow-up after treatment is recommended.

Vascular anomalies of the large bowel.

INTRODUCTION: Vascular anomalies of the large bowel, commonly referred to as vascular malformations of the colon (VMC) constitute a rare but important condition, potentially causing significant morbidity and mortality. Our aim is to provide an up-to-date, practical summary evaluating this disease entity, focussing on pathogenesis, as well as diagnostic and therapeutic modalities. MATERIALS AND METHODS: We reviewed available data in the literature, and discussed it in the form of a narrative, readily applicable review. RESULTS: Most VMC (over 70%) are detected in the caecum and ascending colon, and affect people aged over 50 years. VMC are almost always symptomatic, presenting with lower bleeding. Endoscopy is crucial to identify and locate VMC, and to treat the lesions. In patients who fail or do not fit endoscopic treatment, aggressive approaches (interventional angiology or surgery) are mandatory. Up to 40% of patients may have relapse in the long term. CONCLUSIONS: VMC are rare but potentially life-threatening. Advances in endoscopic imaging and therapy have improved the results of treatment. Long-term follow-up after treatment is recommended.

Inguinal hernia repair in patients with coagulation problems: prevention of postoperative bleeding with human fibrin glue.

BACKGROUND: Our purpose was to establish the efficacy of human fibrin glue (HFG) in preventing coagulative complications after inguinal hernia repair in patients with coagulation disorders. METHODS: A randomized controlled trial of 50 patients with coagulation disorders undergoing hernia repair was performed. Patients had concurrent coagulopathies as a consequence of liver disease or long-term treatment with anticoagulants. Coagulopathies were defined according to the following criteria: prothrombin time < 10.5 seconds, activated partial thromboplastin time < 21 seconds, and fibrinogen < 230 mg/dL. Patients were randomized in a 1:1 ratio with (group A) or without (control group B) use of HFG. RESULTS: Postoperative hemorrhagic complications were significantly reduced in group A (4%) compared with group B (24%). CONCLUSION: This study shows that HFG is effective in preventing local hemorrhagic complications after herniorrhaphy in patients with concurrent coagulation disorders. This implies that the use of HFG reduces the costs of prolonged hospitalization related to such complications.

Diagnostic and surgical approaches to recurrent varicose veins of lower limbs.

A consecutive series of 82 patients (98 legs) suffering from recurrent varicose veins underwent surgical treatment. In all patients clinical and hand-held US Doppler preoperative examinations were performed, but a phlebography was necessary in 33 legs to certainly visualize the anatomy of venous system and the potential sites of recurrent deep to superficial reflux. The causes of recurrence were: incompetent saphenofemoral junction in 59 legs, saphenopopliteal reflux in 6 legs, incompetence of perforator veins in 18 legs, both insufficiencies of great saphena and perforators in 15 legs. Seventy-four legs with saphenofemoral reflux underwent groin redissections through transversal (44 legs) or vertical (30 legs) incisions; the approach to the saphenopopliteal junction was vertical in two legs and transversal in four legs; the interruption of incompetent perforator veins was performed through incisions in 29 legs and according to Linton's technique in 4 legs. Clinical and US Doppler follow-up was performed every 6 months and no recurrent reflux was demonstrated; seven patients were affected from new small varices that were treated by injection sclerotherapy. This study indicates that more than 1/3 of recurrent varices need phlebography to be clearly studied: only diagnostic accuracy may assure a correct surgical approach, but the strategy of treatment must be adapted to the single patient.