Use of telemedicine in the postoperative assessment of proctological patients: a case-control study.

BACKGROUND: Telemedicine is emerging as an easy way to communicate between patients and surgeons. Use of telemedicine increased during the coronavirus disease 2019 (COVID-19) pandemic. WhatsApp is one of the most common smartphone applications for user-friendly telemedicine. The aim of this study was to evaluate patient perception of health quality and positive outcomes using a diary sent by the patient to the surgeon via WhatsApp during the first post-discharge week after proctologic surgery. METHODS: Ninety-eight patients discharged after proctologic surgery at the Israelite Hospital of Rome and the AOU Policlinico Umberto I of Rome in 1 January-31 December 2019 were divided into two groups: the WhatsApp group (group A), (n = 36) and the no WhatsApp group (group B) (n = 62). Group A patients received a protocol to follow for the day-by-day diary during the first post-discharge week and sending it by WhatsApp to the surgeon. Group B patients only received recommendations at discharge. The tool's usefulness was assessed by a questionnaire one month after the intervention. RESULTS: The two groups were homogeneous for age, sex, schooling, employment, and proctologic pathology. Group A patients had less difficulty keeping a diary (p < 0.0001). Group A patients had the perception of better follow-up post-discharge (p = 0.002). The use of the diary sent by WhatsApp significantly improved the perception of positive post-intervention outcomes (p = 0.007). WhatsApp was the only independent predictor of perception of post-surgical positive outcomes (odds ratio = 4.06; 95% CI 1.35-12.24; p = 0.01). CONCLUSIONS: The use of WhatsApp in the post-discharge period improves the lifestyle quality of the patients and their perception of the safety and quality of care received.

Posterior pelvic tilt is a risk factor for rectal prolapse: a propensity score matching analysis.

BACKGROUND: There is little evidence about possible effects of pelvic anatomical characteristics on proctological complications. The aim of our study was to investigate the potential correlation between sagittal pelvic position and rectal prolapse. METHODS: A study was conducted on a proctology patients and patients without any specific history of proctological disorders who were divided into two groups according to the presence or the absence of rectal prolapse. In all cases, the pelvic angle was measured with a pelvic goniometer and categorized as posterior (< 10°), neutral (10°-15°), and anterior (> 15°). To minimize effects of potential confounders in the analysis, 3:1 nearest neighbor propensity score matching (PSM) method was implemented using age, sex, and diagnose of rectal disorders as confounding variables. RESULTS: Among the 143 screened patients, posterior tilt was more frequent in the 19 patients with rectal prolapse than in those without prolapse (42 vs. 18%; p = 0.027). This result was also confirmed in the post-PSM analysis (42 vs. 14%; p = 0.036) using 35 propensity score (PS)-matched controls compared with the rectal prolapse group. Posterior tilt was associated with an increased risk of prolapse in both the unmatched population (odds ratio = 3.37; p = 0.020) and PS-matched subset (odds ratio = 4.36; p = 0.028). CONCLUSIONS: A posterior pelvic angle was more frequently associated with the diagnosis of rectal prolapse. In both the entire population and in the PS-matched subset, posterior tilt was a significant risk factor for rectal prolapse. The easy-to-do investigation of the pelvic angle can provide several benefits in terms of rectal prolapse prevention and more precise management of post-surgical prolapse recurrence.

Hemoperitoneum: a rare complication of hemorrhoid treatment.

Pile suturing has always been used by surgeons to treat hemorrhoidal disease. We report a case of hemoperitoneum complicating a pile suture. Ultrasonography and computed tomography scan indicated the need for an emergency laparoscopic procedure and conservative management. As other authors have pointed out, we do not know how to prevent this type of complication. This case suggests the possibility of life-threatening complications following treatment procedures for hemorrhoids and underlines the importance of conservative treatment when this is possible.

Relief of hemorrhoid symptoms: pilot study of a new topical ally.

AIM: The pathogenesis of hemorrhoids involves vascular congestion, fragmentation of supporting tissues and, in many cases, increased resting anal pressure. A new ointment (Hemolen®) has been devised to control hemorrhoids symptoms acting on all the pathophysiologic mechanisms involved. METHODS: Pilot study on patients with grade I-III hemorrhoids. The ointment was applied twice daily for 30 days and follow-up visits were scheduled 7 days (T1), 14 days (T2) and 30 days (T3) after recruitment (T0). Signs and symptoms (bleeding, discomfort, itching, edema, thrombosis, congestion, inflammation, pain) were evaluated at each visit using dedicated scores and VAS scale. Resting anal pressure was measured at time T0, 1 hour after the first application and at T1. Use of painkiller was recorded. RESULTS: 48 patients (25 females; mean age 47±15.8 years) were enrolled; 52.1% of them had II degree hemorrhoids and 27.1% had III degree hemorrhoids. The severity scores significantly dropped from T0 to each scheduled visit and a significant reduction of resting anal pressure was observed from T0 to 1 hour after application (z=13.5; p<0.001) and from T0 to T1 (z=6; p<0.001). The comparison of the resting pressure among whole time series showed a significant reduction (Fr=124.4; p=<0.001). Use of pain-killers decreased significantly from T0 to T1 (p<0.001) and from T1 to T2 (p=0.001). CONCLUSION: The new ointment tested in the present study is safe and effective for the management of hemorrhoid symptoms in the early stages hemorrhoids, during the acute phases and in patients with more severe hemorrhoids awaiting surgery. Prospective, randomized controlled trials are needed to confirm these encouraging results.

Evolution of the transfixed stitches technique hemorrhoidectomy.

AIM: To date, the types of surgical hemorrhoidal treatments available for a surgeon are manifold. The authors, beginning from an original interpretation of the indications for a surgical treatment of hemorrhoids, based on the new disease classification defined PATE 2006, hereby present the results related to the evolution in performing hemorrhoidectomy with the transfixed stitches technique (TPT). METHODS: A total of 50 patients, 30 males and 20 females, with diagnosis of hemorrhoids of grade III-IV underwent hemorrhoidectomy with the TPT, which consisted in using two suture threads (Monofil) for each nodule. Patients' follow-up was prolonged for six months after the surgical intervention. RESULTS: The mean score, according to the PATE 2006 classification, after the intervention was significantly lower in all patients in comparison to the initial mean score (23.7 versus 7.2, P<0.01). The mean score value of the early stage complications was 4.8 while that of the late stage complications was 2.2. We found a reduction in the score related to the recorded pain after 24 and 96 hours from the intervention (3 versus 1.4, P=0.05). Only 26% of the patients who underwent hemorrhoidectomy with the new TPT were administered non-steroidal anti-inflammatory drugs. The relapse rate was only of 2%. CONCLUSIONS: The TPT, performed with the new technique, allows to reach best results in comparison to the previous surgical options, by reducing the incidence of disease relapse and the infectious events during the postoperative period, thus reducing the needed time for return to working activity.

[Overnight surgery in proctology and anesthesia type: our experience on 320 patients]. / Overnight surgery in proctologia e tipo di anestesia: nostra esperienza su 320 pazienti.

BACKGROUND: Several evidences demonstrated that general anaesthetics associated with local anaesthesia show more advantages in comparison to spinal anaesthesia in proctological surgery. Aim of this study was to verify the efficacy of deep general anaesthesia associated with a loco-regional anesthesiological technique, in a grade population of 320 patients affected by haemorrhoidal disease and anal fissure. PATIENTS AND METHODS: Patients with III-IV grade haemorrhoids and chronic posterior anal fissures has been eligible for this study while were excluded patients with history of allergic reaction or pharmacological hypersensibility to naropine, propofol o similar drugs. All patients (group A) were submitted to general anaesthesia associated with loco-regional anaesthesia, Control patients (group B) underwent spinal anaesthesia. At the end of all surgery procedure, it has been evaluated the presence of early and late complications according to our classification recently proposed. RESULTS: A total of 320 patients were included, 240 submitted to haemorrhoidectomy for prolapse and 80 surgically treated for anal fissures. Anesthesia obtained has been satisfactory in the all treated patients and has not been observed permanent side-effects. Among the early post-operative complications it has been observed urinary retention in 9% of patients and pain in 30%. Among late post-operative complications it has been observed pain in 8% and urinary retention in 1% of patients. In two patients has been observed the development of abscess in correspondence of anaesthetic infiltration area. The local anaesthetical effect was present for a mean period of 4-8 hours. CONCLUSIONS: Loco-regional anesthesiological technique with posterior block, associated to general anaesthesia, has been demonstrated efficacious for the treatment of the most frequent proctological pathologies. This method allowed a low incidence of early and late complications and a more fast resolution of clinical sequelae of the surgery.

The evolution of transfixed sequential suturing technique (TSST) in the treatment of rectocele: advantages and efficacy in 10 cases.

AIM: Rectocele, or posterior vaginal prolapse, is considered a herniation of the anterior rectal and posterior vaginal wall into the lumen of the vagina, which arises from either a tear or an attenuation of the rectovaginal (Denonvilliers') fascia. To date, all the surgical techniques proposed both through the anus and through the vagina have not demonstrated a real clinical efficacy in terms of a complete solution of this anatomic disorder. The authors of the present study have improved the surgical treatment outcome of rectocele introducing a new technique called transfix sequential suturing technique (TSST). Hereby its evolution is described, using a new suture called Monofil (Assut Europe s.p.a., Magliano dei Marsi, L'Aquila, Italy) and a new single-use operating kit. METHODS: Ten consecutive female outpatients were treated surgically, after diagnosis of rectocele has been made both clinically and by imaging. Seven patients were found at stage 2 and three at stage 3 rectocele. The surgical technique performed was the same in all patients, and consisted in fixing sutures sequentially into the rectum until a complete closure of the rectocele pouch was obtained. All patients underwent a gloved finger examination of the rectum, anoscopy with the sphere-test, a defecagram and a total colonoscopy. Each patient was asked to fill a Quality of Life questionnaire (Agachan-Wexner Score) before surgery, and after three and six months of follow-up. RESULTS: In our series, no serious postoperative complication was registered. The Quality of Life average score before treatment was 25, after three months of follow-up it decreased to 14, and to 12 after six months. The difference was found statistically significant (P<0.05). CONCLUSIONS: The introduction of Monofil and that of a single-use operating kit demonstrated to be more efficacious in treating rectocele compared to TSST performed with an interrupted running suture and compared to other surgical techniques. Patients' quality of life improved significantly and a lower incidence of postoperative discomfort was found.

The Effect of a Physical Training with the Use of an Exoskeleton on Depression Levels in Institutionalized Elderly Patients: A Pilot Study.

CONTEXT: The Human Body Posturizer (HBP) is an exoskeleton used in the neurorehabilitation. The HBP may improve motor control by stimulating the pre-frontal cortex, a brain region involved also in the inhibitory modulation of the amygdala whose hyperactivity is involved in the mechanisms of depression. OBJECTIVE: The aim of the study was to investigate in institutionalized elderly patients the effects on depression of a physical training with the use of the HBP compared to a traditional training. DESIGN: Randomized controlled trial. PARTICIPANTS: 20 institutionalized patients (mean age = 88, ds = ± 5, 3 males) with moderate depression levels. INTERVENTION: The participants were randomly assigned to: a) HBP Group, which carried out physical training using the HBP; b) Excercise Group, which carried out a training without the use of the orthosis. The training was conducted for 6 months (3 sessions each week), with the same kind of exercises with or without the HBP according to the assignment group. MEASUREMENTS: Participants were evaluated at baseline using the Tinetti balance and Gait scale, the Mini Mental State Examination and the Geriatric Handicap Scale. The Geriatric Depression Scale was administered to the participants before and after the period of training. RESULTS: The two groups were homogeneous for age, baseline motor ability (risk falls), handicap score, cognitive functioning and depression levels. After 6 months of exercise training a significant reduction in depression levels was reported only in the HBP Group (p <.01). CONCLUSIONS: A positive effect of the HBP in the modulation of mood in institutionalized elderly subjects was found. It is possible to hypothesis that a traditional training without the HBP may require more time to achieve significant results. Clinical implications will be discussed.

[Haemorrhoid disease during pregnancy: focus on delivery unit]. / La malattia emorroidaria durante la gestazione: focus sulle sale parto.

OBJECTIVE: Hemorrhoidal disease (HD) is most frequent during and after the pregnancy, always resulting disabling and not without the occurrence of complications that make necessary a surgical therapy. In these cases the HD could be underestimated by obstetricians, precluding the patient's access to possible medical and surgical or rehabilitative treatments to correct eventual dysfunction related to the delivery. MATERIALS AND METHODS: For this purpose the Authors have administered a questionnaire at 165 obstetricians regarding the occurrence of HD symptoms according to our experience, the prevalence and the modalities of treatment of HD and the knowledge of specialists and methods to cure HD. RESULTS: The interviewed obstetricians in a proportion of 95% referred the presence of HD symptoms during pregnancy in particular in three-fourths of patients who have a natural (57%) or a vaginal operative delivery (41%). It was resulted that only the 42% of obstetricians refer to the specialist for HD and approximatively the half of them not known the role of perineologist or the pelvic rehabilitative methods. CONCLUSIONS: Our study seems to confirm that the management of HD during pregnancy is inadequate due to the lack of collaboration between obstetrician, gynaecologist and the specialist of anal and pelvic pathologies.

iProcto: new digital technology in Proctology. A randomized study.

BACKGROUND AND AIM: Advancements in technology have proved useful for many businesses including medical practices. Consequently, these improvements have increased the need to develop new applications for mobile devices. Our group conceived and developed an application for tablets, PCs, and smartphones with the aim to assist the physician in the management of the pelvic floor diseases: iProcto. The aim of this study was to evaluate the receptivity of patients resulting from using the said pelvic floor application (iProcto) during a colon-proctologic visit; and to establish whether it can be more efficient in helping with diagnosis compared to a traditional visit. METHODS: We enrolled 126 patients with pelvic floor disorders during the period of 2013 and 2014. The average age of the patients ranging from 16 - 43 years of age, 80 of those, being women. Sixty-three patients were randomly assigned to iProcto consultation (group A), the remaining 63 patients to attended a regular consultation that did not include iProcto (group B). Post consultation, all patients were asked to answer a questionnaire anonymously where they were asked questions about their level of satisfaction, and clarity of the doctor's explanation, on a scale from 1 (dissatisfied) to 5 (completely satisfied). RESULTS: Patients in group A have a score average relative to the degree of satisfaction of 4.2 ± 0.7 vs 3.5 ± 0.7 in the group B (m ± sd; p 0.001). Only 3 patients in group A and 15 in group B did not consider the visit satisfactory (score ≤2). With regard to the clarity of the physician the group A patients presented a means score of 4.4 ± 0.8 vs 3.5 ± 0.4 in the group B (m ± ds; p 0.001). Data shows that 95% showed a gain in satisfaction during the iProcto visit as compared to 78% without iProcto. CONCLUSIONS: In conclusion the use of iProcto for the pelvic floor diseases can improve the understanding of the disease and increase the degree of patient satisfaction.

[Scientific background and clinical implementation: three new proposals in coloproctology]. / Ideazione scientifica e sperimentazione clinica: tre moderne proposte in colonproctologia.

OBJECTIVE: The Authors underline three clinical problems in coloproctology: the surgical access to the anal canal, the lacking aspects of the actual classification of hemorrhoids, the difficult choice of the surgical treatment in case of coexisting III degrees and IV degrees degree of hemorrhoids. They propose a new anal retractor which enables the surgeon to better calibrate all the surgical procedures inside the anal canal and to operate alone without the help of another operator. A new computerized software is able to rapidly guarantee a numeric score for hemorrhoids which is repetable before and after treatment of the disease. The Authors present a new surgical technique defined of transfixed stichtes for the resolution of the most advanced stage of hemorrhoids. PATIENTS AND METHODS: The new anal retractor was used in fifthy consecutive patients operated on for proctological problems. A quickly computerized score coming from the new classification PATE 2000 Sorrento was evaluated in one hundred patients, while the surgical technique of transfixed stichtes was utilized in fifthy. RESULTS: All the surgical procedures performed with the new device were concluded without complications. The highest values of the score from PATE 2000 Sorrento always fit with the surgical treatment of the disease, while transfixed stitches gave dysuria in five patients, but a better quality of life was referred by 38 over 50 patients treated. CONCLUSIONS: The Authors underline in this paper the results of the clinical implementation of these three new solutions in colon-proctology.

[Nerve sparing total mesorectal excision for rectal cancer. Technical notes and results]. / Nerve sparing total mesorectal excision per neoplasia del ret- to. Note di tecnica e risultati.

OBJECTIVE: To evaluate the quality of life after nerve sparing total mesorectal excision for rectal cancer. PATIENTS AND METHODS: Crucial technical aspects of the procedure such as the preservation of genitourinary innervation and the achievement of optimal local control of the disease have been emphasized. It is known that local recurrences, sexual and urinary dysfunctions may have a significant impact on postoperative quality of life of the patients. Postoperative evaluation of functional outcomes of nerve sparing total mesorectal excision has been carried out utilizing the QLQ C30 (version 3) (All CR38). RESULTS: At one year follow-up 27.2% of the patients presented sexual activity related dysfunctions, 6.1% complained of urinary dysfunction and 21% of the patients complained of some significant psychologic disturbances. CONCLUSIONS: A correct surgical dissection with preservation of inferior hypogastric plexus and all genitourinary nerve supply yield the best results either in terms of quality of life and of oncologic control of the disease.

Manual reduction in acute haemorrhoids.

AIM: In prolapsed internal hemorrhoids exposed outside the anus, manually reducing the prolapse with 48 hours of commencement of anal pain, decreased the progression of thrombosis. The aim of our study was to evaluate the effects of manual reduction of the inflamed piles hemorrhoids. MATERIALS OF STUDY: Eleven patients, 7 males and 4 pregnant females (in early post partum) with an average age of 34 years ± 8 (range 23- 52) were enrolled with anal pain cause by haemorrhoidal congestion, but prior to full blown thrombosis. Patients underwent a manual reduction of the external prolapsed haemorrhoidal plexus. In the 48 hours following the procedure, patients were instructed on how to insert any prolapsed hemorrhoid (piles) themselves. Pain intensity was measured using the visual analog scale (VAS) at time of consultation and then 10 days after the reduction. RESULTS: At day 10 following treatment we observed a statistically significant reduction in anal swelling (11 vs 1, n° pzt; p = 0.001), anal pain (11 vs 2, n° pzt; p = 0.001) and VAS score (8.6 ± 0.7 vs 0.4 ± 1.2; p = 0.001). Two patients (18%) underwent surgical haemorrhoidectomy sec. Milligan Morgan and 1 patient (9%) underwent excision of thrombosed external hemorrhoids. 73% of patients did not require surgery. CONCLUSIONS: Manual reduction of the prolapsed piles outside the anus decreased pain immediately and it also allows postponement of surgery or any other treatment.

Surgical management of substernal goitres. When is sternotomy inevitable?

PURPOSE: Aim of this retrospective study is to report personal experience in the surgical management of substernal goitres emphasizing the guidelines for preoperative planning of sternotomy in selected cases. PATIENTS AND METHODS: Medical records of all patients (n=355) submitted to thyroidectomy for struma in our Operative Unit, between 1993-2003, were analysed. A substernal goitre was defined as a goitre having a significant retrosternal extension (>50%) requiring mediastinal dissection. RESULTS: A total of 18 out of 355 patients undergoing thyroidectomy for struma in our Operative Unit had substernal goitres. The most common symptoms, at presentation, were the presence of neck mass and respiratory disorders. Standard cervical incision was adequate to achieve total thyroidectomy in 17 cases while, in one patient with computed tomography images showing the presence of a huge goitre extending below the aortic arch, a sternotomic approach was inevitable to ensure safe removal. No major morbidity or perioperative deaths occurred. One patient with scleroderma experienced bilateral paralysis of laryngeal nerves for two months, with full recovery thereafter. CONCLUSIONS: While removal of the majority of substernal goitres can be achieved by means of cervical incision, this approach is not always safe. In a selected number of cases with an iceberg shaped substernal goiter and with >70% of the volume lying below the thoracic outlet, a sternotomic approach is inevitable. Preoperative diagnostic work-up should, thus, include chest X-ray and computed tomography. Overall results in the present patient population, have been excellent since morbidity has been minimal and mortality absent, and all patients are symptom free.

[Local and late complications in anorectal surgery]. / Complicanze locali tardive nella chirurgia anorettale.

BACKGROUND AND AIMS: Our experience in colon-proctology showed the need to update the post-surgical complications score we published (1), adding others that may have an impact on outcome of treatment. The aim of this study was to assess the efficacy of a score obtained from the analysis of the quality of life and severity of complications after proctologic surgery. MATERIALS AND METHODS: Between January and December 2013, we studied 150 patients undergoing several ano-rectal surgeries for the presence of hemorrhoids of grade III and IV (63 patients), anal fissures (42 patients), anal fistulas (19 patients), rectocele (15 patients) and mucosal prolapse of the rectum (11 patients). After surgery, patients were evaluated through outpatient visits at 3, 6 and 12 months, by a questionnaire concerning the surgery complications and quality of life, the latter expressed with a score from 0 (poor) to 10 (excellent). RESULTS: Only 134 patients [mean age: 49 years (range 35-61 years), 62 M] completed the entire follow-up. The score of complications has been gradually decreasing from 11.3 (baseline) to 9.6 to 3 months, 3.6 to 6 months and 2.3 at 12 months, while the score of the quality of life progressively increased from 4.5 to 6, 8 and 8.5 respectively (p<0.05), with a correlation between the two score (r=-0.6, p= 0.03). CONCLUSIONS: The quantification by scores of quality of life and postoperative complications in colon-proctology is an important prognostic predictor.

[Rubber band ligation in treatment of hemorrhoids: our experience]. / Legatura elastica delle emorroidi: nostra esperienza.

OBJECTIVES: Hemorrhoids are a very common condition. The treatment depends upon persistence and severity of symptoms. For hemorrhoids of II and III grade the rubber band ligation may be therapeutic. Our aim is to report the outcomes of rubber band ligation of hemorrhoids, with a follow up of 6 months. MATERIALS AND METHODS: A total of 50 patients underwent rubber band ligation for symptomatic hemorrhoids (grade II and III) without prolapse, between June 2012 and June 2014. All patients underwent plug test to rule out presence of rectal mucosal prolapse and were classified according to PATE classification (1). Each hemorrhoid was ligated with one rubber band through a ligator. All patients were evaluated immediately at the end of the procedure, after ten days and six months after the treatment. Patient's demographic and operative data were collected and analyzed. RESULTS: The mean patients age was 47.6±12.3 years (range 24-72). All procedures were performed without complications. Before rubber band ligation, 42 patients had rectal bleeding, 38 had perineal discomfort and 27 had itching. Ten days after the treatment, 12 patients presented self-limited rectal bleeding, but 10 of these had more hemorrhoids and underwent a second rubber band ligation. No patients complained perineal discomfort, and 8 patients had itching; 78% and 16% of patients respectively, experienced feeling of a foreign body inside the canal anal and anal pain. After 6 months, only 13 patients were occasionally symptomatic: 4 patients had rectal bleeding, 2 had perineal discomfort and 4 had itching. Three more patients presented both perineal discomfort and hitching. None had the feeling of a foreign body in anal canal or anal pain. CONCLUSIONS: Rubber band ligation is an efficacious, cost-effective and simple treatment for the second and third degree hemorrhoids without rectal mucosal prolapsed. In our hands, no severe complications developed and minor complications could be handled with ease.

[Constipation following hysterectomy. Retrospective study based on 105 cases]. / Stipsi post isterectomia. Studio retrospettivo su 105 casi.

Constipation after surgery is considered as a subgroup of patients in whom the disorder begins after pelvic surgery. A group of patients (median age 52 years with a range of 34-65 years) who had a hysterectomy underwent a retrospective study with the aid of a questionnaire and clinical records, to evaluate the incidence of constipation before and after the operation. Forty patients were operated on for benign pathology and 65 for malignant pathology. Forty-two patients underwent a Wertheim-Meigs, 39 had laparohysterectomy, 20 had a colpohysterectomy and 4 had a Schauta. The incidence of constipation increased from 25% preoperatively to 38% postoperatively (p < 0.05). There is no difference in the incidence of postoperative constipation among the various operations. Constipation after hysterectomy is associated with urinary disorders. These data confirm previous studies on the effect of hysterectomy on urinary and defaecatory functions and they show how a simple colpohisterectomy can cause constipation.