The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Topical treatment of anal condylomata with Propionibacterium acnes lysate: results of a multicentric observational study.

BACKGROUND: Condylomata are a manifestation of HPV infection of the ano-genital epithelium. Recurrence is frequent after any type of treatment (from 20% up to 50%). We assessed the use of a gel containing panthenol, tocopheryl acetate and Propionibacterium extract in the treatment of anal warts. METHODS: Enrollment period was from January 15 to June 15, 2018. Main exclusion criteria were immunodepression, extensive condylomatosis and other treatments (topical/ablative) in the previous six months. RESULTS: Seventy-nine patients were included. Median age was 33 years (19-65), 72.2% were males. Median number of partners and symptoms duration were 6 (1-98) and 3 months (1-18), respectively. Almost all cases had perianal disease (97.5%), while endoanal warts were present in 51.9% of cases. After 30 days of treatment, complete regression occurred in 17 (21.5%) patients, while partial or absent response was reported in 36 (45.6%) and 26 (32.9%) cases, respectively. Forty-seven (59.5%) patients underwent a second month of topical therapy. After a 6-month follow-up, complete or partial response was reported in 53 (67.1%) patients, while in 26 (32.9%) cases the disease remained stable or even worsened. Nineteen (24.1%) patients required cryotherapy, 23 (29.1%) surgical excision, while 2 (2.5%) needed both cryotherapy and surgery. Absence of clinical response was associated with a number of partners ≥10 and symptoms duration of 6 months or shorter (P<0.001 and P=0.050). CONCLUSIONS: In our study, the gel containing P. acnes lysate was a safe topical treatment for perianal and endoanal condylomata and could help to overcome HPV infection. A high number of partners and short symptoms duration appeared to worsen the outcome.

A 10-year retrospective cohort study to assess objective and subjective outcomes of combined stapled transanal rectal resection and urogynecological surgery for pelvic floor dysfunction.

PURPOSE: To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up. METHODS: This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital. RESULTS: Fifty-three patients with a median age of 60 years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery. CONCLUSION: The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery.

Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids.

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II-III degrees hemorrhoids. Consecutive patients with II-III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.

D-shape asymmetric excision in recurrent pilonidalis disease: an analytic longitudinal long-term evaluation.

Sacrococcigeal pilonidalis disease (SPD) recurrence is a major factor influencing surgical outcomes. Several different surgical treatments have been reported, however, there is a lack of long-term data on reoperation. Aim of this study was to analyze outcomes of a single center adopting a standardized off-midline asymmetric procedure (D-shape). Analytic longitudinal assessment of 83 patients (median age 35 years, range 23-59 years) with recurrent SPD that completed the 5-year study design following D-shape reoperation. Among a cohort of 607 patients, we enrolled 83 recurrent SPD. After D-shape reoperation, second recurrence rate was 9.6% (8/83). Second recurrence rate was not statistically significantly different among patients undergone D-shape as first surgery compared to patients of symmetric excision group (11.8% vs. 7.4%, p = 0.57). Similarly, there was no statistical difference among patients who underwent D-shape as first surgery compared to patients who underwent symmetric excision elsewhere (11.8% vs. 9.1%, p = .75). D-shape is a safe and effective when adopted as revisional surgery at a long-term follow-up. Comparative evaluation is warranted to establish the potential superiority over different surgical surgery in case of recurrence.

A mini-invasive procedure for the treatment of supralevator abscess of cryptoglandular origin by extrasphincteric extension: preliminary results at 1-year follow-up.

AIM: The aim of this retrospective study is to evaluate the preliminary results of a mini-invasive procedure for the treatment of supralevator abscesses (SLA) of cryptoglandular origin by extrasphincteric extension. METHOD: In this clinical study, an innovative two-stage procedure was tested for the surgical treatment of SLA. As first step and as a preparation for surgery, the interventional radiologist positioned a CT-guided percutaneous perianal guidewire inside the abscess cavity under local anesthesia. As second step, the surgeon performed an abscess incision and drainage around the guidewire, with a complete debridement of all the necrotic tissue. If a complex anal fistula was identified, a loose seton was placed in situ. RESULTS: Nine patients, comprising 5 men (55%) and 4 women (45%), underwent the above-mentioned two-stage procedure to treat SLA of cryptoglandular origin. Median age was 32 years (range, 25-42 years). A silicone draining seton was placed during the surgical procedure in 5 patients (55%), since a coexisting fistula was also revealed by surgery. A repeat surgery, along with a new drainage procedure, was required in one patient out of nine (11.1%) for a complete wound healing. The complete wound healing was achieved after a median of 30 days (range, 26-38). At the 1-year follow-up, the healing rate was 89%. CONCLUSIONS: The treatment of SLA of cryptoglandular origin by using this innovative two-stage procedure may be a safe and convenient surgical option to effectively decrease the risk of recurrence and anal sphincteric injuries.

Permacol Collagen Paste Injection for Treatment of Complex Cryptoglandular Anal Fistulas: An Observational Cohort Study With a 2-Year Follow-up.

BACKGROUND: Permacol paste injection is a novel treatment approach for complex cryptoglandular anal fistulas. This study was performed to evaluate the long-term clinical outcomes of treatment with Permacol paste for complex cryptoglandular fistulas. METHODS: Patients with primary or recurrent complex cryptoglandular anal fistulas treated with Permacol paste from 2014 to 2016 were retrospectively analyzed. RESULTS: A total of 46 patients (median age, 41.3 years; 21 female) underwent Permacol paste injection; 20 patients (43%) had previously undergone failed fistula surgery. The patients had experienced anal fistula-related symptoms for a median of 10 weeks (range, 3-50 weeks). All patients had a draining seton in situ for a median of 10 weeks (range, 4-46 weeks). The median follow-up time was 24 months (range, 1-25 months). At the 1-month follow-up, 2 patients had paste extrusion and 2 had anal abscesses. The mean preoperative Continence Grading Scale score was 1.10 ± 1.40, and that at 3 months postoperatively was 1.13 ± 1.39 ( P = .322). There was a significant difference in the preoperative and the 1- and 3-month postoperative pain scores ( P < .001). At the 24-month follow-up, the healing rate was 50% (n = 23). A total of 19 patients (41%) with a recurrent fistula after failed Permacol paste injection required additional operative procedures. The satisfaction rate at the 2-year follow-up was 65%. CONCLUSION: Permacol paste injection is minimally invasive and technically easy to perform. It can be considered as a viable and reasonable option for the treatment of complex cryptoglandular anal fistulas in patients with fecal continence disorders.

Comparison of porcine collagen paste injection and rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a 2-year follow-up study.

BACKGROUND: Rectal advancement flap is the standard surgical treatment for complex cryptoglandular anal fistulas, while Permacol™ collagen paste is considered an innovative treatment option for anorectal fistulas. This study aimed to compare the clinical outcomes of patients with complex cryptoglandular fistulas treated by endorectal advancement flap versus Permacol™ paste. METHODS: This study was a retrospective analysis of patients with complex cryptoglandular anal fistulas. Thirty-one patients were treated with the rectal advancement flap (RAF group), while 21 were treated with Permacol™ paste injection (PP group). In PP group, the approach consisted of loose seton positioning followed several weeks later by closure internal opening with a resorbable sutures associated with paste injection into the fistula track. Clinical outcomes were assessed in terms of healing rate, faecal continence and patient satisfaction. RESULTS: Seton drainage was done in all patients in both groups for a median duration of 8 weeks (range 4-18 weeks) before the final surgery (p = 0.719). No patient had faecal incontinence (CGS ≥ 5) preoperatively. Five patients (16%) in the RAF group and one (5%) in the PP group experienced faecal incontinence postoperatively. The 2-year disease-free survival was 65% in the RAF group and 52% in the PP group (p = 0.659). The median satisfaction scores were 5 (range 1-10) in the RAF group and 7 (range 2-10) in the PP group (p = 0.299). CONCLUSION: The RAF appeared superior to PP in terms of fistula healing, although this result was not statistically significant. On the contrary, PP has a potential advantage in terms of continence disorders. Permacol™ paste can be considered as the initial treatment option for complex cryptoglandular anal fistulas in patients with faecal continence disorders.

A new technique for tension-free reconstruction in large incisional hernia.

In the surgical management of large incisional hernias, the main target is the closure of the abdominal wall defect on the midline without a dangerous increase in the intraabdominal pressure. In this setting, new intraperitoneal prosthesis and components separation techniques were proposed to solve this problem. Both solutions present some critical issues. A new surgical approach with a free lateral double layer prosthesis totally in polypropylene both sides (FLaPp®) is proposed to overcome this problem. This is a retrospective cohort analysis study with a prospectively collected database from two different Italian hospitals. Twenty-nine patients operated from April 2010 to December 2015 were treated using the new prosthesis. Four patients developed postoperative complications: one (3.4%) presented wound infection, two (6.9%) experienced seroma, and one had a hematoma (3.4%). No deaths were recorded. At a median follow-up of 28.5 months (IQR 22-36), no hernia relapse occurred. The application of FLaPp® mesh is a safe and feasible option that can be employed to manage Rives repair in cases of abdominal wall defects with difficult closure of the posterior plan when the conventional prosthetic meshes could be unsuitable.

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.

Italian Biological Prosthesis Work-Group (IBPWG): proposal for a decisional model in using biological prosthesis.

INTRODUCTION: Indications for repair of abdominal hernia are well established and widely diffused. Controversies still exist about the indication in using the different prosthetic materials and principally about the biological ones. MATERIAL AND METHODS: In February 2012, the Italian Biological Prosthesis Work-Group (IBPWG), counting a background of 264 biologic implants, met in Bergamo (Italy) for 1-day meeting with the aim to elaborate a decisional model on biological prosthesis use in abdominal surgery. RESULTS: A diagram to simplify the decisional process in using biologics has been elaborated. CONCLUSION: The present score represents a first attempt to combine scientific knowledge and clinical expertise in order to offer precise indications about the kind of biological mesh to use.

Glyceryl trinitrate ointment (0.25%) and anal cryothermal dilators in the treatment of chronic anal fissures.

INTRODUCTION: Chronic anal fissure is a common benign disorder; for this condition, lateral internal sphincterotomy is the "gold standard" of treatment. Alternative medical treatments have not proven to be as effective as left lateral internal sphincterotomy. AIM: This randomized trial was designed to compare the use of 0.25% glyceryl trinitrate ointment and anal cryothermal dilators with the use of 0.4% glyceryl trinitrate ointment alone in the treatment of chronic anal fissures. METHODS: Between 1 June 2006 and 31 December 2007, 60 consecutive patients who were suffering from chronic anal fissures were randomized into two groups. The patients in group A (n = 30) were treated with 0.25% glyceryl trinitrate ointment and anal cryothermal dilators twice daily, and those in group B (n = 30) were treated with 0.4% glyceryl trinitrate ointment alone twice daily. The treatment was administered to the patients in each group for 6 weeks, and all patients were examined 7 weeks after the start of the trial. RESULTS: Prior to treatment, the symptoms and the measurements of anal pressure were similar in both groups. At 7 weeks, the maximum resting pressure was significantly lower in group A (P < 0.05), in which 86.6% of the patients were asymptomatic in comparison with 73.3% of the patients in group B. After 1 year of follow-up, 25 patients (83.3%) in group A and 18 patients (60%) in group B presented no recurrence of symptoms (P < 0.05) CONCLUSIONS: Treatment of chronic anal fissures with 0.25% glyceryl trinitrate ointment and anal cryothermal dilators was more effective than the administration of 0.4% glyceryl trinitrate ointment alone.

Late cutaneous fistulae after prosthetic hernia repair of the abdominal wall.

Late cutaneous fistulae, after a hernioplasty operation for a hernia in the abdominal wall, represent an unusual complication. They can appear a considerable time after a hernioplasty operation and feature the presence of a fistula between the prosthesis and the cutaneous wall. The Authors report the cases of five patients who developed late cutaneous fistulae after an operation for the repair of a hernia of the abdominal wall and the treatment established in the end to correct the existing complication. All five patients were subjected to a second operation to achieve recovery. In fact, conservative medical treatment, before the operation, using antibiotic-therapy for this purpose proved to be ineffective. Only one patient developed hernia recurrence after surgical treatment. Late cutaneous fistulae represent a complication that is difficult to deal with as their treatment has yet to be clearly identified.

The diagnosis of non-palpable lesions in laparoscopic surgery of the colon.

The identification of small neoplasms or areas presenting lesions associated with previous endoscopic polypectomy is one of the major problems in laparoscopic colonic resection. The aim of our study was to evaluate the effectiveness of tattooing with Indian ink to identify the area of the colon that is the site of the lesion in order to be able to perform colonic resections with oncologically correct margins. Eighty-four patients were observed with polypoid lesions or diagnosed as presenting lesions associated with endoscopic polypectomy for which colonic resection had been recommended. Marking was performed during preoperative colonoscopy by injecting 1 ml of Indian ink solution with a sclerotherapy needle into each of the four quadrants of the colon wall. This method, which is simple to execute, invariably allowed easy identification of the site of the neoplasm and laparoscopic colon resection with correct oncological margins. In the 84 cases, we recorded only one complication (1.1%) due to a paucisymptomatic microperforation discovered during the operation. The identification of small colon lesions can be performed easily using Indian ink. It is a simple, quick method which, if performed properly, always allows the site of the lesion to be identified and is associated with a negligible rate of complications.

[Pancreatic echinococcosis]. / L'echinococcosi pancreatica.

Echinococcosis is a widespread parasitosis which is endemic in many countries of Latin America, Asia and Southern Europe. Cysts are generally to be found in the liver and lungs. If exceptionally located in other organs, the condition may pose serious problems of differential diagnosis versus neoplasms. Furthermore, if unnoticed, they may expose the patient--in case of surgery--to the risk of anaphylaxis due to leakage of cystic fluid. The pancreas is one of least frequent locations. Multiple surgical procedures are possible. Pericystectomy is often difficult and exposes patients to the risk of postoperative complications. Marsupialisation and internal drainage into the gut are the most common interventions; percutaneous drainage, too, has been described in patients at high surgical risk. The authors report the case of a patient from Morocco who emigrated to Northern Italy, where the disease is not endemic. The radiological examinations led to a suspicion of disease, later confirmed by serological tests. A cystojejunostomy with a Roux loop was carried out due to the large size of the cyst. The lack of surgical radicality forced the patient to undergo adequate medical therapy. At present the patient shows no signs of recurrence of the disease.

Chondroid syringoma. A case report.

Chondroid syringoma is a benign skin tumour characterized by several histological aspects similar to salivary gland adenomas. It generally affects the head and neck, mainly in the 6th and 7th decade of life. Its incidence in males is twice as high as in females. The neoplasm is usually an asymptomatic subcutaneous swelling that patients want removed for aesthetic reasons. Excision is the elective treatment. A few cases of malignant chondroid syringoma, however, have been reported. The neoplasm tends to produce metastases to both the regional and distant lymph nodes, causing the death of the patient. In these cases, radiation therapy follows the surgical excision. The authors report the case of a woman with chondroid syringoma located in the occipital region of the scalp. After a period of slow growth, the neoplasm suddenly increased in size. The patient asked for it to be removed out of concern for the concomitant hair loss.