The impact of experience on short- and long-term outcomes on gastric ESD: a western series.

Endoscopic submucosal dissection (ESD) represents the standard of care for early gastric cancer in Eastern countries. Nevertheless, in the West, this procedure is not widespread. Aim of the study was to confirm the feasibility and the efficacy of ESD in the West. A total of 60 ESD were performed between January 2005 and December 2014 by two expert endoscopists. The analysis, based on a retrospective collected database, was conducted by dividing the study period in three subgroups. Clinical and technical outcomes have been compared. Rates of complete, curative and en bloc resection did not significantly change among the study periods. Three cases of perforation occurred (5%), one in each period. The operation time significantly decreased from the second to the third period (p < 0.001). When adjusting for gender, tumor size and site in multivariable analysis, operation time decreased by nearly 90 min from the first to the second period, and by more than 3 h from the first to the last period. The median follow-up was 33 months. No cases of local or lymphnodal recurrence were detected during the study period. One patient presented a synchronous lesion, whilst four metachronous lesions have been discovered after a median follow-up of 11 months. Our experience supports the feasibility and safety of ESD in the West, if an adequate learning curve is accomplished. Long-term outcomes are comparable to the Eastern series.

Experience with a new device for pathological assessment of colonic endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is gaining popularity worldwide in the treatment of neoplastic lesions of the gastrointestinal tract. However, the experience in Western countries is quite limited and restricted to large or academic centers. Besides, this approach requires an optimal pathological assessment. The aim of this study was to report our experience with colonic ESD using a new device that allows complete handling of the resected specimens and especially of lateral margins, for pathological analysis. In a 1-year period, 14 patients (6 men, 8 women, age range 50-82 years) underwent colonic ESD in a non-academic hospital. The endoscopic procedure was carried out successfully en bloc in more than 90 % of cases. Perforation requiring surgery occurred in one patient (7 %). Pathological assessment with the new device allowed entire and complete examination of both the deep and lateral margins of the excised specimens. Colonic ESD is a viable option for non-surgical treatment of large bowel lesions even in relatively small centers and in non-academic settings. The new device allows good handling of the specimens, and it seems to be useful for the entire examination of the resection margins.

[Ideation of a new operative anoscope in proctology]. / Ideazione di un nuovo anoscopio operativo in proctologia.

BACKGROUND: Rectocele is defined as an erniation of the anterior rectal and vaginal wall in the vaginal lumen due to the loss of recto-vaginal septum. Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the rectal lumen. The Authors, herein, reported the results of a new surgical technique defined Sequential Transfixed Stitch Technique (STST) using a new anoscope. MATERIALS AND METHODS; A total of 30 consecutive patients symptomatic III or IV stage rectocele assessed with clinical and instrumental criteria were submitted to STST using the new anoscope. The new anoscope, consisting of non-toxic metallic material, designed and realized according to surgery needs and tested by the authors, increases the vision of the anal canal can be fixed according to the operator's needs. RESULTS: STST was correctly performed in all the cases without early and late complications. The mean value was of 17 according to the Agachan-Wexner for patients with rectocele, significantly improved score in comparison to pre-operatory condition (p<0.05). Surgical procedure of rectocele repair was judged satisfactory in 80% of the cases. CONCLUSIONS: The new operative anoscope was useful in III and IV stage rectocele repair with STST, ensuring ease of implementation of the binding repair in the absence of side effects for the patient.

[Identification of internal fistolous orifice: evolution of methylene blue technique with a mini-probe]. / Identificazione dell'orifizio fistoloso interno: evoluzione della tecnica di iniezione con blu di metilene tramite mini-catetere.

INTRODUCTION: Often perianal fistulas can be difficult typing and traditional anatomical classifications do not help the surgeon in accurate diagnosis of the fistula as an outpatient procedure and therefore does not allow a timely surgical currettage. The aim of our study was to introduce in the management of anal fistulas performed on an outpatient injection with methylene blue of the fistula through a small polyethylene catheter in order to detect in real time the internal opening of the fistula and drive so the next currettage surgery. MATERIALS AND METHODS: A total of 50 consecutive patients 21 female and 29 male, relating to our clinic with symptoms suggestive of colon proctology perianal fistula, aged between 36 and 69 years were selected for our study. After running the news-gathering medical history, physical examination, digital examination through examination anoscope, using a polyethylene catheter in a small scale, of methylene blue was injected through the external fistula orifice looking inside the spreading of liquid. Subsequently, the patient was started on specillazione currettage and possible surgery. RESULTS: 62 outpatients were treated intramural fistulas, diagnosed with the injection technique with methylene blue running always probing and practiced a wide dish made of the mucosa, submucosa and circular muscle layer of the internal drainage with sphincterotomy. In particular, the technique injection of methylene blue was sufficient to diagnose 42 out of 62 cases examined (67.7%). In the remaining 20 cases it was necessary to integrate diagnosis with MRI-defecates on the complexity of fistulas (10 horseshoe, 6 trans sphincteric and 4 intersphincteric. CONCLUSIONS: Methylene blue injection is a low-cost screening technique, simple to perform on an outpatient basis and in the case of suprasphincteric fistulas also a simple diagnostic technique is sufficient to allow the closure of the fistula.

[Utility of plug test during anoscopy for the ambulatory evaluation of rectal mucosal prolapse]. / Utilità del test della garza durante anoscopia per la stadiazione ambulatoriale del prolasso mucoso del retto.

INTRODUCTION: Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the anal lumen. The Authors, to correctly establish the intraoperatory stage of rectal mucosal prolapse have performed a test based on the intrarectal introduction of a plug of great dimension, to successively pull-through the anal canal during anoscopy. PATIENTS AND METHODS: A total of 30 patients with proctological symptoms and with diagnosis of rectal mucosal prolapse has been submitted, in ambulatory setting, to a less invasive test with a small plug and in second time, using a plug entirely inserted in rectal lumen and to remove outside through the anus during anoscopy. RESULTS: In all cases the plug test used during anoscopy permitted the perfect evaluation of the prolapse extension. In 12 patients the plug test evidenced a mucosal prolapse occupying the 25% of anal canal, in 10 patients the 50% of anal canal and in 8 patients a mucosal prolapse occupying up to the 50% of the anal circumference. The first 22 patients were treated transfixed stitch technique (TST) while for the other patients Longo surgical technique was preferred. CONCLUSIONS: The plug test during anoscopy is efficacious to achieve differential diagnosis between rectal mucosal prolapse and haemorrhoidal prolapse. Indeed. it is useful to choice more precisely the type of surgical intervention.

[Treatment of rectocele and rectal mucosal prolapse with mucosal flaps excision and with manual reconstruction]. / Trattamento del rettocele e del prolasso mucoso del retto con escissione a lembi della mucosa con sutura manuale (Tecnica di "Delorme interna" modificata).

BACKGROUND: Rectocele is defined as an erniation of the anterior rectal and vaginal wall in the vaginal lumen due to the loss of rectovaginal septum. Rectal mucosal prolapse was characterized by the protrusion of the mucosa alone in the rectal lumen. The Authors, herein, reported the results of a new surgical technique with the excision of one or more mucosal or muco-muscolar flaps and reconstruction with Sequential Transfixed Stitch Technique (STST) using a anal retractor designed by them. MATERIALS AND METHODS: The new surgical technique was applied to 40 consecutive patients with rectal mucosal prolapse and 20 with symptomatic rectocele of III degree assessed with proctological evaluation, digital examination of the anal canal, sphere test, defecography and total colonoscopy were submitted to STST. Patients with previous colorectal or pelvic surgery were excluded from the study. The quality of life was defined using a questionnaire before surgery, at 3 and 6 months of follow-up. Data were evaluated according to the Agachan-Wexner score. RESULTS: The new technique was correctly performed in all the cases without early and late complications. The mean value was of 18.2 according to the Agachan-Wexner for patients with rectocele and 17.6 for rectal mucosal prolapse, both significantly improved score in comparison to pre-operatory condition (p<0.05). Surgical procedure with flaps excision and manual procedure of STST was judged satisfactory in 89% of the cases. CONCLUSIONS: The treatment of symptomatic rectocele and rectal mucosal prolapse with multiple excision of exceeding tissue flaps and the reconstruction with STST manually conducted showed optimal results for the surgical treatment of in our experience with a significant improvement of quality of life referred by the patients and absence of significant post-operative side effects.

A proposal for an evidence-based model of the screening for the colorectal carcinoma in an Italian setting.

INTRODUCTION: The aim of this paper is to improve the feasibility perception of policymakers, health care workers and target population about the cost-effectiveness of the implementation of colorectal screening as Public Health strategy. METHODS: Retrospective study by application of a three-step model designed for a local setting in Sicily (Palermo and its Province) in order to distribute Fecal Occult Blood Tests (FOBTs), offer colonoscopy and surgery, by district allocation of pharmacies, public digestive endoscopic centres and oncologic and general surgery units. Mean adherence to consolidated colorectal screening programs in Italy was applied in order to evaluate the feasibility of an operative model in our area. RESULTS: Applying the model to the target population (269,368 individuals of both sexes), it can be expected a mean percentage of 79% delivered invitation and a mean participation rate of 46.3% accounting for a total of 213,070 invited individuals and 98,651 participating in the first round of the program. Furthermore, considering the national mean of 6% positive FOBT, 82% of colonscopy adhesion and 7% CRC detection rate, it can be scheduled a burden for health care structures involved in the program accounting for 49,325 FOBTs, 2,338 colonscopies and 141 surgeries for each year. DISCUSSION: This work demonstrates the feasibility of a colorectal screening project in our area, showing a sustainable impact for local health care involved structures. Furthermore, this program may be spread as an applicative model to other areas, adapting the project to the needs of the local setting in which the colorectal screening will be organized.

[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.

Our experience with endoscopic repair of large colonoscopic perforations and review of the literature.

BACKGROUND: Colonic perforation is the most severe complication of lower gastrointestinal endoscopy. Recently successful closure with endoscopic clips has been reported. However large (>10 mm) perforations and perforations occurring during diagnostic colonoscopy are considered a contraindication to endoscopic closure. METHODS: We retrospectively reviewed our own experience with endoscopic closure of colonoscopic perforations. The size of the perforations was determined by comparison with the maximal opening of the clipping device. In addition we reviewed all cases of colonoscopic perforation published in the English language literature. RESULTS: From January 2006 we performed closure of three large colonoscopic perforations in three patients. One perforation occurred after en-bloc endoscopic mucosal resection of two polyps in the descending colon. The other two perforations occurred during diagnostic colonoscopy. All three cases were promptly diagnosed and successfully repaired with TriClips. Patients were kept on intravenous antibiotics and a clear liquid diet until bowel movement and were discharged between the 2nd and the 8th day after the procedure. A review of the literature, including our series, revealed 75 reported cases of colonoscopic perforations repaired with endoclips. Of these, four perforations were larger then 10 mm and four occurred during diagnostic colonoscopy. Of the perforations occurring during therapeutic colonoscopy, clip closure was carried out in 55-96% of the immediate perforations and was successful in 69-93% of cases. CONCLUSIONS: Nonsurgical management of colonoscopic perforations with endoclips is a highly feasible option. From our initial experience large perforations and perforations occurring during diagnostic colonoscopy are not a contraindication to endoscopic repair, but due to the small number of patients these data must be interpreted with caution.

[A new disposable isostatic anal retractor for proctology]. / Un nuovo divaricatore anale isostatico monouso in proctologia.

The Authors present the characteristics and the advantages derived by the use of a new disposable isostatic retractor resulted of the positive operative experience of several years. The aim of this experimentation was to test a new instrument helpful and simple to use in coloproctology. The efficiency of the new kit constitued by plastic material has been tested on 30 patients with haemorrhoidal disease, rectocele and anal fissures. The therapeutical results obtained, demonstrated that the new isostatic anal retractor have ameliorate the surgical procedures in all treated patients. The use of kit is indicated for the praticity, the manoeuvrability, a more visibility of operative space and in case of sphincterial hypotonia.

Improved detection of colorectal neoplasms with selective use of chromoendoscopy in 2005 consecutive patients.

BACKGROUND: Colorectal cancer mortality is decreased by endoscopic polypectomy, but conventional colonoscopy may be inadequate for detecting subtle colonic lesions. METHODS: We selectively performed chromoendoscopy in all patients undergoing colonoscopy between January 1999 and December 2005 at the International Health Union of Rome. Patients with a history of colorectal polyps, inflammatory bowel disease, colorectal surgery or coagulopathy and those with poor bowel preparation were excluded from this analysis. Whenever colonoscopy revealed suspicious mucosal areas, dye-spraying with 0.2% indigo carmine solution was also performed. Findings from conventional and dyespraying views were classified morphologically, and specimens were analyzed histologically. Non-adenomatous lesions were classified as negative findings. RESULTS: A total of 2005 patients underwent conventional colonoscopy and in 305 cases (15%) chromoendoscopy was also performed. Conventional colonoscopy identified 508 neoplasms in 381 patients (19%). Selective chromoendoscopy found an additional 244 neoplasms in 212 patients (11%). Thus, chromoendoscopy was positive in 212 (70%) of 305 patients in whom the examination was performed. Overall, 56 large, ulcerated, advanced cancers and 696 non-advanced neoplasms were found. Of the 696 nonadvanced neoplasms, 448 (65%) were polypoid and 248 (35%) were non-polypoid. All but 4 non-polypoid lesions were only detected with chromoendoscopy. Of the 248 non-polypoid lesions, 12 (5%) were depressed and 236 (95%) were flat. Advanced histology was present in 39 non-polypoid lesions (15%) and was more common in depressed lesions than in flat ones (58% vs. 13%; p<0.001). CONCLUSIONS: Our study confirms the existence of flat and depressed neoplasms in an Italian population. The vast majority of non-polypoid lesions were only detected by chromoendoscopy, and many lesions with advanced histology were missed by conventional colonoscopy. We therefore recommend selectively performing chromoendoscopy when conventional colonoscopy provides clues for non-polypoid lesions. Therefore, endoscopists should be trained in the detection of these subtle mucosal clues, as well as in the use of chromoendoscopy to enhance their detection.

[Incidental diagnosis of caecum adenocarcinoma due to retention of endoscopic videocapsule: a clinical case]. / Diagnosi incidentale di adenocarcinoma del cieco dovuto a ritenzione della videocapsula endoscopica: un caso clinico.

Capsule endoscopy is a new technique for the study of small intestine particularly in cases of obscure gastro-intestinal bleeding or chronic iron-deficiency anemia. In our study we present a case of 62 years-old man with a chronic iron-deficiency anaemia developed at least six months before and refractory to iron therapy. The patient was submitted to upper gastro-intestinal endoscopy and to partial colonscopy due to abdominal adhesions for previous abdominal surgery. A capsule endoscopy was indicated to achieve a definitive diagnosis. Wich discosed an intestinal obstruction. So far a surgical resolution was indicated. The surgery revealed a stricturing neoplasia of the cecum in which the capsule endoscopy was retained.

Hemorrhoids and rectal internal mucosal prolapse: one or two conditions? A national survey.

The surgical modalities for the treatment of hemorrhoids are quite numerous due to the rapid diffusion of new surgical techniques and to the different approaches to the pathophysiology of the disease by the proctologists. Stapled hemorrhoidopexy, one of the most recent surgical options proposed, emphasizes the role of rectal internal mucosal prolapse (RIMP) as the main cause of the disease. We performed a national survey among the most important proctologists on this particular clinical condition, in order to better define the indications for the surgical treatment of hemorrhoids. A questionnaire concerning the main clinical features of RIMP was mailed to 84 coloproctology centers. Two-thirds of the 41 proctologists who responded found RIMP in a minority of patients with hemorrhoids, whereas only one-third found RIMP in more than half of their patients. A circumferential RIMP was identified by only 10% of the surgeons, whereas a coincidence between pre- and postoperative diagnoses of this condition was possible in half of proctologists' patients. RIMP is not frequently associated with hemorrhoids. Therefore, it is unlikely to be a cause of hemorrhoidal disease, and many surgeons still recognize it as a difficult clinical condition to define.