[Fecal incontinence. Personal experience in direct sphincteric repair]. / Incontinenza fecale. Nostra esprienza nella riparazione sfinterica diretta.

BACKGROUND: Fecal incontinence is a disabling condition causing social isolation, whose real incidence is difficult to be exactly valued because patients are often reluctant to speak about it, even with their physician, or because they don't trust on surgical procedure. Aim of this study is report our experience in sphincteric reconstruction by direct sphincteric repair in patients suffering from post-traumatic fecal incontinence. METHODS: Seven patients suffering from fecal incontinence due to traumatic lesions of anal sphincterial apparatus were surgically treated between 1981-2000; in the first patient cause was an injury due to impaling, in the second a previous obstetrical lesion and in the last five a previous fistulectomy. Direct sphincteric reconstruction after finding and isolation of two retracted terminals of sectioned sphincter was performed in all the patients. Sphincteric reconstruction has been always accompanied by total parenteral nutrition for about two weeks during the postoperative period. A protective colostomy was never performed. RESULTS: In five cases the results were excellent: patients had continence total recovery and postoperative manometry recorded basal and voluntary contraction pressures normalisation. In the two remaining cases there was only a modest improvement because of concomitant pudendal neuropathy. No operative wound infection was observed. CONCLUSIONS: We hope that more attention is paid to fecal incontinence either regarding instrumental semeiotics or medical or surgical therapy. In particular, direct sphincteroplasty can restore a satisfactory continence in a strong number of patients with anal sphincterial apparatus single traumatic lesions without pudendal neuropathy, relieving them from a heavily disabling condition.

[Our experience in the transanal excision of tubulovillous adenomas of the rectum]. / Nostra esperienza in tema di escissione per via transanale degli adenomi tubulo-villosi del retto.

BACKGROUND: Personal experience on transanal excision of rectal adenomas without affecting sphincteric function is reported. METHODS: From 1985 to 1997, 27 patients suffering from rectal adenomatous polyps underwent surgery; the sites of lesions were within 3 to 10 cm from anal orifice in the whole series; the age of patients ranged from 30 to 81 years. Two different procedures were employed: the Parks' technique and the electroresection by traction flap technique according to Faivre. RESULTS: Any postsurgical complication such as hemorrhage, stenosis or incontinentia occurred; surgical mortality was absent. Histological examination disclosed severe dysplasia as well as in situ carcinoma in 6 patients (22.2%) and malignant polyps in 9 patients (33.3%). Only in a case a palliative excision was performed since the poor general conditions of this patient did not permit a more extended treatment; a local relapse of the tumour associated with liver metastases led the patient to death 22 months after surgery. Three patients were lost to follow-up and 2 patients died because of other causes, 6 and 8 years after surgical excision, respectively. CONCLUSIONS: The conclusions are is drawn that either Park's and Faivre's procedures are useful and safe for the surgical treatment of rectal villous polyps extended up to 8-12 cm from anal orifice, in spite of the presence of malignant foci within their mass. These surgical procedures are simple and relatively poor traumatic; for this reason they are more suitable than other transabdominal or abdomino-perineal approaches for older patients and other at risk-patients. It is underlined that the treated patients require a long-term follow-up aimed at the early diagnosis of possible relapses of adenomatosis.

[Our experience in internal medioposterior sphincterotomy with anoplasty]. / Nostra esperienza in tema di sfinterotomia interna mediana posteriore con anoplastica.

BACKGROUND: The technique of the posterior medial internal sphincterotomy according to Arnous is described and advice from personal experience reported. METHODS: From 1981 to 1995 posterior medial internal sphincterotomy with anoplasty was performed in 270 patients (132 males and 138 females) affected with chronic anal fissure, alone (112 cases) or associated with hemorrhoids (80 cases); moreover, the Arnous's operation was performed as well for hemorrhoids with posterior subsidiary packet and internal sphincter hypertonia (52 cases), relapsed hemorrhoids with postoperative anal stenosis (24 cases) and postoperative anal stenosis with painful fissure and residual internal sphincter hypertonia (2 cases). RESULTS: The results have been excellent; the average stay in hospital has been 7 days and the complete recovery occurred after 4-6 weeks without early or late complications. CONCLUSIONS: The importance of anorectal manometry for the preoperative valuation of the sphincteric hypertonia is emphasized: in this manner it is possible to modulate the sphincterotomy avoiding too economic sphincteric sections with next residue hypertonia or, in the contrary, too plentiful sphincteric section with problems of continence. Finally, the internal lateral-left sphincterotomy is mentioned, which is efficacious in the treatment of acute anal fissure. However, the proctological surgeon, on the basis of his experience, will propose the most convenient technique.

[Hemorrhoidectomy: Milligan and Morgan technique]. / L'emorroidectomia secondo Milligan e Morgan.

Milligan and Morgan and Arnous anoplasty procedures are described; their indications come from pathological features and associate pathology. Left internal sphincterotomy and posterior sphincterotomy and anoplasty are described and discussed on the basis of the Author experience about 523 haemorrhoidectomies. Internal sphincterotomy, when indicated, avoids pain, urinary retention, fissure and stenosis. Early and late complications are evaluated for both the procedures.

Management of perianal Crohn's disease. Results of a multicenter study in Italy.

PURPOSE: Management of perianal Crohn's disease is still controversial, and reports on large series are very few in the literature. The aim of this multicenter study was to investigate the outcome of both medical and surgical treatment in 225 patients. METHODS: Patients cared for at different institutions were followed up for a median of six years. Most of them had either anal fistula or an abscess (86 percent and 43 percent, respectively), but fissures were also present in 26 percent of the cases. Diarrhea and anal pain were the most common symptoms. Anal lesions preceded the onset of intestinal symptoms in 19 percent of cases. RESULTS: Medical treatment was curative only in 21 of 123 patients. Overall, medical and surgical treatment either cured or improved 62 percent of the cases. Fifty percent had an intestinal resection. Abscess drainage and fistulotomy were the most common anal surgeries. Rectovaginal fistulas (n = 30) required intestinal surgery in 36 percent and anal surgery in 20 percent of the cases, 50 percent with good results. Of 166 patients who had anal surgery, 97 (58 percent) had a positive outcome. Recurrence of anal disease requiring further surgery occurred in 24.5 percent of the cases. CONCLUSIONS: Limited surgeries seem to achieve satisfactory results in more than one-half of the patients affected by perianal Crohn's lesions, whereas medical treatment alone is curative in a small portion of them.

[Indications for internal, medioposterior with anoplasty or lateral sphincterectomy during hemorrhoidectomy. Our experience]. / Le indicazioni alla sfinterotomia interna, mediana posteriore con anoplastica o laterale, in corso di emorroidectomia. Nostra esperienza.

The authors report their experience of internal, medial posterior with anoplasty and left lateral, sphincterotomy during haemorrhoidectomy according to Milligan and Morgan. Internal sphincterotomy represents a valid complement to haemorrhoidectomy assuring a better postoperative period: it removes the pain by hypertone of the internal sphincter and avoids the stenosis. The indications for both sphincterotomy techniques are suggested by anatomo-clinical characteristics of the lesion and by combined pathologies.

[Verneuil's peri-anal suppurative hidrosadenitis. Considerations on 2 clinical cases]. / L'idrosadenite suppurativa peri-anale di Verneuil. Considerazioni su due casi clinici.

Two cases of perianal Verneuil's disease personally observed are described. It is a rare chronic inflammation of the apocrine sweat glands in several skin areas. The exasperating chronicity and the propensity to extend of the disease involve complicated problems of diagnosis and therapy. A squamous cell carcinoma can rarely complicate long lasting hidrosadenitis. The treatment consist in a radical surgical excision of the involved areas. The patient must be controlled for a long time since the evolution of this disease cannot be foreseen.

[The use of DuoDerm in the surgical wound after surgical treatment of pilonidal fistulae using the open method]. / L'impiego del "DuoDerm" nella ferita operatoria dopo trattamento chirurgico delle fistole pilonidali col metodo aperto.

The results of a study on the use of DuoDerm Hydroactive sterile occlusive dressing on the operative wound after simple excision of pilonidal fistula are reported. Two groups of 20 patients were studied: in the first group the wound was treated with traditional medications, in the second group with DuoDerm. Comparing the results obtained from these two groups, the Authors conclude underlining the therapeutic efficacy of the dressing which stimulates granulation and accelerates re-epithelialization with complete healing in 6 weeks on average compared with the 10 needed with traditional medications.