The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton.

The management of trans-sphincteric anal fistula (TAF) includes several surgical options; however, during the COVID-19 pandemic, the access to the operating rooms was severely limited, leaving only the choice of minimally invasive procedures. This study aimed to evaluate the safety and effectiveness of the slow cutting seton technique for TAF performed in an outpatient setting during the COVID-19 pandemic.Patients treated for TAF between January 2020 and July 2022 and followed-up for at least 12 months were retrospectively evaluated. A vascular silicone tie used as seton was positioned in the fistula tract using a Lockhart-Mummery fistula probe. The seton was maintained in moderate tension until the sphincter muscle was passed. Percentage and time for healing, recurrence, SF-36, VAS and Vaizey's Score were recorded.Fifty-eight patients [36 male/22 female, median age 56.5 years (IQR 41.25-65.75) [with TAF were included. After a median time of 4 months, complete healing occurred in 53 cases (91.5%), the anal pain VAS decreased from 6 to 0, the anal incontinence scores did not change significantly and the QoL improved significantly in all the SF36 domains. No complications were recorded, but the fistula recurred in five cases (8.5%). Two of them had additional seton treatment, and three underwent other surgical procedures after the COVID-19 emergency.The slow cutting seton technique is a safe and effective treatment for outpatient procedure with minimal patient discomfort. This treatment option in healthcare delivery for TAF should be reconsidered, even outside the limited in-hospital access during the COVID-19 pandemic.

Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice.

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.

Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system.

Introduction: Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system. Material and Methods: A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment. Results: Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively. Conclusion: The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.

Ageing with sacral nerve modulation for fecal incontinence: how many patients get benefit after more than 10 years?

Sacral nerve modulation (SNM) has represented a major advancement in the minimally invasive management of patients with fecal incontinence (FI). Although the success rate in the short-medium term has widely been demonstrated, the very long-term outcomes are poorly investigated. This study aims to assess the effectiveness of SNM in a cohort of patients with a follow-up longer than 10 years. Clinical records of patients submitted to SNM for FI in our tertiary referral colorectal Unit between 1998 and 2010 were retrospectively reviewed looking for status of the implantable pulse generator (IPG), follow-up duration, severity of FI by the St Marks' score and quality of life. 58 patients fulfilled the entry criteria and 36 (58%, median follow-up, 12 years) accepted to take part to the telephone interview, while 22 (38%) were lost to the follow-up. Nineteen patients had their IPG removed (Group A) while 17 (27%) had the SNM still active after a median follow-up of 13 years (Group B). In the group A, the median baseline St Marks' score was 13 and did not change after the IPG removal. In group B, the median baseline St Marks' score was 14, at last IPG substitution, it was of 7 and at the last follow-up dropped to 4. In the group A, the median SF-12 physical and mental scores did not change significantly while they improved significantly in group B. A progressive deterioration of the success rate of SNM with the time has been documented after a very long-term follow-up.

Effects of temporary sacral nerve stimulation on gastrointestinal motility and function in patients with chronic refractory slow-transit constipation.

BACKGROUND: The efficacy of sacral nerve stimulation (SNS) on patients with chronic refractory slow-transit constipation is controversial and its mechanism of action on gastrointestinal motility and transit is not fully understood. The aim of this study was to document the effects of temporary SNS on the gastrointestinal and biliary tract motility and on gastrointestinal transit in patients with refractory slow-transit constipation. METHODS: This was a prospective interventional study. Patients with slow-transit chronic constipation, unresponsive to any conservative treatment, were enrolled between January 2013 and December 2018. Patients' quality of life [patient assessment of constipation quality of life (PAC-QOL) questionnaire], constipation scores (Cleveland Clinic Constipation Score) colonic transit time (CTT), orocecal transit time (OCTT), gastric and gallbladder kinetics, together with the assessment of the autonomic nerve function were evaluated before and during temporary SNS. RESULTS: 14 patients (12 females, median age 38 years, range 24-42 years) had temporary SNS. The Cleveland Clinic Constipation Score did not change compared to baseline (23 ± 3 vs 21.4; p = 070). The PAC-QOL did not improve significantly during the stimulation period. Gallbladder/stomach motility (half-emptying time) did not change significantly before and after SNS. OCTT was delayed at baseline, as compared to standard internal normal values, and did not change during SNS. CTT did not improve significantly, although in two patients it decreased substantially from 97 to 53 h, and from 100 to 65 h. CONCLUSIONS: Temporary SNS did not have any effect on upper/lower gastrointestinal motility and transit in patients with severe constipation.

Chemical signature of colorectal cancer: case-control study for profiling the breath print.

BACKGROUND: Effective screening for colorectal cancer can reduce mortality by early detection of tumours and colonic polyps. An altered pattern of volatile organic compounds (VOCs) in exhaled breath has been proposed as a potential non-invasive diagnostic tool for detection of cancer. The aim of this study was to evaluate the reliability of breath-testing for colorectal cancer screening and early diagnosis using an advanced breath sampler. METHODS: The exhaled breath of patients with colorectal cancer and non-cancer controls with negative findings on colonoscopy was collected using the ReCIVA® Breath Sampler. This portable device is able to capture the alveolar breath fraction without environmental contamination. VOCs were desorbed thermally and analysed by gas chromatography-mass spectrometry. The discriminatory ability of VOCs in detecting colorectal cancer was evaluated by receiver operating characteristic (ROC) curve analysis for each VOC, followed by cross-validation by the leave-one-out method, and by applying stepwise logistic regression analysis. RESULTS: The study included 83 patients with colorectal cancer and 90 non-cancer controls. Fourteen VOCs were found to have significant discriminatory ability in detecting patients with colorectal cancer. The model with the diagnosis of cancer versus no cancer resulted in a statistically significant likelihood of discrimination of 173·45 (P < 0·001), with an area under the ROC curve of 0·979. Cross-validation of the model resulted in a true predictive value for colorectal cancer of 93 per cent overall. Reliability of the breath analysis was maintained irrespective of cancer stage. CONCLUSION: This study demonstrated that analysis of exhaled VOCs can discriminate patients with colorectal cancer from those without. This finding may eventually lead to the creation of a smart online sensory device, capable of providing a binary answer (cancer/no cancer) and directing to further screening.

ANTECEDENTES: Un cribaje efectivo del cáncer colorrectal (colorectal cáncer, CRC) puede reducir la mortalidad mediante la detección precoz de cáncer/pólipos del colon. La identificación de un patrón de compuestos volátiles orgánicos (volatile organic compounds, VOCs) en el aire espirado se ha propuesto como un procedimiento potencial de diagnóstico no invasivo para la detección del cáncer. El objetivo de este estudio fue evaluar la factibilidad del test de la respiración para el cribaje del CRC y diagnóstico precoz empleando un equipo avanzado de muestreo del aliento. MÉTODOS: Se recogieron muestras de aire espirado de 83 pacientes con CRC y de 90 controles sin cáncer con colonoscopia negativa empleando el ReCIVA Breath Sampler©. Este equipo portátil es capaz de capturar la fracción de aire alveolar espirada ausente de contaminación ambiental. Los VOCs fueron aislados térmicamente y analizados mediante cromatografía de gases acoplada a espectrometría de masas. La capacidad discriminatoria de los VOCs para detectar pacientes con CCR se evaluó mediante un análisis de la curva ROC para cada VOC seguida de validación cruzada mediante el método ir eliminando paso a paso cada uno de los VOCs en un modelo de regresión logística. RESULTADOS: Se observó que 14 VOCs tenían habilidad discriminatoria significativa para la detección de pacientes con CRC. El modelo con el diagnóstico de cáncer versus no cáncer mostró una probabilidad estadísticamente significativa de 151,03 (P < 0,0001) con un área bajo la curva (area under the curve, AUC) de 0,963. En la validación cruzada del modelo se obtuvo un valor global predictivo verdadero para el CRC del 92,5%. La fiabilidad del análisis del aire espirado se mantuvo con independencia del estadio del cáncer. CONCLUSIÓN: Este estudio ha demostrado que el análisis de los VOCs en el aire espirado puede discriminar pacientes con CRC de pacientes sin cáncer. Este hallazgo podría ser de ayuda para diceñar un dispositivo sensorial inteligente en línea, capaz de proporcionar una respuesta binaria (cáncer/NO cáncer) y asimismo contribuir a la indicación de una futura colonoscopia.

Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation.

AIM: To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation. METHODS: A retrospective study (June 2012-December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark's and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients' satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry. RESULTS: Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0 cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6). CONCLUSION: Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

Pelvic floor function following ventral rectopexy versus STARR in the treatment of obstructed defecation.

BACKGROUND: Obstructed defecation syndrome (ODS), most commonly found in females, can be treated by a transanal or abdominal approach with good success rate. Nevertheless, patients may experience de novo or persisting pelvic floor dysfunctions after surgery. The aim of this study was to compare the functional outcome of stapled transanal rectal resection (STARR) and ventral rectopexy (VRP) in a series of ODS patients. METHODS: Forty-nine female patients who had surgery for ODS between 2006 and 2016 were retrospectively evaluated: 28 (median age 60 years, IQR 54-69 years) had VRP and 21 (median age 58 years, IQR 51-66 years) had STARR. ODS was scored with the ODS score while the overall pelvic floor function was assessed with the three axial perineal evaluation (TAPE) score. Quality-of-life was evaluated by the patient assessment of constipation quality-of-life (PAC-Qol) questionnaire administered preoperatively and after 1 year of follow-up. RESULTS: The preoperative median ODS score and TAPE score were comparable in both groups. After a median follow-up of 12 months (range 12-18 months), the median ODS score was 12 (range 10-20) in the STARR group and 9 (range 3-15) in the VRP one (p = 0.02), while the median TAPE score was 70.5 (IQR 60.6-77.3) in the former and 76.8 (IQR 70.2-89.7) in the latter (p = 0.01). Postoperatively the physical domain of the PAC-QoL score had a median value of 2.74 (IQR 1.7-3.75) in the STARR group compared to 1.5 (IQR 1-2.5) in the VRP group (p = 0.03). No major complications were recorded in either group. CONCLUSIONS: VRP and STARR can improve defecation in patients with ODS with minimal complications, but the overall pelvic wellness evaluated by the TAPE score improves significantly only after VRP, suggesting a better performance of VRP than STARR when overall pelvic floor function is concerned.

Cyanoacrylate sealant compared to fibrin glue in staple line reinforcement during laparoscopic sleeve gastrectomy. Pilot prospective observational study.

Laparoscopic Sleeve Gastrectomy (LSG) is associated with serious complications, such as staple line leaks and bleeding. This paper presents a novel approach aimed at the successful consolidation of the suture by the use of the cyanoacrylate, here compared to the use of fibrin glue. Fifty consecutive patients, recruited from October 2015 to March 2016, were submitted to laparoscopic sleeve gastrectomy by standardized surgical technique. The staple line was reinforced with cyanoacrylate or fibrin glue. There were no post-operative complications and no operative time prolongation. An early removal of the draining and a reduction of the average hospitalization were observed. The results suggest that staple line reinforcement with cyanoacrylate during laparoscopic sleeve gastrectomy is as easy, safe and cost-saving as with fibrin glue. Furthermore, cyanocrilate allows a chemical omentoplasty with the result of restoring the anatomy. Therefore, this approach is viable and useful for future trials on the efficacy in preventing surgical post-operative complications.

Short-term outcome of percutaneous tibial nerve stimulation for low anterior resection syndrome: results of a pilot study.

AIM: Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive procedure which has been demonstrated to be effective in faecal/urinary incontinence but has never been tested in low anterior resection syndrome (LARS). The severity of LARS may be evaluated by the LARS score, but rectal cancer treatments may also affect urinary and sexual function, which are not explored by the LARS score. The Three Axial Perineal Evaluation (TAPE) score is a new validated index addressing the overall pelvic floor functions. This study aims to assess the efficacy of PTNS in LARS patients and to evaluate the results by the LARS and TAPE scores. METHODS: Twenty-one patients operated on for rectal cancer between 2009 and 2014 complaining of LARS underwent PTNS (12 sessions of 30 min each). Six patients reported urinary incontinence and all except two (men) were sexually inactive. The LARS score and the TAPE score questionnaires were administered at baseline and after 6 months of follow-up. RESULTS: At 6 months' follow-up, nine patients reported a significant improvement of faecal incontinence and 3/6 an improvement of urinary incontinence after PTNS. Median LARS score significantly decreased from 32 to 27 (P = 0.009), while the median TAPE score improved significantly from 55 to 58 (P = 0.004). CONCLUSIONS: PTNS may be a further option in the treatment of selected patients with LARS and in addition may improve associated urinary incontinence. The severity of LARS can be detected by the LARS score; however, the adoption of the TAPE score is preferred in the case of concomitant urinary and/or sexual problems not explored by the LARS score.

Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long-term outcome of a randomized controlled trial.

AIM: The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy. METHOD: In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria. RESULTS: Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021). CONCLUSION: The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH.

IN-VITRO evidence for the protective properties of the main components of the Mediterranean diet against colorectal cancer: A systematic review.

AIM: Epidemiological studies have shown that the incidence and mortality rates of colorectal cancer (CRC) vary over 10-fold worldwide where within Westernized societies lower rates are observed amongst populations living within the Mediterranean basin, suggesting a significant influence of environment and dietary style in CRC carcinogenesis. Interpretation of the data concerning the benefits of mediterranean (MD) diet is difficult in vivo because of the variability of alimentary regimens used, the differing compliance with dietary supplementation and because of the non-uniform duration of patient cohort observation. Therefore, the aim of this review is to evaluate the in-vitro effects on colorectal cancer cell lines. METHODS: the literature concerning the in-vitro effects of 4 of the principal components symbolizing the MD such as olive oil (polyphenol), red chili (capsaicin), tomato (lycopene) and red grapes (resveratrol) have been systematically reviewed. RESULTS: Several studies have demonstrated that polyphenols form olive oil, lycopene, resveratrol and capsaicin have multiple anticancer properties affecting several metabolic pathways involved in cancerogenesis, apoptosis, and metastasis in CRC cell lines. CONCLUSION: This review summarizes some of the most recent data potentially supportive of the use of MD in CRC chemoprevention, analyzing the in vitro effects of individual components of the MD on CRC cell development, progression, metastasis and apoptosis.

Impact of pericardium bovine patch (Tutomesh(®)) on incisional hernia treatment in contaminated or potentially contaminated fields: retrospective comparative study.

PURPOSE: This retrospective comparative study analyzes the outcome of patients affected by incisional hernia in potentially contaminated or contaminated field, treated by three operative techniques. METHODS: 152 patients (62 M:90 F; mean age 65 ± 14 years) underwent incisional hernia repair (January 2002-January 2012) in complicated settings. Criteria of inclusion in the study were represented by the following causes of admission: mesh rejection/infection, obstruction without gangrene but with possible peritoneal bacterial translocation, obstruction with gangrene, enterocutaneous fistula or simultaneous presence of ileo- or colostomy. The patients were divided into three groups: A (n = 76), treated with primary closure technique; B and C (n = 38 each), with reinforcement by synthetic or pericardium bovine mesh (Tutomesh(®)), respectively. The prosthetic groups were divided into Onlay and Sublay subgroups. RESULTS: Significant decreases in C vs A were observed for wound infection (3 vs 37%) and recurrence (0 vs 14%), and in C vs B for wound infection (3 vs 53%), seroma (0 vs 34%) and recurrence (0 vs 16%). Patients with concomitant bowel resection (BR) (43%) showed (all P < 0.05) an increase of overall morbidity (55 vs 33%) and wound infection rate (42 vs 24%) compared to cases without BR. Morbidity presented no significant differences in C-Onlay or Sublay subgroups. B-Sublay subgroup has (all P < 0.05) lower overall morbidity (20 vs 75%), wound infection (10 vs 68%) and seroma (0 vs 46%) than B-Onlay. CONCLUSIONS: The pericardium bovine patch seems to be safe and effective to successfully repair ventral hernia in potentially contaminated operative fields, especially in association with bowel resection.

Bowel dysfunction following nerve-sparing radical hysterectomy for cervical cancer: a prospective study.

OBJECTIVE: To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients. MATERIAL AND METHODS: Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant. RESULTS: Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy. CONCLUSIONS: Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction. © 2014 S. Karger AG, Basel.

An original surgical approach to manage complete rectal lumen obliteration following stapled hemorrhoidopexy.

Rectal lumen obliteration (RLO) is a rarely described, but fearful and potentially life-threating complication following stapled hemorrhoidopexy. Its management is not standardized and should take into account the time of recognition of the complication, the completeness of obliteration, and the integrity of the rectal wall. Here, we describe a case of complete RLO after stapled hemorrhoidopexy (the first case published to the best of our knowledge), successfully treated via an intra-abdominal approach with full rectal mobilization and recanalization of the rectum using a 31 mm EEA(®) stapler.

Safety and short-term effectiveness of EEA stapler vs PPH stapler in the treatment of degree III haemorrhoids: prospective randomized controlled trial.

AIM: Stapled haemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan-Morgan hemorrhoidectomy. The aim was to investigate a new stapler device designed to overcome these side effects. METHOD: In all, 135 patients (71 men, mean age 42 years) with degree III haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH® staplers (Ethicon EndoSurgery) (63 patients) or with an EEA® stapler (Covidien) (72 patients) in four referral colorectal centres. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in square centimetres) and any postoperative bleeding within 30 days were recorded. RESULTS: The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35.75 ± 17.51 vs 28.05 ± 10.23 cm(2), P = 0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median value 1, vs 3, interquartile range 0-2, vs 2-5, P < 0.0001). Intraoperative haemostasis was better in the EEA group compared with the PPH01 and PPH03 groups. Postoperative bleeding occurred only in two PPH patients. CONCLUSION: Data suggest that the EEA stapler has better haemostatic properties than the PPH stapler and allows resection of a larger area of mucosal prolapse with potential benefits over the recurrence rate of haemorrhoid prolapse.

Recurrent varicose veins of the legs. Analysis of a social problem.

The present study was aimed at assessing the experience of a single referral center with recurrent varicose veins of the legs (RVL) over the period 1993-2008. Among a total of 846 procedures for Leg Varices (LV), 74 procedures were for RVL (8.7%). The causes of recurrence were classified as classic: insufficient crossectomy (13); incompetent perforating veins (13); reticular phlebectasia (22); small saphenous vein insufficiency (9); accessory saphenous veins (4); and particular: post-hemodynamic treatment (5); incomplete stripping (1); Sapheno-Femoral Junction (SFJ) vascularization (5); post-thermal ablation (2). For the "classic" RVL the treatment consisted essentially of completing the previous treatment, both if the problem was linked to an insufficient earlier treatment and if it was due to a later onset. The most common cause in our series was reticular phlebectasia; when the simple sclerosing injections are not sufficient, this was treated by phlebectomy according to Mueller. The "particular" cases classified as 1, 2 and 4 were also treated by completing the traditional stripping procedure (+ crossectomy if this had not been done previously), considered to be the gold standard. In the presence of a SFJ neo-vascularization, with or without cavernoma, approximately 5 cm of femoral vein were explored, the afferent vessels ligated and, if cavernoma was present, it was removed. Although inguinal neo-angiogenesis is a possible mechanism, some doubt can be raised as to its importance as a primary factor in causing recurrent varicose veins, rather than their being due to a preexisting vein left in situ because it was ignored, regarded as insignificant, or poorly evident. In conclusion, we stress that LV is a progressive disease, so the treatment is unlikely to be confined to a single procedure. It is important to plan adequate monitoring during follow-up, and to be ready to reoperate when new problems present that, if left, could lead the patient to doubt the validity and efficacy of the original treatment.

The effects of weight loss due to gastric banding and lifestyle modification on red blood cell aggregation and deformability in severe obese subjects.

OBJECTIVE: To investigate the changes in the aggregation index (AI) and the elongation index (EI), in severe obese subjects (MbObS) undergoing laparoscopic adjustable gastric banding (LAGB). AI and EI are measured by Laser assisted Optical Rotational Red Cell Analyzer (LORCA) and are markers of erythrocyte aggregation and deformability, respectively. DESIGN AND SUBJECTS: Before, 3 and 6 months after LAGB plus lifestyle changes (Mediterranean diet plus daily moderate exercise), we evaluated AI, EI, body mass index (BMI), total (ToT) cholesterol (Chol), high-density lipoprotein (HDL)-Chol, low-density lipoprotein (LDL)-Chol, triglycerides and fasting glucose and insulin levels in 20 MbObS. The Student's t-test was used for comparisons between independent groups and the analysis of variance to assess differences in AI and EI at the 3 time points. Pearson's correlation coefficient was used to assess correlation among continuous variables and multiple linear regression analysis to assess predictive factors for AI and EI changes. RESULTS: BMI and all blood parameters showed a statistically significant decline 3 and 6 months after LAGB as compared with basal, except for EI and HDL-Chol that significantly increased. Stepwise selection of predictors shows that at 3 and 6 months, EI values depended on HDL-Chol values at the same time point. In the EI model, blood glucose was also statistically significant at 6 months. CONCLUSION: Our data show a significant improvement in EI after LAGB-induced weight loss, which correlates with an improved lipid pattern and support the idea that the rapid weight loss induced by LAGB plus lifestyle changes might reduce the thromboembolic risk and the high mortality risk found in MbObS.

Fecal incontinence: up to date on pathophysiology and treatment.

This study analyzes the most recent insight into the pathophysiology of fecal incontinence considering each of the factors contributing to the mechanism of fecal continence both during urgency to defecate and in resting state. In fact different types of incontinence are caused by different damage to one or more of these physiologic factors. The second part of the study focuses on the therapeutic choices of fecal incontinence. The recent introduction of sacral nerve electrostimulation and the progressive broadening of its clinical indications is progressively replacing and challenging other traditional surgical techniques because of their disappointing long-term results and because they are much more invasive. An emerging new treatment based on the injection of anal bulking agents is nowadays even more preferred for the less severe cases of fecal incontinence. An increasing number of materials is now proposed by the industry in order to identify the best biocompatible material to be injected trans-anally. Traditional surgery could be reserved for patients non-responding to these new treatments.