Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study.

PURPOSE: To evaluate the potential benefits associated with the short-term (6 months) treatment with transanal irrigation (TAI) in patients suffering from functional constipation (FC), functional fecal incontinence (FI), and low anterior resection syndrome (LARS). METHODS: A multicenter observational study (12 centers; 369 patients) was conducted to assess the following primary and secondary objectives: to evaluate the level of satisfaction regarding bowel control and quality of life (QoL); to evaluate bowel symptoms severity and dropout frequency and reason. To this aim, validated questionnaires were provided to the patients at baseline (T0) and after 6 months of TAI treatment (T6) performed with the medical device Peristeen® Plus (Coloplast A/S, Denmark). Statistical analyses were conducted to compare the outcomes obtained at T0 and T6. RESULTS: A 6-month treatment with TAI enabled a statistically significant (p < 0.05) improvement of QoL scores, satisfaction scores regarding bowel control, and severity indexes of disorder-related symptoms in patients suffering from FC, FI, and LARS. Globally, 8.0% of patients discontinued the treatment after 6 months as a result of occurrence of symptoms (2.4%) or other justifications (3.8%) such as personal reasons. None of the dropouts were due to treatment inefficacy. CONCLUSION: Results of the present study suggest that short-term TAI treatment is beneficial for patients suffering from functional bowel disorders and LARS. Future analysis of prospective data will focus on the clinical outcomes associated with the long-term use (up to 24 months) of TAI when dealing with these types of medical conditions.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease.

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a "special interest" in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: "A + : strongly agree; A-: agree; N: unsure/no opinion; D-: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

Italian guidelines for the surgical management of enteral stomas in adults.

BACKGROUND: Worldwide, stomas represent a medical and social problem. Data from the literature on stoma management are extensive but not homogeneous. In Italy, no guidelines exist for this topic. Thus, clear and comprehensive clinical guidelines based on evidence-based data and best practice are need. In 2018, the Multidisciplinary Italian Study group for STOmas, called MISSTO, was founded. The aim was to elaborate guidelines for practice management of enteral and urinary stomas in adults. METHODS: A systematic review of the literature was performed using PubMed, National Guideline Clearinghouse, and other databases. The research included guidelines, systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care", and "stoma reversal". The systematic review was performed for each topic, and studies were evaluated according to the GRADE system, AGREE II tool. RESULTS: Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low levels of scientific evidence statements, a consensus conference composed of expert members of the major Italian scientific societies in the field of stoma management and care was held. After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines was elaborated and prepared for publication. This manuscript is focused on statements on the surgical management of enteral stomas. CONCLUSIONS: These guidelines are the first Italian guidelines on multidisciplinary management of enteral stomas with the aim of assisting surgeons during stoma management and care.

Pelvic floor dysfunction in inflammatory bowel disease.

Advances in tailored medical therapy and introduction of biologic agents for inflammatory bowel disease (IBD) treatment have ensured long-term disease remission. Some patients, however, still report defecatory symptoms. Patients present with a wide spectrum of conditions - anal incontinence, obstructed defecation and pelvic pain among the most frequent - that have a great impact on their quality of life. Due to IBD diagnosis, little relevance is attributed to this type of symptoms and their epidemiologic distribution is unknown. Pathogenetic hypotheses are currently under investigation. Routine diagnostic workflow and therapeutic options in pelvic floor service are often underused. The evaluation of these disorders starts with an endoscopy to rule out ongoing disease; the following diagnostic workflow is the same as in patients without IBD. For fecal incontinence and obstructed defecation, simple conservative therapy with dietary modifications and appropriate fluid intake is effective in most cases. In non-responding patients, anorectal physiology tests and imaging are required to select patients for pelvic floor muscle training and biofeedback. These treatments have been proven effective in IBD patients. Some new minimally invasive alternative strategies are available for IBD patients, as sacral nerve and posterior tibial nerve stimulation; for other ones (e.g., bulking agent implantation) IBD still remains an exclusion criterion. In order to preserve anatomical areas that could be useful for future reconstructive techniques, surgical options to cure pelvic floor dysfunction are indicated only in a small group of IBD patients, due to the high risk of failure in wound healing and to the possible side effects of surgery, which can lead to anal incontinence or to a possible proctectomy. A particular issue among defecatory symptoms in patients with IBD is paradoxical puborectalis contraction after restorative proctocolectomy: if this disorder is properly diagnosed, a conservative treatment is indicated, thus avoiding unnecessary laparotomy for small bowel occlusion. Pelvic pain management, coordinated by a specialist with expertise in pelvic floor disorders, includes many options, which vary from oral or local therapies to pelvic floor rehabilitation and sacral nerve stimulation. Surgical procedures often have unsatisfactory outcomes. Diagnosis and investigation of anorectal functional disorders in patients with IBD is important in order to implement better-suited diagnostic and therapeutic strategies, so as to avoid unnecessary and potentially detrimental medical and surgical therapies, with the final aim of improving patients' quality of life.

The relationship between etiology, symptom severity and indications of surgery in cases of anal incontinence: a 25-year analysis of 1,046 patients at a tertiary coloproctology practice.

BACKGROUND: The etiology of anal incontinence (AI) is often multifactorial. There is little data on the relationship between the etiology of AI, symptom severity, and the need for surgery. The aim of our study was to investigate this association in a large number of unselected patients with AI referred to a tertiary specialist coloproctological practice. METHODS: Patients with AI seen at our unit between 1983 and 2008 were analyzed. The main etiologies were categorized as congenital, traumatic, neurologic, idiopathic, post-operative, post-obstetric, secondary to rectal prolapse, or inflammatory bowel disease. The severity of AI was graded using the validated Pescatori incontinence scale. RESULTS: Overall, 1,046 patients were studied. The AI score was higher in patients with congenital (4.7 ± 1.1), traumatic (4.6 ± 1.4), and neurological (4.4 ± 1.2) incontinence. Surgical treatment was indicated in 214 cases (20.5%). Patients with AI related to trauma and congenital anomalies required surgery in 43.5 and 31.4% of cases, respectively, a percentage significantly higher than that for patients with other etiologies (P = 0.002). Prolapse-related AI usually responded to correction of the prolapse. CONCLUSIONS: Patients with congenital, traumatic, and neurological AI tend to have greater symptom severity. Traumatic, rectal prolapse-related, and congenital AI cases more often require surgery.

[Spontaneous pneumothorax caused by lung metastasis of sarcoma of the thigh]. / Pneumotorace spontaneo da metastasi polmonare di sarcoma della coscia.

Relapsing spontaneous pneumothorax can be the first manifestation of pulmonary metastases of soft tissues sarcomas. Standard imaging techniques and computed tomography may not be able to detect small malignant cystic lesion or to distinguish between them and benign bollous lesions. We report the case of a 33 year-old male who, in the past, underwent surgical treatment for a synovial sarcoma of the inferior limb. The patient was admitted to our hospital because of right spontaneous pneumothorax; both chest x-ray and CT scan didn't detect any metastatic pulmonary lesion. A few days after the discharge the patient was readmitted because of relapsed pneumothorax; high-definition CT of the chest revealed a pulmonary cystic lesion that was resected thoracoscopically. Histological examination revealed a pulmonary metastases of synovial sarcoma.