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.

Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal fissure.

To evaluate the outcome of a left lateral internal sphincterotomy extended for 20% of total sphincter length in female patients with chronic anal fissure, high anal resting pressure and normal preoperative anal continence. Between January 2014 and January 2018 all the female patients with chronic anal fissure showing failure of medical therapy, perfect anal continence (Cleveland Clinic Florida incontinence score = 0) and high anal resting pressure underwent a lateral internal sphincterotomy extended for 1/5 of total lateral sphincter length, basing on the preoperative measurements by three-dimensional endoanal ultrasound. Postoperative follow-up included clinical assessment at 3, 6 and 12 months associated with manometric and ultrasonographic evaluation at 6 months. Thirty-two patients, [median age 45 (range 19-68)] were included and, of these, 2 (6.2%) were lost to follow-up. At 6 month follow-up success rate was 93.3% (28/30) and continence score was 0 in all the patients. Two patients (6.2%) with poor outcome showed incomplete sphincterotomy at EAUS and underwent re-surgery. At three-dimensional endoanal ultrasound the median length of sphincterotomy was 6 mm (5-8.2). At 12 month follow-up the success rate was 100% and Cleveland Clinic Florida incontinence score remained 0 in all the cases. Open left lateral internal sphincterotomy extended for about 20% of total left lateral internal sphincter length seems to be safe and effective in the treatment of chronic anal fissure in suitable female patients achieving a high success rate without compromising anal continence.

Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis.

PURPOSE: The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. METHODS: From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. RESULTS: A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. CONCLUSION: 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.

Role of 0.4 % glyceryl trinitrate ointment after stapled trans-anal rectal resection for obstructed defecation syndrome: a prospective, randomized trial.

PURPOSE: The anal fissure and spasm represent possible complications and causes of postoperative anal pain in patients that have undergone stapled trans-anal rectal resection (STARR). The etiology of these complications is still questioned such as the treatment modality. This study was designed to evaluate the effectiveness of topical glyceryl trinitrate (GTN) 0.4 % in determining decrease of incidence of postoperative anal spams and fissure and reduction of early postoperative pain. METHODS: From a total of 243 patients referred for obstructed defecation syndrome (ODS) 104 (42.7 %) underwent STARR and were randomized to receive (Group 1) or not (Group 2) topical 0.4 % GTN ointment every 12 h for four postoperative weeks. Postoperative evaluation was made at 1, 6, and 12 months. RESULTS: At 1 month follow-up, the incidence of anal spasm in Groups 1 and 2 was, respectively, 0 and 14.6 % (6/41) (p = 0.010; Fisher's exact test). The incidence of anal fissure was 4/41 (9.7 %) in Group 2 and 0/44 (0 %) in Group 1 (p = 0.05; Fisher's exact test). Significant differences in median visual analogue scale score between groups were found at 1 week and 1 month follow-up (1; 0-5 vs. 2; 0-7: p = 0.0104; Mann-Whitney U test). CONCLUSION: Anal spasm and fissure may represent a cause of early postoperative anal pain in patients that have undergone STARR procedure for ODS. The use of topical GTN 0.4 % ointment in the early postoperative course seems to reduce the incidence of anal spasm and fissure and to improve the associated early postoperative pain.

Laparocopic ventral hernia repair with primary transparietal closure of the hernial defect.

BACKGROUND: The treatment of ventral hernias is still a subject of debate. The affixing of a prosthesis and the subsequent introduction of laparoscopic treatment have reduced complications and recurrences. The high incidence of seromas and high costs remain open problems. METHODS: At our Department between January 2008 and December 2011, 87 patients (43 over 65 years), out of a total of 132, with defects of wall whose major axis was less than 10 cm, or minor and multiple defects (Swiss-cheese defect) on an axis not exceeding 12 cm underwent laparoscopic ventral hernia repair (LVHR) with primary and transparietal closure of the hernial defect. Through small incisions in the skin we proceeded to close the parietal defect with sutures tied outside. Then the mesh was fixed as usual with double row of stitches and an overlap of 3-5 cm. RESULTS: In all patients, 43 of them elderly, surgery was successfully conducted. The juxtaposition of the edges of the hernial defect has not been time consuming and has not developed new complications. The postoperative course was uneventful, with discharge on the third day, except in 5 patients. Were observed only small gaps and not the formation of large seromas. There were no infections wall. We do not have relapses, but some small and asymptomatic solutions continuously up to 2 cm at the sonographic study. In elderly patients the absence of dead space and the feeling of greater stability of the wall, early mobilization and pain control have facilitated the post-operative course. CONCLUSIONS: The positioning of sutures transcutaneous is simple and effective, the reduced incidence of seromas and the greater stability of the wall suggest to adopt this procedure fully.The possibility to close the margins of the defect may allow to change the size and setting of the mesh, since the absence of dead space allows to download physiologically tensions of the wall.

Improved clinical outcomes with a new contour-curved stapler in the surgical treatment of obstructed defecation syndrome: a mid-term randomized controlled trial.

BACKGROUND: Stapled transanal rectal resection has become the primary surgical procedure for surgical treatment of obstructed defecation syndrome caused by rectocele or rectal intussusception. The procedure is generally performed with 2 circular staplers. Recently, a dedicated contour-curved stapler was developed. OBJECTIVE: This study was designed to compare the effects of these stapler types on relief of symptoms. DESIGN AND SETTING: A randomized controlled trial was conducted at a regional referral center in Naples, Italy. PATIENTS: Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated from November 2005 through September 2007. INTERVENTIONS: Participants were randomly assigned to undergo stapled transanal rectal resection with 2 circular staplers or the contour-curved stapler. MAIN OUTCOME MEASURES: The primary end point was success rate at 24 months, defined by symptom improvement on an obstructed defecation syndrome scale. Secondary end points included success rate at 12 months, Agachan-Wexner constipation score, and rates of early and late complications at 12 and 24 months. RESULTS: Of 198 patients evaluated, 63 patients (31.8%) satisfied criteria. Follow-up data were available for 61 patients: 30 patients (28 women) in the circular stapler group (mean age, 53; range, 41-75 years) and 31 (29 women) in the contour-curved stapler group (mean age, 55; range, 38-69 years). At 24-month follow-up, success was achieved in 21 patients (70.0%) with the circular staplers and in 27 (87.0%) with the contour-curved stapler (P = .10). Symptom scores improved significantly in both groups from baseline to 12 months (P < .0001). Improvement was maintained in the contour-curved stapler group: mean score, 5.0 (SD, 1.6) at 12 months and 5.5 (1.5) at 24 months (P = .20). In the circular stapler group, symptom scores worsened from 4.5 (1.5) at 12 months to 9.0 (1.3) at 24 months (P < .0001). At 24 months, the groups differed significantly in symptom scores (P < .0001) and constipation scores (P = .03). No significant differences were seen in duration of postoperative hospital stay or rate of early or late complications. CONCLUSIONS: Stapled transanal rectal resection with either circular or contour-curved staplers can achieve relief of symptoms in patients with obstructed defecation syndrome. The contour-curved stapler appears to result in more stable clinical results over time.

Stapled trans-anal rectal resection (STARR) by a new dedicated device for the surgical treatment of obstructed defaecation syndrome caused by rectal intussusception and rectocele: early results of a multicenter prospective study.

BACKGROUND AND AIM: Obstructed defaecation syndrome (ODS) represents a very common clinical problem. The aim of the this prospective multicenter study was to evaluate the efficacy and safety of stapler trans-anal rectal resection (STARR) performed by a new dedicated device, CCS-30 Contour Transtar, in patients with ODS caused by rectal intussusception (RI) and/or rectocele (RE). MATERIALS AND METHODS: All the patients who underwent STARR for ODS caused by RI and/or RE at Colorectal Surgery Units of S. Stefano Hospital, Naples, Gepos Hospital, Telese, Benevento and S. Maria della Pietà Hospital, Casoria, Naples, Italy were prospectively introduced into a database. Preoperatively, all the patients underwent anorectal manometry and cinedefecography. The grade of ODS was assessed using a dedicated obstructed defaecation syndrome score (ODS-S). All the patients with a ODS-S >or=12 and RI and/or RE were enrolled. Patients were followed up clinically at 6 months. RESULTS: Thirty patients, 28 (93.3%) women, mean age 56.6+/-12.7 years, underwent STARR, by Transtar, between February and October 2006. Preoperatively, ODS-S was 15.8+/-2.4. RI was present in 26 (89.6%) and RE (34.4+/-15.2 mm) in 27 (93.1%) patients. No major postoperative complications occurred. The length of hospital stay was 2.5+/-0.6 days. At 6-month follow-up, ODS-S was 5.0+/-2.3 (P<0.001). Successful outcome was achieved in 25 (86.2%) patients. CONCLUSION: STARR, performed by the new dedicated device, CCS-30 Contour Transtar, seems to be an effective and safe procedure to treat ODS caused by RE and/or RI. A longer follow-up and a larger number of patients is needed to confirm these results.

Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial.

PURPOSE: This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure. METHODS: All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months. RESULTS: Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001). CONCLUSIONS: As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence.

Laparoscopic treatment of an uncommon abdominal localization of Castleman disease.

Castleman disease is a rare lymphoproliferative disorder overall localized in the mediastinum and rarely in the abdomen. It appears as a tumor-like mass characterized by a massive growth of lymphoid tissue. Benign forms are usually associated to a good prognosis even if multifocal variants present more aggressive behavior. Two different histologic types have been described: the hyaline vascular and the plasma cell form. The diagnosis is often achieved only at the histologic evaluation of the surgical specimen. Presented here is the rare occurrence of this disease in the abdominal cavity treated by the laparoscopic approach. No postoperative complications were observed. No recurrence has been detected at 12 months CT scan follow-up. Until now, no reports of this kind of treatment have been available in literature.

A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up.

OBJECTIVE: The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. SUMMARY BACKGROUND DATA: Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying. MATERIALS AND METHODS: Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. RESULTS: In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. CONCLUSIONS: Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Buschke-Löwenstein tumor. Successful treatment by surgical electrocautery excision alone: a case report.

Perianal giant condyloma acuminatum is a rare variant of condyloma acuminata and its therapy often proves distinctly challenging. We report on a case successfully treated with surgical electrocautery excision alone.