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.

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients.

PURPOSE: Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis. METHODS: Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work. RESULTS: We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2. CONCLUSIONS: The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Buschke-Lowenstein tumor successful treatment by surgical excision alone: a case report.

Perianal giant condyloma acuminatum is a rare variant of condyloma acuminata and often represents a therapeutic challenge. We report a case successfully treated with surgical excision alone.

Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial.

PURPOSE: This prospective, multicenter trial was designed to assess the safety and effectiveness of a novel technique in the treatment of outlet obstruction caused by the combination of intussusception and rectocele by using a double-transanal, 33-mm circular stapler. METHODS: From January to October 2001, 90 patients with outlet obstruction were operated on and followed (mean, 16.3 +/- 2.9 months) by the validated Constipation Scoring and Continence Grading Systems, clinical examination, defecography, and anorectal manometry. Anal ultrasound also was performed in 58 multiparous patients. RESULTS: Operative time and hospital stay were short (mean, 43.3 +/- 8.7 minutes and 2.1 +/- 0.8 days, respectively), and postoperative pain was minimal. The mean time to resume normal activity was 10.2 +/- 4.5 days. Complications were 17.8 percent fecal urgency, 8.9 percent incontinence to flatus, 5.5 percent urinary retention, 4.4 percent bleeding, 3.3 percent anastomotic stenosis, and 1.1 percent pneumonia. All constipation symptoms significantly improved (P < 0.001) without worsening of anal continence. No patient complained of dyspareunia. At postoperative defecography, all patients had a double incisure of the lower rectal outline in the site of anastomosis, with the disappearance of both intussusception and rectocele. Anal pressure was not significantly modified, whereas rectal compliance was restored (P < 0.05). No lesions of anal sphincters caused by the operation were found in multiparous patients. The outcome at one year was excellent in 48 of 90 patients, good in 33, fairly good in 5, and poor in 4. CONCLUSIONS: This novel technique seems to be safe and effective in the treatment of outlet obstruction caused by the combination of intussusception and rectocele. Randomized trials are required to confirm these findings.