FISSIT (Fistula Surgery in Italy) study: A retrospective survey on the surgical management of anal fistulas in Italy over the last 15 years.

BACKGROUND: Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. METHODS: This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. RESULTS: A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). CONCLUSION: Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.

The HAS-BLED Score is Associated With Major Bleeding in Patients After Cardiac Surgery.

OBJECTIVE: The Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol (HAS-BLED) score has been developed to predict the risk of potential bleeding in anticoagulated patients affected by atrial fibrillation. The aim of this study was to test the hypothesis that the HAS-BLED score is associated with major bleeding also in patients after cardiac surgery. DESIGN: Prospective, single-center nonrandomized study. SETTING: Single hospital center. PARTICIPANTS: Patients. INTERVENTIONS: Standard cardiac operation and analysis of major bleeding events. A total of 1,173 consecutive adult patients who underwent cardiac surgery were recruited. Major bleeding was defined according to the Bleeding Academy Research Consortium classification (3, 4, 5). Bleeding events were classified as early bleeding (within 48 hours after the operation) and late bleeding (after 48 hours and within 90 days, postoperatively). Patients were followed after the discharge for 120 days, through outpatient clinic visits and by phone calls. MEASUREMENT AND MAIN RESULTS: A total of 29 (2.5%) patients experienced early bleeding events (2.5%), while 34 (2.9%) experienced late bleeding events. Univariate and multivariable analysis did not find that the HAS-BLED score was associated with early bleeding, but it was associated significantly with late bleeding (odds ratio [OR], 1.86; 95% confidence intervals [CI] 1.32-2.62, and OR 1.67; 95% CI 1.19-2.35, respectively). CONCLUSION: The HAS-BLED score is associated with increased risk of major bleeding events after cardiac surgery procedures. This may help to plan the standard anticoagulation/antiplatelet therapy in cardiac surgical patients with a higher HAS-BLED score.

'Fertility' and the Carnival 2: Popular Frazerism and the Reconfiguration of Tradition in Europe Today.

This article examines European festive culture through the lens of two ethnographic case studies of carnivals, conducted in Italy and the Czech Republic. The article analyses processes of meaning construction, cultural circulation, and reconfiguration of local traditions that are currently widely at work in rural and marginal European contexts. It explains why I propose to name the cultural complex shaped by those processes 'popular Frazerism'. The article also argues that these phenomena are representative of a certain post-modern romantic imaginary of magic, antiquity, and primitiveness, and explores the symbolic sources and the social needs from which this imaginary draws its strengths and legitimacy. This article is the second part of a broader study divided into two parts.

A Formal Methodology to Design and Deploy Dependable Wireless Sensor Networks.

Wireless Sensor Networks (WSNs) are being increasingly adopted in critical applications, where verifying the correct operation of sensor nodes is a major concern. Undesired events may undermine the mission of the WSNs. Hence, their effects need to be properly assessed before deployment, to obtain a good level of expected performance; and during the operation, in order to avoid dangerous unexpected results. In this paper, we propose a methodology that aims at assessing and improving the dependability level of WSNs by means of an event-based formal verification technique. The methodology includes a process to guide designers towards the realization of a dependable WSN and a tool ("ADVISES") to simplify its adoption. The tool is applicable to homogeneous WSNs with static routing topologies. It allows the automatic generation of formal specifications used to check correctness properties and evaluate dependability metrics at design time and at runtime for WSNs where an acceptable percentage of faults can be defined. During the runtime, we can check the behavior of the WSN accordingly to the results obtained at design time and we can detect sudden and unexpected failures, in order to trigger recovery procedures. The effectiveness of the methodology is shown in the context of two case studies, as proof-of-concept, aiming to illustrate how the tool is helpful to drive design choices and to check the correctness properties of the WSN at runtime. Although the method scales up to very large WSNs, the applicability of the methodology may be compromised by the state space explosion of the reasoning model, which must be faced by partitioning large topologies into sub-topologies.

DG-RAR (Doppler-guided recto-anal repair): a new mini invasive technique in the treatment of prolapsed hemorrhoids (grade III-IV): preliminary report.

We present preliminary data from a prospective observational study on an initial group of 40 patients, selected from our Department, affected by grade III-IV hemorrhoids and treated with a new less invasive technique called Doppler-guided recto-anal repair [DG-RAR; Agency for Medical Innovations GmbH (AMI), Feldkirch, Osterreich, Austria]. This study was performed by analyzing bleeding, pain, and prolapse in the preoperative period and after surgery. Follow-up ranged from 5 to 37 months. We used this technique to treat the "vascular factor" with a Doppler-guided suture of the terminal branches of the hemorrhoidal arteries (HAL Doppler), and then we reduced hemorrhoidal prolapse [recto-anal repair (RAR)]. Recto-anal repair was performed with a special proctoscope with an oblique slot that when rotating shows a progressively wider portion of anorectal mucosa and submucosa in a longitudinal direction. Furthermore, this rotation enables the performance of a longitudinal pexy where the prolapse is located. The result is an immediate reduction of hemorrhoidal prolapse. Postoperative follow-up showed disappearance of pain and no bleeding. Relapse of prolapse occurred in 2 (5%) patients. Complications included 2 rectal impactions and 2 cases of thrombosis. The data appear encouraging for grade III-IV hemorrhoids treated with DG-RAR because of reduced trauma and a lower rate of complications with respect to other techniques used for prolapse reduction.

The blind colonic J-pouch: an original technique to reduce the surgical risk in the treatment of extra-peritoneal rectal cancer.

BACKGROUND: Low and ultra-low anterior resection with colo-rectal or colo-anal anastomosis is accompanied by high frequency of postoperative anastomotic leakage. The aim of this report is to describe a novel technical approach to colorectal reconstruction. MATERIALS AND METHODS: The innovative procedure introduces the principle of 'no anastomosis-no leakage', and it can be performed both laparascopically or by means of a laparotomy. It consists of a simple colo-rectal or colo-anal apposition with latero-terminal modality, with the creation of a colonic J-pouch called "blind" because it remains closed in the external site and the anus is sealed up. The surgery is completed with an exclusive derivative colostomy, and the reconstruction of the intestinal continuity is postponed to a second operation. Within 4-6 weeks from the first, the blind pouch is opened, the communication between the anus and the colon is established, and the colostomy is closed and reduced in the peritoneal cavity. RESULTS AND CONCLUSIONS: Ethics committee of our hospital approved the experimental program; actually, we are finishing the first step on 15 patients, and preliminary clinical results look like to be very good. The innovative methodology is here described in advance, and we pledge to spread clinical results in a subsequent report.

Dynamic self-regulating prosthesis (protesi autoregolantesi dinamica): the long-term results in the treatment of primary inguinal hernias.

The dynamic self-regulating prosthesis (protesi autoregolantesi dinamica, PAD) is a double-layered prosthesi, in use since 1992 in inguinal hernia repair. In 1999, we published the short-term results on 500 patients and herein we report the long-term follow-up. Five hundred eighty-five PAD procedures were performed on 500 adult male, unselected patients. Hernias were unilateral in 415 patients, were bilateral in 85 patients, were direct in 197 patients (33.7%), were indirect in 269 patients (46.0%), and were combined in 119 patients (20.3%). Four hundred sixty-four patients were alive at the follow-up period of minimum 5 years, whereas 36 died (7.2%) of causes unrelated to the hernia. No information was available on 73 patients (14.6%). Therefore, the follow-up was consisted of 391 patients (78.2%) with 469 hernias. The recurrence and testicular atrophy rates were nil. Three patients (0.77%) presented chronic pain and 18 (4.6%) suffered persistent discomfort or paresthesia. A hydrocoele was observed in one patient (0.2%). The long-term data confirm the efficacy of the dynamic self-regulating posthesis hernioplasty. We propose it as a standard of care in all cases of primary inguinal hernia in adult males, retaining it as a definitive and comfortable solution.