European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

The treatment of acute appendicitis in two age-based groups during COVID-19 pandemic: a retrospective experience in a COVID-19 referral hospital.

PURPOSE: During the past months, the Italian Government has reduced the restrictions and access to hospitals as well as outpatient. Since then, up to 40% of non-traumatic abdominal emergencies have had unusual delayed treatment. Given the rapidly evolving situation and the absence of evidence to support recommendations during the COVID-19 pandemic, it is useful to assess how the current situation is influencing the management of elderly patients with acute appendicitis. METHODS: Between February 2020 and December 2020, all patients 18 years or older undergone appendectomy were included. Patients were divided in two age-based groups (young groups, YG; elderly group, EG). Surgical approach, hospital stay, post-operative complications, radiology reports, and histologic examination were included in the retrospective analysis. RESULTS: One hundred eight patients underwent appendectomy, 81 patients into the YG, and 27 in the EG. Laparoscopy was performed in 87.7% of the YG and in 51.8% of the elderly (p < 0.000), while conversion to laparotomy was necessary in 3.7% in the YG vs 22.3% of the other group (p < 0.009). Open procedures were more frequent in the EG, 25.9% vs 8.6% (p value < 0.05). No mortality rate was reported in both groups; moreover, the mean hospital stay was greater in the EG than the YG (p < 0.000). CONCLUSION: Our data highlighted a partial delay in diagnosis in the elderly group, and an increase in complicated appendicitis also demonstrated by the need for conversion to laparotomy despite no significant relationship between these findings and the histologic examination was reported.

Sclerotherapy with 3% polidocanol foam for third- and fourth-degree hemorrhoids as "bridge treatment" during the COVID-19 pandemic in Italy.

PURPOSE: In Italy, colorectal surgery has been strongly affected with the vast majority (90%) of operations treating benign diseases, with an estimated overall 12-week cancellation rate of 72%. Little is known on how to best manage patients with benign diseases and the consequences this interruption of care will have in post-pandemic times. Proctologic diseases have social, psychological, and healthcare repercussions for their high incidence and great impact on the quality of life. METHODS: We decided to treated 10 urgent cases affected from III- and IV-degree hemorrhoids with 3% polidocanol foam in attempt to reduce hemorrhoidal symptoms while waiting for surgery so called "bridge treatment". RESULTS: During the follow-up no complications were occurred, and all patients had resolution of bleeding and pruritus with a mean VAS of 1 (range, 0-1). CONCLUSIONS: This treatment could reduce the bleeding that is the main symptom from which patients suffer and for which they underwent proctological evaluation and surgery. According to our preliminary experience in the impossibility of accessing the surgery during the COVID-19 pandemic, ST could be considered as the treatment of choice in those patients who are suffering from grade III- and IV-degree hemorrhoids while waiting for surgery.

Endoscopic pilonidal sinus treatment (EPSiT) in recurrent pilonidal disease: a prospective international multicenter study.

BACKGROUND: Pilonidal disease (PD) is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. Recurrent PD after surgical treatment is frequent event for the 25-30% of cases. The present study evaluated endoscopic pilonidal sinus treatment (EPSiT) in recurrent and multi-recurrent PD. METHODS: Of the consecutive prospective patients with recurrent PD, 122 were enrolled in a prospective international multicenter study conducted at a secondary and tertiary colorectal surgery centers. Primary endpoint was to evaluate short- and long-term outcomes: healing rate/time, morbidity rate, re-recurrence rate, and patient's quality of life (QoL). RESULTS: Complete wound healing rate was occurred in 95% of the patient, with a mean complete wound healing time of 29 ± 12 days. The incomplete healing rate (5%) was significantly related to the number of external openings (p = 0.008), and recurrence was reported in six cases (5.1%). Normal daily activity was established on the first postoperative day, and the mean duration before patients returned to work was 3 days. QoL significantly increased between the preoperative stage and 30 days after the EPSiT procedure (45.3 vs. 7.9; p < 0.0001). CONCLUSIONS: The EPSiT procedure seems to be a safe and effective technique in treating even complex recurrent PD. It enables excellent short- and long-term outcomes than various other techniques that are more invasive.

Transperineal rectocele repair with biomesh: updating of a tertiary refer center prospective study.

PURPOSE: Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. A variety of surgical procedures have been used in the rectocele repair to enhance anatomical and functional results and to improve long-term outcomes. METHODS: In this prospective study, we treated 25 selected women suffering from simple symptomatic rectocele with transperineal repair using porcine dermal acellular collagen matrix Biomesh (Permacol®). Watson score and SF-36 questionnaire were used to evaluate postoperative outcomes and quality of life. RESULTS: Follow-up ranged from 12 to 24 months, the mean total Watson score was significantly lower than the preoperative score (P < 0.001), and every patient has improved functional outcomes. There were no major intraoperative or postoperative complications. Two cases of urinary infection and 4 patients delayed wound healing were reported. Those patients who were sexually active prior to surgery have not experienced problems with sexual function or dyspareunia. CONCLUSIONS: Despite lack of comparative study in literature, rectocele repair with Permacol® by the transperineal approach seems an effective and safe procedure that avoids some of the complications associated with synthetic mesh use.

Intracorporeal Ileocolic Anastomosis in Laparoscopic Right Colectomy: A New Way to Make it Simple?

Although there has been a recent increase in the use of laparoscopy in colorectal surgery, the percentage of patients who undergo surgery using entirely minimally invasive techniques is still quite low, and there are substantial differences among centers. It has been argued that the limiting factor in the use of laparoscopic procedures is not the tumor or patient characteristics, but rather the number of surgeons with adequate skills to perform an entirely laparoscopic colectomy. To address this issue, we report here our totally laparoscopic right colectomy technique, with particular focus on a new way to perform the enterotomy closure, which may simplify ileocolic anastomosis.

Over-Sewing of Staple Line in Laparoscopic Sleeve Gastrectomy: Initial Experience of a Comparative Study.

INTRODUCTION: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. Recently, over-sewing has been proposed as a cost-effective and helpful method for reinforcing the staple line. The purpose of this study was to report our initial experience with LSG comparing over-sewing over the entire staple line with the upper-third staple line. MATERIALS AND METHODS: All obese patients seen at Negrar Sacro Cuore, Don Calabria Hospital were entered into our prospective database and were retrospectively evaluated. Complications (divided as major complications: leaks and bleeding; and minor complications: dysphagia, esophagitis, and reflux disease) and reoperations were recorded for all patients. Complications were graded according to the Clavien classification system. RESULTS: From February 2015 to March 2016, 30 patients underwent LSG. Patients were divided in two groups according to over-sewing: Group A-over-sewing over the entire staple line; and Group B upper-third over-sewing. Mean total operative time was longer in Group A-90 minutes-compared with 85 minutes in Group B. In regard to minor complications, we reported one esophagitis and two cases of dysphagia in Group B and one dysphagia in Group A. Gastroesophageal reflux was higher in Group B than in Group A (3 vs. 1, p=0.149). Three major complications were observed (10%): two bleeding and one hematoma in Group B and no major complications occurred in Group A. All major complications were conservatively treated. No leaks were reported in both groups. No mortality was observed. CONCLUSIONS: Over-sewing of the staple line was associated with fewer leaks but no conclusions can be drawn regarding the effects of over-sewing on staple line bleedings. Before standardizing surgical techniques further, trials are necessary to improve our knowledge about over-sewing in LSG.

Surgical Treatment of Rectovaginal Fistula in Crohn's Disease: A Tertiary Center Experience.

BACKGROUND: Rectovaginal fistula (RVF) is a disastrous complication of Crohn's disease (CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a woman's quality of life. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics, and its published success rates vary with initial success being around 50% rising to 80% with repeated surgery. Several surgical and sphincter sparing approaches have been described for the management of rectovaginal fistula, aimed to minimize the recurrence and to preserve the continence. MATERIALS AND METHODS: A retrospective study was performed for RVF repair between 2008 and 2014 in our tertiary centre at the University Hospital of Tor Vergata, Italy. All the patients were affected by Crohn's disease and underwent surgery for an RVF under the same senior surgeon. All patients were prospectively evaluated. RESULTS: All 43 patients that underwent surgery for RVF were affected by Crohn's disease. The median age was 43 years (range 21-53). Four different surgical approaches were performed: drainage and seton, rectal advacenment flap (RAF), vaginal advancement flap (VAF), transperineal approach using porcine dermal matrix (PDM), and martius flap (MF). The median time to success was six months (range 2-11). None of the patients were lost during the 18 months of follow-up. The failure group rate was 19% in contrast with the healing rate group that was 81%. No demographic of disease-related factors were found to influence healing. CONCLUSION: The case series of this study supports the dogma that "there are no absolute rules when treating Crohn's fistula". There is no gold standard technique; however, it is mandatory to minimize the recurrence with a sphincter saving technique. Randomized trials are needed to find a standard surgical approach.

Endoluminal Vacuum Therapy as Treatment for Anastomotic Colorectal Leakage.

BACKGROUND: The clinical leakage rate after anterior resection varies from 2.8-20%, with a 6-22% mortality rate and a 10-80% risk of permanent stoma. Endo-SPONGE® (B. Braun Melsungen AG, Melsungen, Germany) may treat extraperitoneal anastomotic leakage in the lesser pelvis. It consists of an open-pored sponge inserted into the cavity. A drainage tube fixed to a low vacuum drainage system is then connected to the sponge through the anus. MATERIAL AND METHODS: Between January 2007 and December 2014, 14 patients with anastomotic leakage following low anterior resection were treated with Endo-SPONGE® and were prospectively evaluated. In all patients, a CT-scan was performed and they received an intravenous antibiotic therapy with piperacillin+tazobactam (4.5g,3 times/daily). Complete healing was defined as endoscopically proven closure of the insufficiency cavity with a normal mucosa. RESULTS: Stapled straight end to end, colorectal anastomoses were performed in all patients between 3-7 cm above the anal verge, a protective loop ileostomy was performed in every patient. The diagnosis of anastomotic leakage was performed after a median interval of 14 days, the median size of the cavity was 81x46 mm. Fluid collection was drained, percutaneosly in 12 cases, surgically in two patients. The median duration of therapy was 35 days, with 3-14 sponge exchanges for each patient. Median healing time was 37 days. No intraoperative complications were recorded, however, we found five cases of mild anal pain treated medically. CONCLUSION: Considering the literature and our results, the Endo-SPONGE® seems an effective, minimally invasive procedure to treat extraperitoneal anastomotic leakage, reducing morbidity, mortality, and hospital stay.

Laparoscopic Treatment of Giant Ventral Hernia: Experience of 35 Patients.

BACKGROUND: Minimal access surgery for incisional hernia repair is still debated, especially for giant wall defects. Laparoscopic repair may reduce pain and hospital stay. This study was designed to evaluate the feasibility of the laparoscopic technique in giant hernia. MATERIALS AND METHODS: From 2007 to 2013, 35 consecutive patients with giant ventral hernia, according to the Chevrel classification, underwent laparoscopic repair. Fourteen patients were obese, with a body mass index (BMI) > 30 and in 21 patients the mean BMI was 24 (range 22-28). In all patients, the wall defect was larger than 20 cm. RESULTS: Mean operative time was 159±30 minutes, and, for defects larger than 25 cm, it was 210±20 minutes. Patient conversion did not occur. In 29 patients, the mean wall defect was 20x25 cm, and in six patients the mean wall defect was 26x31 cm, and, as measured from within the peritoneal cavity, the mean overlap was 5 cm (range 3-6). Short-term antibiotic prophylaxis consisted of Cefazolin 2 g IV (intravenous) the day of surgery. All patients were discharged within 72-96 hrs. The mean follow-up was 24 months. No infection occurred and no chronic pain was recorded. However, three seroma were observed (outpatient treatment) and two xiphoid recurrences were observed. CONCLUSIONS: Laparoscopic hernia repair is technically feasible and is safe in patients with giant fascial defects as well as obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence. This approach should be reserved for patients with no history of previous hernia repair. Further studies are expected to confirm these promising results.

Does a relationship still exist between gastroesophageal reflux and Helicobacter pylori in patients with reflux symptoms?

BACKGROUND: The nature of the relationship between Helicobacter pylori and reflux esophagitis (RE) is not fully understood. In addition, the effect of H. pylori eradication on RE and gastroesophageal reflux disease (GERD) is unclear. This study was designed to investigate the relationship between H. pylori infection and the grade of GERD in patients with reflux symptoms. METHODS: Between January 2010 and July 2013, 184 consecutive patients with daily reflux symptoms for at least one year were evaluated at the ambulatory for functional esophageal disease, Tor Vergata University Hospital, Rome, Italy. All patients underwent a pretreatment evaluation, which included anamnesis, clinical examination, Esophagogastroduodenoscopy (EGDS) with biopsy, esophageal manometry and 24-hour pH-metry. All statistical elaborations were obtained using Statigraphies 5 plus for Window XP. RESULTS: There was no statistical difference regarding Lower Esophageal Sphincter (LES) pressure between patients who were H. pylori-positive and H. Pylori-negative (19.2 ± 9.5 (range: 3.7 to 46.2) and 19.7 ± 11.0 (range: 2.6 to 61), respectively). Further, no significant difference was evidenced in esophageal wave length (mean value: 3.1 seconds in H. pylori-negative patients versus 3.2 seconds in H. pylori-positive patients) or in esophageal wave height (mean value: 72.2 ± 39.3 in H. pylori-negative patients versus 67.7 ± 28.4 in H. pylori-positive patients). We observed that hiatal hernia (P = 0.01), LES opening (P = 0.05), esophageal wave length (P = 0.01) and pathological reflux number (P = 0.05) were significantly related to the presence of esophagitis. However, H. pylori infection was not significantly related to the presence of reflux esophagitis. CONCLUSIONS: Our clinical, endoscopic, manometric and pH-metric data shows no significant role of H. pylori infection in the development of GERD or in the pathogenesis of reflux esophagitis. However, current data do not provide sufficient evidence to define this relationship and further prospective large studies are needed.

Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study.

BACKGROUND: No robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures. OBJECTIVES: The objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair. SETTING: This is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures. METHODS: The audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone. RESULTS: A total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%). CONCLUSION: Combining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

Colorectal Cancer: Current Updates and Future Perspectives.

Colorectal cancer is a frequent neoplasm in western countries, mainly due to dietary and behavioral factors. Its incidence is growing in developing countries for the westernization of foods and lifestyles. An increased incidence rate is observed in patients under 45 years of age. In recent years, the mortality for CRC is decreased, but this trend is slowing. The mortality rate is reducing in those countries where prevention and treatments have been implemented. The survival is increased to over 65%. This trend reflects earlier detection of CRC through routine clinical examinations and screening, more accurate staging through advances in imaging, improvements in surgical techniques, and advances in chemotherapy and radiation. The most important predictor of survival is the stage at diagnosis. The screening programs are able to reduce incidence and mortality rates of CRC. The aim of this paper is to provide a comprehensive overview of incidence, mortality, and survival rate for CRC.

Laparoscopic Banded One Anastomosis Gastric Bypass: A Single-Center Series.

INTRODUCTION: Laparoscopic one anastomosis gastric bypass (LOAGB) is a relatively new procedure for the treatment of morbid obesity and related comorbidities. On average, this procedure results in good postoperative weight loss with a low complication rate. Recent publications suggest that dumping syndrome and weight regain might be reduced by placing a silicone ring over the gastric pouch during the procedure, so called laparoscopic banded one anastomosis gastric bypass (LBOAGB). METHODS: 86 patients undergoing LBOAGB between 2018 and 2020 were enrolled in this retrospective study. Hospital records were used to assess weight loss, comorbidity resolution, and any complications either in the short or medium term. RESULTS: 54 Female and 32 male patients were included with a mean age of 43 years (25-64), preoperative body mass index of 42 kg/m2 (35-49), and preoperative weight of 114 kg (86-162). Thirty-four patients presented with type 2 diabetes (39.5%), 42 patients (49%) diagnosed with hypertension, 24 presented with OSAS (28%), and 21 (24%) hypercholesterolaemia patients were included. In total, 36 patients were diagnosed with multiple comorbidities. The operative data showed an average operative time of 48 minutes with 3.4% of patients suffering from early (minor) complications and 2.3% with a late (minor) complication. One patient required reoperation due to intra-abdominal bleeding. The median length of hospital stay was 2.5 days. Median follow-up was 18 months (5-36). In that period, no patient required ring removal or conversion to Roux-en-Y gastric bypass surgery. Food intolerance/vomiting was present in 1 patient (1.1%), bile reflux was present in 1 patient (1.1%), and no stomal ulcers were observed. Mean % excess weight loss at 12 and 24 months was 72% and 80%, respectively. Fifty-two out of 86 patients (60%) had a complete resolution of comorbidities. A CONUT score >2 (mild malnutrition) was found in 40% of patients, while a CONUT score 0-1 was found in 60% of patients. CONCLUSION: LBOAGB shows promising results in terms of safety and efficacy in the short term. Further prospective studies will be required to evaluate the consistency of the results in the long term.

Laparoscopic right colectomy: changes in surgical technique and perioperative management allow better postoperative results in a comparative series of 361 patients.

To compare the short-term outcomes in patients who underwent laparoscopic right colectomy with a traditional minimally invasive approach versus patients who underwent a laparoscopic colectomy with an enhanced perioperative pathway. A retrospective analysis was conducted on a consecutive series of patients who underwent elective laparoscopic right colectomy for neoplastic disease between January 1, 2011 and December 31, 2020. The patients were divided into two groups: the first cohort (FC), who underwent a traditional laparoscopic colectomy, mainly with extracorporeal anastomosis, between January 1, 2011 and December 31, 2015 and the second cohort (SC), who underwent a laparoscopic colectomy with an enhanced intraoperative (intracorporeal anastomosis) and perioperative pathway (ERAS protocol) between January 1, 2016 and December 31, 2020. There were a total of 361 patients, including 177 in the FC and 184 in the SC. In the SC a higher number of intracorporeal anastomoses was performed (91.8% vs. 19.2%, p < 0.001), drains were placed in 42 patients only (22.8% vs. 100% in the FC) and nasogastric tubes were placed in 21 patients only (11.4% vs. 100% in the FC). In the initial period of the SC. the procedures required a slightly longer operative time (median 105 vs. 95 min; p = 0.002), but postoperative surgical complications were lower (12% vs. 17.4%, p = 0.179). Postoperative recovery was faster in SC along with time to discharge (4 vs. 7 days; p < 0.001). Intraoperative anastomosis and enhanced pathways in right laparoscopic colectomy seem to guarantee better results with lower surgical complications and faster postoperative recovery.

Benign Anorectal Disorders and Pelvic Floor Disease After Bariatric Surgery.

The correlations between morbid obesity, bariatric surgery and gastrointestinal disorders are well known and reported. Symptoms like abdominal pain, constipation, bloating, heartburn and gastroesophageal reflux disease are known to be significantly more prevalent in overweight patients and body mass index is associated positively with abdominal pain and diarrhea. In spite of these conditions, less is known about the lower gastrointestinal tract. Of these, anorectal disorders and pelvic floor disease are both believed to be more frequent in obese patients compared to the general population. Weight loss related to bariatric surgery seems to improve quality of life and weight-related symptoms, although some of these conditions may get worse. All these conditions are rarely studied in patients undergoing bariatric surgery for morbid obesity. This concise review aimed to focus on these conditions in patients undergoing bariatric surgery for morbid obesity in order to improve patient selection and post-operative management.