Rectal lumen obliteration (RLO) is a rarely described, but fearful and potentially life-threating complication following stapled hemorrhoidopexy. Its management is not standardized and should take into account the time of recognition of the complication, the completeness of obliteration, and the integrity of the rectal wall. Here, we describe a case of complete RLO after stapled hemorrhoidopexy (the first case published to the best of our knowledge), successfully treated via an intra-abdominal approach with full rectal mobilization and recanalization of the rectum using a 31 mm EEA(®) stapler

Abstract AIM: The treatment of desmoid tumours (DTs) is controversial. Anti-oestrogen therapy has frequently been used, but clear information of its efficacy is lacking. In this systematic review we have undertaken a comprehensive analysis to assess the effectiveness of anti-oestrogen therapy in terms of ability to induce partial or complete regression of DTs. METHOD: A systematic review of articles published in English between January 1983 and December 2009 was carried out according to the RECIST criteria. A literature search was performed on electronic databases including: United States National Library of Medicine (MEDLINE-PubMed), Excerpta Medica (EMBASE), Cochrane Library and Google search engine. Two-hundred articles dealing with DTs were identified but only fourty-one were were selected as appropriate for the study. The chi-square test was used for statistical analysis. RESULTS: Data on 168 DTs treated with anti-oestrogen agents, alone or in combination with nonsteroidal anti-inflammatory drugs, were identified with an overall response rate of 51%. There was no difference in response according to the type of DTs or between different anti-oestrogen therapies. Combination with anti-inflammatory drugs did not improve the outcome. Toremifene was sometimes effective in cases resistant to tamoxifen. Response did not seem to be related to oestrogen receptor status. CONCLUSIONS: Despite potential inaccuracies in the methodology, the results of the review indicate that anti-oestrogen therapy produces some effect in about one half of patients with DTs. Its indication compared with other treatments is discussed.

Objective: To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients. Material and Methods: Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant. Results: Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy. Conclusions: Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction

Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results. PATIENTS AND METHODS: Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8-84) and 52.5 (12-156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score. RESULTS: Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45-76.6), indicating a good stoma function in 95 % of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15-120); Wexner, 13 (2-19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0-4); coping/behaviour, 1.3 (0-3.5); depression, 2.1 (0-5.2); embarrassment, 2 (0-4.6)] and 11 complained of obstructed defecation [7.5 (3-16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2-80.3)]. CONCLUSIONS: QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL

Chronic constipation is a common and extremely troublesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a "Question-Answer" format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient's quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here

Abstract AIM: Milligan-Morgan hemorrhoidectomy (MM) is still the most common treatment for grades III and IV hemorrhoids despite prolonged post-operative anal pain and wound healing. This multicenter, double blind, randomized, controlled trial was designed to assess the safety and the efficacy of anal wound cleansing with Triclosan (Proctocid®) in the control of symptoms and healing time after MM. METHODS: A total of 113 patients with grades III and IV hemorrhoids, undergoing open hemorroidectomy by diathermy or Ligasure vessel sealing device, were randomly assigned to Triclosan or sodium hypochlorite solution. All patients received analgesics and a fiber-rich diet after hemorrhoidectomy. Postoperative anal pain, bleeding and/or secretion and itch were assessed 7, 14 and 21 days after hemorrhoidectomy by a Visual Analogue Scale (VAS) and the day of complete re-epithelialization of anal wounds was recorded. RESULTS: Fifty-five patients were randomized for Triclosan treatment and 58 for the control drug. The two groups were comparable for demographics, severity of hemorrhoids and technique used for the hemorrhoidectomy. The comparison of days to get complete anal wound healing shows a trend of significance (P=0.05) for the Triclosan group. Bleeding and/or secretion, anal pain and itch were significantly better (P=0.003; P<0.0001 and P=0.01, respectively). CONCLUSION: Triclosan solution for the treatment of post-hemorrhoidectomy wounds is safe and improves the control of post-operative symptoms and wound healing time compared to sodium hypochlorite

Patients with gallstones are often affected by alimentary disorders contributing to the onset of gallstones disease. Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted.

There are conflicting data on the biological and prognostic significance of disseminated tumour cells (DTCs) in the bone marrow of colorectal cancer patients since bone metastasis are rare in this disease. The study aimed to determine the origin of bone marrow -DTCs using human colorectal cancer cells in in vivo and in vitro experimental settings. METHOD: CD1 nude female mice were xenotransplanted with SW620 cells (colorectal cancer cell line isolated from a male patient) injected in the colon wall. At autopsy, the presence of SW620 in the bone marrow (BM), colon and other organs/tissues was recognized by detection of the epithelial marker cytokeratin-19 (CK19) and Y-chromosome. In addition SW620 cells or their conditioned media were cultured with human BM cells. RESULTS: Macroscopically evident CK19+/Y-chromosome+ tumours developed only in five mice receiving SW620 cells while putative DTCs (CK19+) were found in the bone marrow of all treated mice. Most of these CK19+ cells were Y-chromosome-negative, only few being Y-chromosome-positive. In vitro SW620 cells or their conditioned medium induced CK19 expression in cultured human bone marrow cells. CONCLUSION: Experimental colorectal cancer can induce the appearance of two distinct CK19+ cell populations in the bone marrow, one of metastatic origin and the other of murine origin. These findings suggest that bone marrow cells may undergo phenotypic modifications induced by cancer cells.

OBJECTIVE: The aim of this study was to determine whether the volatile organic compounds (VOCs) pattern in colorectal cancer (CRC) patients is modified by curative surgery for a potential application in the oncologic follow-up. BACKGROUND: CRC has been proved to induce metabolic derangements detectable by high through-output techniques in exhaled breath showing a specific pattern of VOCs. METHODS: Forty-eight CRC patients and 55 healthy controls (HC) entered the study. Thirty-two patients (M/F: 1.4; mean age 63 years) attended the oncologic follow-up (mean 24 months) and were found disease-free. Breath samples were collected under similar environmental conditions into a Tedlar bags and processed offline by thermal-desorption gas chromatography-mass spectrometry (TD-GC-MS). VOCs were selected by U test to build a Probabilistic Neural Network (PNN) model to set-up a training phase, which was cross-validated using the leave-one out method. RESULTS: A total of 11 VOCs were finally selected for their excellent discriminant performance in identifying disease-free patients in follow-up from CRC patients before surgery, (sensitivity 100%, specificity 97.92%, accuracy 98.75%, and AUC: 1). The same VOCs pattern discriminated follow-up patients from HC, with a sensitivity of 100%, specificity of 90.91%, accuracy of 94.25%, and AUC 0.959. CONCLUSIONS: Exhaled VOCs pattern from CRC patients is modified by cancer removal confirming the tight relationship between tumor metabolism and exhaled VOCs. PNN analysis provides a high discriminatory tool to identify patients disease-free after curative surgery suggesting potential implications in CRC screening and secondary prevention.

Effects of curative surgery of colorectal cancer on exhaled volatile organic compounds (VOCs) after 1 year follow up

The aim of this paper is to present the results of the Italian Society of Colorectal Surgery [or Società Italiana di Chirurgia Colorettale (SICCR)] Logbook of adverse events (AE) occurring in relation to emerging technologies in coloproctology (ETCs), over a 3-year period. METHODS: A total of 245 AE were reported (patients age: mean = 49.6 years, range = 20-75 years; gender: 155 = F, 90 = M). The "observations" originated from the same institution of the AEs in 44 cases (18.0%), while 201 patients (82.0%) had been operated on somewhere else. RESULTS: The three most reported ETCs were: Procedure for prolapsed haemorrhoids (PPH) (n = 120-48.9%), stapled transanal rectal resection (STARR (n = 96-39.2%), and transanal haemorrhoidal dearterialization (THD) (n = 11-4.5%). PPH, STARR, and THD together accounted for n = 227 (92.6%) observations. For the three main reported ETCs, the various AEs are listed. Chronic pain after PPH was 46/120 (38.3%), and after STARR of 21/96 (21.9%). The overall re-operation rate was n = 135 (55.1%) versus n = 110 (44.9%) no reoperation. In particular, for the three main reported ETCs, n = 68/120 (56.7%) following an AE after PPH, n = 47/94 (50.0%) following an AE after STARR, and n = 6/11 (54.5) following an AE post-THD. The various types of treatment to solve AE after each of the three most observed ETCs are reported in the text. CONCLUSIONS: Our results do not allow us to draw statistical conclusions; however, this was not the aim of our survey. ETCs are important, yet they are not without major risks. Manufacturers should help colorectal surgeons to convey the right message to patients

Background: An effective screening tool for colorectal cancer is still lacking. Analysis of the volatile organic compounds (VOCs) linked to cancer is a new frontier in cancer screening, as tumour growth involves several metabolic changes leading to the production of specific compounds that can be detected in exhaled breath. This study investigated whether patients with colorectal cancer have a specific VOC pattern compared with the healthy population. Methods: Exhaled breath was collected in an inert bag (Tedlar (R)) from patients with colorectal cancer and healthy controls (negative at colonoscopy), and processed offline by thermal-desorber gas chromatographymass spectrometry to evaluate the VOC profile. During the trial phase VOCs of interest were identified and selected, and VOC patterns able to discriminate patients from controls were set up; in the validation phase their discriminant performance was tested on blinded samples. A probabilistic neural network (PNN) validated by the leave-one-out method was used to identify the pattern of VOCs that better discriminated between the two groups. Results: Some 37 patients and 41 controls were included in the trial phase. Application of a PNN to a pattern of 15 compounds showed a discriminant performance with a sensitivity of 86 per cent, a specificity of 83 per cent and an accuracy of 85 per cent (area under the receiver operating characteristic (ROC) curve 0.852). The accuracy of PNN analysis was confirmed in the validation phase on a further 25 subjects; the model correctly assigned 19 patients, giving an overall accuracy of 76 per cent. Conclusion: The pattern of VOCs in patients with colorectal cancer was different from that in healthy controls. The PNN in this study was able to discriminate patients with colorectal cancer with an accuracy of over 75 per cent. Breath VOC analysis appears to have potential clinical application in colorectal cancer screening, although further studies are required to confirm its reliability in heterogeneous clinical settings. Copyright (c) 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. RI de gennaro, gianluigi/B-6237-2013 OI de gennaro, gianluigi/0000-0002-6868-6569

Abstract AIM: Sacral nerve stimulation (SNS) is an effective but expensive treatment for faecal incontinence. About 50% of the patients are unresponsive for unknown reasons, hence knowledge of any factors predictive of success would be highly desirable. The aim of this study was to analyse the potential factors associated with a successful outcome of the temporary test of electrostimulation. METHOD: Eighty-five patients with faecal incontinence were tested for SNS. The cause was idiopathic in 45, iatrogenic or obstetric in 28, spinal lesion or neurological diseases in nine and anal malformation in three patients; 43 were tested with a unipolar electrode and 42 with a quadripolar electrode. The severity of faecal incontinence was evaluated using the American Medical System (AMS) score and Wexner's score. RESULTS: A positive response was obtained in 45 patients (53%); 40 (47%) were implanted with a permanent pulse generator. Responders and nonresponders were comparable in age, duration of incontinence, anal manometry, pudendal nerve terminal motor latency and diabetes. Unipolar electrode test (PNE test) was able to elicit positive responses in 18 of 43 (42%) and the quadripolar in 27 of 42 patients (P &lt; 0.001). Type of incontinence and gender did not affect the success rate. Patients with idiopathic incontinence had a significantly higher response rate (P =0.022). Multivariate regression analysis indicated use of a quadripolar electrode as the only independent variable predicting the success of SNS (OR = 5.58, P = 0.009). Conclusion: Use of the quadripolar electrode is the only factor significantly related to the success of SNS.

BACKGROUND: : Sacral nerve stimulation has been reported as an effective treatment for constipation. OBJECTIVE: : This study aimed to evaluate the therapeutic efficacy of permanent sacral nerve stimulation on the treatment of idiopathic constipation resistant to medical and behavioral management over a median follow-up period of 25.6 (range, 6-96) months. DESIGN: : A retrospective review of a prospectively maintained institutional review board-approved database was performed. SETTING: : The study was performed at 2 tertiary-care European institutions with expertise in sacral nerve stimulation. PATIENTS: : Patients were considered eligible if they had had symptoms for at least 1 year and if conservative treatment had failed. INTERVENTION: : Patients were tested by percutaneous nerve evaluation before the procedure. If this evaluation was successful, patients underwent sacral nerve therapy with an implanted device. MAIN OUTCOME MEASURE: : Patients were evaluated by means of a bowel function diary and the Wexner constipation score. RESULTS: : A total of 48 consecutive patients (39 females, median age 50.0 years (range, 17-79 years) entered the study. Twenty-three patients were implanted with a permanent stimulator. On an intention-to-treat basis, only 14 of 48 patients (29.2%) met the definition of a successful outcome at the latest follow-up period (median, 25.6 (range, 6-96) months). The mean Wexner score decreased from 20.2 (SD 3.6) at baseline to 5.8 (SD 4.1) at the latest follow-up examination (p < 0.001). However, 6 of 14 patients (42.8%) were still using laxatives and/or enemas at the last follow-up. LIMITATIONS: : The study was limited by the pragmatic approach necessary to evaluate the results in routine clinical practice. CONCLUSIONS: : This study shows that sacral nerve stimulation has limited efficacy on an intention-to-treat basis as a routinely recommended therapy for intractable idiopathic constipation.

Rectovaginal fistula is usually a challenging condition for surgeons, but a fistula between the rectum and the neovagina in male-to-female transsexual is even more difficult to treat as it is a rare complication occurring in a patient with modified anatomy of the perineum, with heavy psychological implications for the patient. Here, we report a case of recurrent recto-neovaginal fistula in a male-to-female transsexual successfully treated by perineal graciloplasty.

Local recurrence continues to be a major problem in rectal cancer. After cancer removal, detection of viable cancer cells could be useful to identify patients at risk for local recurrence. Thus, aim of the study was the detection of residual peritoneal cancer cells with a possible prognostic role for local recurrence. Twenty-nine patients were operated (R0) for low (extraperitoneal) rectal cancer, without neoadjuvant radiochemotherapy. Before and immediately after cancer removal, a peritoneal lavage was done to evaluate by RT-PCR the cytokeratin 20 mRNA on isolated cells and in order to detect cancer cells by the Thin-prep test. After a median follow-up of 39 months, 5 patients died (17%), one for non-cancer-related disease, two (7%) for local recurrence and peritoneal carcinosis, and two for distant metastases. Preoperative cytology with Thin-prep test was positive in 4 patients (14%), while postoperative peritoneal cytology was positive only in 1 patient, different from the previous. No patient developed local or distal recurrence and all were disease-free at the end of the follow-up. RT-PCR analysis was positive on the peritoneal lavage after cancer removal in 11 patients. One died for unrelated cause and no one developed local recurrences. Local recurrence occurred in only 1 of the 2 patients with positive RT-PCR analysis on the first lavage and negative on the second lavage. Our study demonstrates a not important prognostic role of Thin-prep test and RT-PCR of cytokeratin 20 mRNA on the detection of patients at risk for local recurrence after curative resection of rectal cancer.

Colorectal cancer (CRC) is a common condition and represents a lethal disease, following a sequential progression from adenoma to carcinoma. Interfering with such natural history of CRC offers clues to prevention and cure, but current screening methods for CRC are still limited by unsatisfactory sensitivity and specificity. Novel diagnostic, prognostic tools are therefore being actively investigated for CRC. The discovery of microRNAs (miRNAs) has led to active research focusing on their role in cancer and several crucial pathways involving angiogenesis, cancer-stem-cell biology, epithelial-mesenchymal transition, formation of metastasis, and drug resistance. MiRNAs might soon represent novel prognostic and diagnostic tools in patients at high risk of CRC or being diagnosed with CRC. MiRNA might prove useful also as therapeutic tools, since dysregulation of miRNAs in cancer cells results in higher levels of messenger RNA (mRNA) specific to tumor promoter genes or tumor suppressor genes. Thus, novel anticancer therapies might originate from manipulation of oncogenic or tumor suppressor miRNAs in CRC. In this review, the innovative aspects of miRNA are discussed, with respect to biogenesis, their role in CRC, and their potential use as biomarkers. Before miRNAs can become available in the clinical setting, however, a number of large prospective studies are still required.

Colorectal cancer (CRC) is still one of the leading causes of cancer-related death in Western countries, despite major improvements in its treatment. The dramatically high social and economic impact of CRC on human health makes the identification of a reliable screening tool of paramount importance. Current screening methods, such as the fecal occult blood test and colonoscopy do not adequately meet the ideal requisites of a screening test because, even if they are effective, they are limited first by too low specificity and sensitivity, or second by high invasiveness, costs and risk. Nowadays extended efforts are made by researchers to look for more reliable and effective screening tests based on a systems biology approach, using biological samples easily available, such as urine, breath, serum and feces. The effectiveness and reliability of several new attempts to screen these patients by non-invasive analysis of their biological samples using genomic (genetic and epigenetic alteration), transcriptomic (miRNA), proteomic (cancer-related antigens, new antibodies against tumor-associated antigens, mutated proteins) and metabolomic (volatile organic metabolites) methods are discussed in this review. Among the most interesting new screening tools, fecal fluorescent long-DNA, fecal miRNA and metabolomic evaluation in breath and/or serum seem to be most promising.

Introduction: Hemorrhoid disease is the cause of most proctologic complaints and hundreds of medical and surgical therapies have been proposed to relieve symptoms. However, the role and the correct indication of medical treatments are still controversial. Further, the utility of conservative measures are rarely scientifically supported by adequate trials. Areas covered: This narrative review is based on the search and analysis of full papers in English language selected from PubMed in the past 30 years using the following MeSH Editing: hemorrhoids, conservative treatment, medical treatment and hemorrhoids, pregnancy and hemorrhoids, thrombosed hemorrhoids, randomized trials and hemorrhoids, postoperative pain and hemorrhoids. Expert opinion: Early stages (I/II degrees) of this disease could be effectively managed conservatively with several approaches as lifestyle changes, fiber supplement, topical ointments and phlebotonic drugs. The more advanced hemorrhoid stages (III/IV degrees) need some type of surgery, but medical therapy is still useful to minimize anal symptoms as a bridge-to-surgery treatment. Further, post-hemorrhoidectomy pain, hemorrhoidal crisis even in pregnancy could benefit from the adjunct of local and systemic medical treatment. This expert opinion, based also on long-lasting clinical practice, also supports the use of medical treatment in symptoms relief in patients with hemorrhoid disease.

Epidemiology data on constipation are not commonly available, particularly in Italy Here we review the prevalence and clinical features of constipated patients attending a tertiary referral Italian center. METHODS: Clinical data of patients attending our Coloproctology Unit in the last 15 years and complaining of constipation as the main clinical features were retrospectively analyzed. Rome-III criteria were adoptedto define constipation. RESULTS: 1041/11881 patients were affected by chronic constipation (8.8%), 376 had slow-transit constipation, 497 obstructed defecation and 168 both types of constipation. 76% of them were females. Patients distribution according to sex and age was Gaussian-like only in females. In the slow-transit group, constipation was idiopathic in 59.3% and secondary to other causes in 40.7% . In patients with anatomic obstructed defecation, rectocele and intussusceptions were the main findings, while pelvic floor dissynergia was the main finding in functional outlet obstruction, although more frequently all these components were associated. In 14.8% no apparent cause was identified. CONCLUSION: Constipation accounts for about 9% of patients attending a tertiary referral Colorectal Unit. Females were much more frequently affected in both types of constipation. Anatomic and functional defecatory disturbances are frequently associated, although in 15% no evident causes were identified.

BACKGROUND: Representatives from the Italian centers experienced in sacral neuromodulation (SNM) for the treatment of bowel dysfunction met in order to define the current clinical practice in Italy and to produce a consensus statement regarding indications for this therapy and patient management. METHODS: Fifty Italian colonproctologists were asked to complete a questionnaire concerning their clinical practice in SNM (290 questions, grouped within 4 broad areas). Physicians expressed their opinion by completing the questionnaire, assigning to each statement their level of agreement according to the 5-point Likert scale; the data were analyzed by attributing to each expert's answers a weight proportional to the degree of experience. During a meeting held 2 months later, the critical aspects of the therapy were re-examined and discussions held with the goal of reaching an agreement on controversial topics. The available literature was reviewed. RESULTS: Patient selection criteria, etiology, diagnostic investigations, test procedures and implantation, follow-up and evaluation of results have been reviewed. The aim was to achieve an algorithm for patient management, showing the place of SNM in the treatment of bowel dysfunction. The approach in case of treatment failure was also discussed. CONCLUSIONS: Analysis of the data collected reveals substantial consensus at the national level concerning all the main points with regard to the therapy. The recommendations expressed in this article can be considered as national guidelines and taken into account by the principal international implantation centers

Introduction:  Stapled hemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan-Morgan hemorrhoidectomy. A new stapler device has been designed to overcome these side effects . Patients and Methods:  135 patients (71 males, mean age 42) with III degree haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH(®) 01/03 stapler (Ethicon EndoSurgery) (63 patients) or with EEA(®) stapler (Covidien) (72 patients) in 4 referral colorectal centers. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in cm(2) ), and any postoperative bleeding within 30-days were recorded. Results:  The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35,75 ± 17,51 vs 28,05 ± 10,23 cm(2) , p=0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median values 1, interquantile range 0-2, vs 3, interquantile range 2-5, p<0.0001). Intraoperative haemostasis was better in the EEA group compared both to PPH 01 and PPH 03 groups. Postoperative bleeding occurred only in 2 PPH patients. Discussion:  Data suggest that the EEA stapler has better haemostatic properties in comparison with PPH and allows resection of larger area of mucosal prolapsed with potential benefits over the recurrence rate of haemorrhoid prolapse.

OBJECTIVE: Fibrin glue treatment of anal fistulae has been proposed to minimize the risk of faecal incontinence but its acceptance by coloproctologists is still poor because the published data is controversial. Therefore, we carried out a prospective randomized crossover trial comparing treatment with a commercial fibrin glue to classical seton treatment, with healing rate, hospital stay, healing time, faecal incontinence and postoperative pain as study outcomes. METHOD: Sixty-four homogeneous patients with trans-sphincteric anal fistulae referred to seven colorectal units were randomized to undergo fibrin glue (39 patients) or seton (25 patients) treatment. Patients failing to heal after treatment with fibrin glue were re-randomized to undergo a second injection with glue or seton treatment. RESULTS: Sixty-two of the 64 patients completed the minimum 1-year follow-up period. Twenty-one of 24 patients healed in the seton group compared with 15/38 in the fibrin glue group (P = 0.0007). The 23 failures after glue treatment were re-randomized to have a second glue injection (eight patients) or a seton treatment (15 patients). Four of the eight (50%) patients treated with a second injection of glue, and nine out of the 15 (60%) patients in the seton group, healed. Patients treated with fibrin glue reported less postoperative pain and had a shorter hospital stay than patients treated with a seton; furthermore, faecal continence and anal manometry significantly worsened after seton treatment. CONCLUSION: Seton treatment has a significantly higher probability of success compared with fibrin glue treatment but poses a higher risk of faecal incontinence. Fibrin glue could be considered as a first line of treatment for patients at risk of faecal incontinence or other comorbidities.

A postoperative complication after Altemeier operation, so far never reported, is described in a 42 years old mentally disabled patient with external full thickness rectal prolapse who usually had prolonged straining at defecation. After 6 d from perineal rectosigmoidectomy, the patient, was discharged free of complications. Four days later he was readmitted in emergency for strangulated perineal trans-anastomotic ileal hernia that occurred at home during efforts to defecate. The clinical feature required an emergency operation for repositioning the ileal loops into the abdomen, resection of the necrotic ileum, and end colostomy. The outcome of the second operation was free of complication and the patient was discharged on the 6(th) postoperative day. In conclusion, after Altemeier operation prolonged straining at defecation should be carefully avoided.

Sacral nerve stimulation is an effective treatment for urinary and faecal incontinence even though its mechanism of action is uncertain. Central nervous system involvement by 'setting-up' neurological mechanisms appointed to control pelvic function has been hypothesized. The study aimed to evaluate whether the effects of long-term sacral nerve stimulation are memorized and therefore maintained after switching off the stimulator. METHOD: Patients having sacral nerve stimulation for faecal and/or urinary incontinence for at least 1 year had the stimulator turned off and the results monitored. Data recorded with the stimulator off were compared with post-implant data. If symptoms recurred the stimulator was switched back on. Nineteen patients entered the study. Fourteen had faecal and/or urinary incontinence and five had faecal incontinence alone. The symptoms were assessed by means of a bowel function diary and dedicated questionnaire. RESULTS: In 10 patients symptoms recurred at different intervals after a median off period of 3.4 months with a probability of symptom relapse of 55%. The Fecal Incontinence Quality of Life (FIQL) score did not show any significant difference in nine patients with the stimulator off for at least 1 year. No factors predictive of symptom recurrence were identified although an idiopathic aetiology, severity of disease and urinary incontinence had higher hazard ratios. During the off period, none of the scores and episodes of incontinence showed significant changes compared with the on period. CONCLUSION: The effects of sacral nerve stimulation on faecal and urinary incontinence were maintained in about half of patients after switching the stimulator off, but in some symptoms returned after different periods of time. The data shed new light on possible effects of sacral nerve stimulation on brain neuroplasticity in the control of continence.

Successful bowel preparation is essential to an adequate performance of colonoscopy. Polyethylene glycol (PEG) with electrolyte solutions induces diarrhea with depletion of substrates fermentable by hydrogen (H2)-producing colonic microbiota. Inulin has recently been suggested as a prebiotic substrate for the H2 breath test because it is resistant to intestinal hydrolysis and is fermented mostly by the colonic bacteria. This study aimed to assess time-dependent changes in H2 breath levels in order to predict the colonic preparation of patients scheduled for colonoscopy with or without oral supplementation of inulin. METHODS: In this prospective nonrandomized trial, 127 subjects drank 4 l of PEG 280-mg solution as bowel preparation for colonoscopy. A subgroup of 31 patients also ingested inulin (10 g in 200 ml of water) at breakfast as an additional substrate to increase colonic H2 production. Measurements of H2 breath levels were performed immediately before and after colonic preparation. As the main outcome measure, the quality of the colonic preparation was scored as excellent to fair (i.e., clean bowel allowing successful pan-colonoscopy, including the terminal ileum) or poor (incomplete colonoscopy due to fecal debris). RESULTS: The H2 breath levels decreased from 11.0 ± 1.8 ppm before PEG to 1.8 ± 0.3 ppm after PEG (n = 18; P &lt; 0.001). The H2 concentrations after PEG ingestion were significantly lower (P &lt; 0.001) in the patients with excellent-to-fair preparation than in the 19 patients with poor preparation. Ingestion of inulin induced an overall increase in H2 breath levels and improved discrimination between the patients with excellent-to-fair colonic preparation and those with poor preparation, leading to the sensitivity and specificity of such a test reaching 100 %. CONCLUSIONS: The H2 breath test with inulin ingestion can be a simple, noninvasive, reliable method for predicting successful colonic preparation that leads to cost savings and less patient discomfort/stress or need to repeat colonoscopy

Abstract AIM: Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. METHOD: A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. RESULTS: There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. CONCLUSION: The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management. Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland. KEYWORDS: Pelvic floor dysfunctions; obstructed defaecation syndrome; scoring systems Comment in Comment on 'The TAPE score'. [Colorectal Dis. 2014]