Introduction: The term "obstructive defecation syndrome" (ODS) describes a complex condition char... more Introduction: The term "obstructive defecation syndrome" (ODS) describes a complex condition characterized by defecatory disorders. Such a condition represents a significant proportion of patients, which is estimated to be up to 30% of patients affected by chronic constipation. Presently, a broad agreement has been reached on diagnostic studies, whereas the choice of treatment that aims to improve the quality of life and/or correct the prevalent abnormalities or all anatomical abnormalities remains controversial. Methods: This was a retrospective cohort study on 174 patients out of a total of 232 with ODS who were observed in a specialized university unit of surgical coloproctology between 2018 and 2022. Clinical assessment included examining the values of the Agachan-Wexner constipation score and Patient Assessment of Constipation (PAC)-quality of life (QoL) scores, a full digital anorectal examination, anoscopy, RX defecography, and a urogynecological consultation; a functional anorectal test, an endoanal ultrasound, and colonoscopy were performed in select patients. The patients were reevaluated after an 8-10-week course of medical treatment based on a high-fiber diet and fluid intake and 6 g of psyllium combined with lactobacillus and tryptophan b.i.d. The results were analyzed by means of the Wilcoxon rank-sum test, comparing pretreatment scores with the results at the first follow-up visit. Results: After 8-10 weeks of conservative treatment, 128 patients declared full satisfaction, 29 reported moderate satisfaction, and 17 (9.7%) declared no improvement. Among these 17, there were 5 patients with paradoxical puborectal contractions. The value of the Agachan-Wexner constipation score after treatment decreased from the pretreatment Agachan-Wexner constipation score mean value of 23.4 ± 3.7 (mean ± SD range 15-27) to a mean value of 5.3 ± 0.7 (range 3-8, p < 0.001). The quality of life improved, as shown by the PAC-QoL score, indicating great improvement in social relationships. Conclusions: Given the benefits of conservative therapies, they represent a cornerstone in the treatment of ODS, a complex disorder. Diet and bulking agents are mandatory forms of treatment prior to making any surgical attempt, also considering the fact that the psychosomatic component of ODS is an essential prerequisite to match patient expectations.
Tumor Progression and Metastasis [Working Title], 2020
Tumor growth and spread are a complicated matter and are the result of many interconnected factor... more Tumor growth and spread are a complicated matter and are the result of many interconnected factors. The analysis of patterns emerging from highly numerous populations might help shed some light on such an intricate mechanism. In this respect, our studies are mostly based on the SEER database, a nation representative dataset collecting data regarding the US population, over a very long time span. This approach is revealed to be particularly useful for rare tumors, as prospective studies are not feasible. Here, we present the results and the clinical implications of our inquires: we show the impact on overall survival of several morphological and demographic characteristics of various malignancies including anorectal melanoma and neuroendocrine tumors of the appendix. The impact of surgical treatment is discussed as well. Finally, we endorse the need to find more reliable markers of tumor biology, such as genetic patterns, to tailor an effective multidisciplinary treatment.
The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hithert... more The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass...
The approach to a patient with overt rectal prolapse remains controversial since the choice of th... more The approach to a patient with overt rectal prolapse remains controversial since the choice of the most appropriate technical option may be a difficult task. The different approaches are based upon patients' age, comorbidities, sex, size of prolapse, associated incontinence, constipation, and urinary and genital disturbances. However, analysis of the literature failed to detect a significant evidence favoring one among the large number of those different surgical techniques proposed for the treatment of rectal prolapse. In fact, many randomized prospective controlled trials, comparing perineal and abdominal operations, rectopexy alone, resection alone and/or resection plus rectopexy could not find significant differences in terms of morbidity, mortality, improvement of incontinence or constipation, quality of life and recurrence. Therefore, without a clear-cut support by the literature, a pragmatic approach is necessary, applying common sense, experience and considering the availability of resources as well. Nevertheless, we may expect that definitive answers to many open questions about surgery of rectal prolapse may come from larger studies and longer follow-up.
This is an open access article under the terms of the Creative Commons Attribution License, which... more This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Haemorrhoidal disease (HD) shows high prevalence in western countries, reaching 4.4% per year in ... more Haemorrhoidal disease (HD) shows high prevalence in western countries, reaching 4.4% per year in the US. Topical preparations are the first-line treatments, which are readily available as “over-the-counter” (OTC) products, often containing a nonstandardised mixture of “natural” remedies, or anaesthetics or cortisol;those latter are not free from undesirable effects. The Zinc-L-Carnosine is a cytoprotective compound, promoting mucosal repair in the gastrointestinal tract and also in mucosal repair, following radiation injuries to the rectum as well as in ulcerative colitis. Our aim was to study the efficacy of Zinc-L-Carnosine in relieving acute symptoms of HD, testing a preparation in the rectal ointment, Proctilor®, in patients complaining of bleeding or thrombosed piles. In a multicentre open trial, 21 patients older than 18 years of age were enrolled. The symptoms of HD were graded according to the Haemorrhoidal Disease Symptoms Score (HDSS) in association with the Short Health S...
Background The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol... more Background The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. Methods A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. Results There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) ...
The syndrome of the so-called “acute abdomen” is sustained by several different pathologic entiti... more The syndrome of the so-called “acute abdomen” is sustained by several different pathologic entities. Among them, mesenteric ischemia is characterized by the worst prognosis, mainly due to diagnostic delay [1,2]. In fact, emergency laparotomy has the highest diagnostic accuracy, albeit does not represent an early, helpful tool against a mostly irreversible infarcted intestinal segment requiring resection. Therefore, timing in diagnosis is of utmost importance to reversing intestinal ischemia and for an early salvage of the intestine. Unfortunately, the biological indicators available are either nonspecific or develop too late to be detected (e.g. leucocyte count, L-lactate, CPK) [3]. The paper by Cekic et al. [4] investigates novel serological biomarkers of intestinal ischemia such as Ischemia-Modified Albumin (IMA) and the Signal peptide-CUB-EGF domaincontaining protein-1 (SCUBE-1). These may represent a fundamental aspect of deep clinical relevance to the field of abdominal, emergency surgery. In a recent systematic review and meta-analysis, Treskes et al. [5] reported a large amount of data on different serological biomarkers of acute intestinal ischemia. In a pooled estimate, they found a significant role for Intestinal Fatty Acid Binding Protein (I-FABP), D-lactate, alpha-Gutathione-S-Transferase (alpha-GST), and Ischemia-Modified Albumin (IMA) as predictors of acute mesenteric ischemia and a promising role for Citrulline. However, all of the markers investigated in the mentioned reports showed a certain degree of bias mitigating their role (false negative rates of 9-14% in I-FABP and IMA for instance) and thus potentially delaying laparotomy. In cases of complete mechanical bowel obstruction, the timing of operation is crucial to a successful surgical strategy. We currently rely upon several clinical, imaging, and biological markers, but they are far from being reliable indicators for early timing of laparotomy. The investigation by Cekic is a valuable contribution to the discovery of indicators for emergency surgery. However, similar to previous work, an undisputed conclusion is not yet reached. The presence of ischemic intestinal segments resulting from obstruction-induced changes deeply impacts the patient’s surgery; the operation can progress from a relatively safe procedure (cutting adhesions) to extensive resection surgery, sometime necessitating a second look with related morbidity and mortality. In this respect, intestinal ischemia represents the final, late complication of an unresolved bowel occlusion, especially in cases of “dileptic” mechanism leading to perforation. Similarly, a strangulated bowel implies an early mechanism of intestinal ischemia, worsening the clinical picture and leading to a necrotic intestinal segment. In these severe conditions, it is obvious that identifying early markers of intestinal ischemia, like those investigated by the authors, can play a helpful role. This may be particularly true in doubtful or ambiguous clinical cases. In the experiments conducted by the authors, the two markers IMA and SCUBE-1 rise sharply in the animals treated by cecum ligation compared to those undergoing shamoperation. In addition, the highest peak is observed between the fourth and sixth hour from the onset of experimental ligature of the cecum, i.e., from the start of the strangulation mechanism. This represents a common delay of patient observation from the appearance of symptoms. Unfortunately, the histopathology of the intestine sampled at those times already shows severe alterations that are suggestive of a non-viable bowel necessitating resection. Undoubtedly, given such a situation in the clinical setting, several physical signs and symptoms (peritonism, severe continuous pain), radiologic features (abdominal fluid, ischemia at CT scan), and biological markers (marked leucocytosis, metabolic acidosis, dehydration) will be detected, supporting the indications for emergency laparotomy and resection. In conclusion, the ideal early marker of intestinal ischemia should appear just after the occurrence of mechanical bowel obstruction with strangulated mesentery. In this respect, the alterations observed in intestinal samples from the animals in group 2, although characterized by a degree of not completely reversible changes, seem to suggest that a conservative approach may be attempted, provided that the patient is observed very early after onset of mechanical occlusion with strangulated bowel. I fear that this will be a very rare condition seldom encountered in routine clinical practice. On the other hand, a sharp increase in IMA and SCUBE-1 is suggestive of ischemic intestine and thus emergency laparotomy is indicated. This result may be helpful in those doubtful cases and it may find a place as a unique marker of intestinal ischemia, avoiding other costly diagnostic tools. Last but not least, when serum levels are below a cutoff level, they may be adopted as indicators able to…
Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associa... more Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associated comorbidities. The aim of the study is to evaluate the prognosis after laparoscopic or open cholecystectomy in these patients. 100 patients aged between 80 and 92 years (group 1) and 241 patients aged between 70 and 79 years (group 2), undergoing cholecystectomy for gallbladder disease, are the subject of the study. Types of disease and surgery and p.o. morbidity and mortality have been evaluated. The patients of group 1 have shown a significant greater incidence of p.o. morbidity (20%) than group 2 (2.3%) (chi2 = 39.5; p < 0.001), regardless to the type of cholecystectomy. Endoscopic sphincterotomy for lithiasis of common biliary duct seems an important risk factor (chi2 = 7.1; p < 0.001). In group 2, the morbidity rate after laparoscopic cholecystectomy was lesser than after open surgery (X2=5.3; p < 0.02). In both groups, postoperative hospital stay was longer after open ...
Octogenarians and nonagenarians with severe symptomatic and asymptomatic carotid disease: does ol... more Octogenarians and nonagenarians with severe symptomatic and asymptomatic carotid disease: does older age indicate "high risk" for carotid endarterectomy?
BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...
PURPOSE We present the outcomes and the recurrences of 848 patients with Pilonidal Disease (PD) t... more PURPOSE We present the outcomes and the recurrences of 848 patients with Pilonidal Disease (PD) treated by punch biopsy excision (PBE) and we weigh our results against the progressively obtained operative experience. BPE is a modified "merged" version of both the Bascom's "pit picking" procedure and of the Gips's procedure. It employs punch biopsies of different calibre, depending on whether treatment is in the natal cleft (calibre as small as possible) or lateral (larger calibre punches or even small incision). Sometimes this procedure is referred to as the "Bascom-Gips" procedure. METHODS Eight hundred and forty-eight consecutive patients with PD were treated from January 2011 until December 2016 [Sex: M=622 (73.4%) and F=226 (26.6%)] [mean age: 24.6 ± 28.99]. Age: median: 26.2 years: mean: 24.6 (range: 14-55) yrs., M=25.1 yrs., and F=24.8 years]. Of these 848 patients, 287 were operated in 2011-2, 301 in 2013-4, and 260 in 2015-6. The recurrence rates were recorded 12, 24 and 60 months after surgery both cumulatively, and examining the outcomes of the three biennia individually (years of treatment: 2011-12 or group A, 2013-4 or group B, 2015-6 or group C). RESULTS The mean operating time was 34 ± 24.45 min. Postoperative complications included early (<24 hours; n = 22 or 2.6%) and delayed postoperative bleeding (>24 hours; n = 26 or 3.1%). Postoperative fluid collections (<2 weeks) occurred in 83 / 848 patients (9.8%) and included haematoma (n= 25) and seroma (n=58). Full recovery was obtained after a mean of 21 ± 12.72 days and work/school/university activities were resumed after a mean of 4 ± 12.02 days. 12, 24, and 60-month follow ups were possible in 725 (85.5%), 682 (80.4%) and 595 (70.2%) out of 848 patients. An overall significant (ꭓ2 = 16.87, p = 0.0002) difference was found in the recurrence rates: 59 recurrences / 725 patients (or 8.1%) after one year, 89 recurrences / 682 patients (or 13.0%) after two years, and 98 recurrences / 595 (or 16.4%) after five years. However, when sub-grouping patients in three 24-month subsets, the recurrence rates showed a steady and progressive decrease in the three biennia 2011-2 (group A), 2013-4 (group B) and 2015-6 (group C) at 12, 48 and 60 month follow-ups. Recurrences after 12 months were: 29 / 225 (12.9%), 19 / 285 (6.7%), and 11 / 215 (5.1%) (ꭓ2 = 8.53, p = 0.014) in groups A,B and C respectively; after 24 months, 36 / 226 (15.9%), 31 / 242 (12.8 %), and 22 / 214 (10.2%) (ꭓ2 = 2.38, p = 0.30 N.S.) in groups A, B and C respectively; after 60 months, 38 / 194 (19.5%), 36 / 215 (16.7%), and 24 / 186 (12.9%) (ꭓ2 = 2.23, p = 0.32) in groups A, B and C respectively. CONCLUSIONS PBE is an effective, disease-targeted, minimally invasive, and inexpensive way to treat PD. Its results are influenced by the experience of the team involved, especially regarding early recurrences / failure of surgery. At least 5-year follow-ups are needed to ascertain the outcome of surgery for PD.
We report the results of the surgical treatment of anal fissures complicated by abscess or fistul... more We report the results of the surgical treatment of anal fissures complicated by abscess or fistula and formulate hypotheses about their nature. Among patients operated between 2012 and 2020 for anal fissure resistant to medical therapy, those affected by septic complications were selected for our inquiry. Surgical treatment consisted in the drainage of the sepsis, fissurectomy, posterior sphincterotomy and anoplasty. Intra-sphincteric fistulas were removed with the fissure, whereas low trans-sphincteric tracks, including horseshoe fistulas, were partially opened and curetted. Patients were followed on post-operative days 7–10 and then until healing. Pre- and post-operative Visual Analog Scale (VAS) and Cleveland Clinic Incontinence Score (CCIS) scores were compared. Recurrence rates of disease were recorded. We operated 988 patients and 55 of them showed local sepsis (5.5%) complicating anal fissures. There were 23 abscesses and 32 fistulas. Of these latter, 17 were intra or inter-sphincteric (2 anterior) and 15 low trans-sphincteric (6 horseshoes). Pre-operative VAS score was 7.6 ± 0.9 (mean ± sd), CCIS was 0.1 ± 0.5. Complete healing occurred after a median of 6 weeks (range 3–14 weeks). Mean VAS score dropped to 2.3 ± 0.6 at first follow-up visit and CCIS rose to 0.4 ± 0.2. After a mean of 56.4 months, 41 patients agreed to a visit and 14 were interviewed by phone. At office visit no disease recurrences were observed; pain and continence scores were within normal ranges in all patients. Abscess and fistula in anal fissures are not frequent and may represent a different disease from cryptoglandular fistulas. Surgical treatment achieves higher success than that reported for cryptoglandular fistulas.
A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme h... more A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme hyperextension of the back in a yoga position. At endoscopy a large lesion of the esophageal epithelium was detected, involving the middle third of the anterior wall of the esophagus. Other symptoms reported by the patient were dysphagia and odynophagia, depicting the typical features of intramural hematoma, also known as intramural dissection or intramural perforation of the oesophagus. The patient was managed conservatively and symptoms disappeared within a week. A barium swallow at six months reported normal findings. Different types of accidents occurring during yoga practice are reported in the literature, mainly involving musculoskeletal or nervous systems. Visceral lesions are exceptional and no similar cases have been reported in the literature. KEYWORDS: Acute chest pain, Esophageal lesion, Intramural hematoma, Management of esophageal lesion.
BACKGROUND Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study... more BACKGROUND Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study was to reach a consensus among experts as to the possible applications of telemedicine in the proctologic field. METHODS A group of 55 clinical practice recommendations was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Proctology Italian Working Group included 47 Italian Society of Colorectal Surgery nominated experts evaluating the appropriateness of each clinical practice recommendations based on published RAND/UCLA methodology in 2 rounds. RESULTS Stakeholder median age was 53 years (interquartile range limits 40-60), and 38 (81%) were men. Nine (19%) panelists reported no experience with telemedicine before the pandemic. Agreement was obtained on a minimum of 3 to 5 years of practice in the proctologic field before starting teleconsultations, which should be regularly paid, with advice and prescriptions incorporated into a formal report sent to the patient by e-mail along with a receipt. Of the panelists, 35 of 47 (74%) agreed that teleconsultation carries the risk of misdiagnosis of cancer, thus recommending an in-person assessment before scheduling any surgery. Fifteen additional clinical practice recommendations were re-elaborated in the second round and assessed by 44 of 47 (93.6%) panelists. The application of telemedicine for the diagnosis of common proctologic conditions (eg, hemorrhoidal disease, anal abscess and fistula, anal condylomas, and anal fissure) and functional pelvic floor disorders was generally considered inappropriate. Teleconsultation was instead deemed appropriate for the diagnosis and management of pilonidal disease. CONCLUSION This e-consensus revealed the boundaries of telemedicine in Italy. Standardization of infrastructures, logistics, and legality remain to be better elucidated.
Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic a... more Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic artery aneurysm. The authors report on two cases of spontaneous hematoma of the mesocolon and examine the relevant literature. The clinical presentation in our patients was, as indicated in the literature, non-specific, with the occurrence of acute abdomen (case 1) or mild abdominal pain (case 2). Only diagnostic imaging (contrast-enhanced CT scan) is capable of yielding an accurate diagnosis, specifying the size and location of the hematoma. A palpable mass or hemoperitoneum due to rupture should be regarded as late signs of presentation. Early diagnosis is of the utmost importance in order to avoid the by no means negligible mortality reported in such instances or ischaemic bowel wall complications.
Introduction: The term "obstructive defecation syndrome" (ODS) describes a complex condition char... more Introduction: The term "obstructive defecation syndrome" (ODS) describes a complex condition characterized by defecatory disorders. Such a condition represents a significant proportion of patients, which is estimated to be up to 30% of patients affected by chronic constipation. Presently, a broad agreement has been reached on diagnostic studies, whereas the choice of treatment that aims to improve the quality of life and/or correct the prevalent abnormalities or all anatomical abnormalities remains controversial. Methods: This was a retrospective cohort study on 174 patients out of a total of 232 with ODS who were observed in a specialized university unit of surgical coloproctology between 2018 and 2022. Clinical assessment included examining the values of the Agachan-Wexner constipation score and Patient Assessment of Constipation (PAC)-quality of life (QoL) scores, a full digital anorectal examination, anoscopy, RX defecography, and a urogynecological consultation; a functional anorectal test, an endoanal ultrasound, and colonoscopy were performed in select patients. The patients were reevaluated after an 8-10-week course of medical treatment based on a high-fiber diet and fluid intake and 6 g of psyllium combined with lactobacillus and tryptophan b.i.d. The results were analyzed by means of the Wilcoxon rank-sum test, comparing pretreatment scores with the results at the first follow-up visit. Results: After 8-10 weeks of conservative treatment, 128 patients declared full satisfaction, 29 reported moderate satisfaction, and 17 (9.7%) declared no improvement. Among these 17, there were 5 patients with paradoxical puborectal contractions. The value of the Agachan-Wexner constipation score after treatment decreased from the pretreatment Agachan-Wexner constipation score mean value of 23.4 ± 3.7 (mean ± SD range 15-27) to a mean value of 5.3 ± 0.7 (range 3-8, p < 0.001). The quality of life improved, as shown by the PAC-QoL score, indicating great improvement in social relationships. Conclusions: Given the benefits of conservative therapies, they represent a cornerstone in the treatment of ODS, a complex disorder. Diet and bulking agents are mandatory forms of treatment prior to making any surgical attempt, also considering the fact that the psychosomatic component of ODS is an essential prerequisite to match patient expectations.
Tumor Progression and Metastasis [Working Title], 2020
Tumor growth and spread are a complicated matter and are the result of many interconnected factor... more Tumor growth and spread are a complicated matter and are the result of many interconnected factors. The analysis of patterns emerging from highly numerous populations might help shed some light on such an intricate mechanism. In this respect, our studies are mostly based on the SEER database, a nation representative dataset collecting data regarding the US population, over a very long time span. This approach is revealed to be particularly useful for rare tumors, as prospective studies are not feasible. Here, we present the results and the clinical implications of our inquires: we show the impact on overall survival of several morphological and demographic characteristics of various malignancies including anorectal melanoma and neuroendocrine tumors of the appendix. The impact of surgical treatment is discussed as well. Finally, we endorse the need to find more reliable markers of tumor biology, such as genetic patterns, to tailor an effective multidisciplinary treatment.
The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hithert... more The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass...
The approach to a patient with overt rectal prolapse remains controversial since the choice of th... more The approach to a patient with overt rectal prolapse remains controversial since the choice of the most appropriate technical option may be a difficult task. The different approaches are based upon patients' age, comorbidities, sex, size of prolapse, associated incontinence, constipation, and urinary and genital disturbances. However, analysis of the literature failed to detect a significant evidence favoring one among the large number of those different surgical techniques proposed for the treatment of rectal prolapse. In fact, many randomized prospective controlled trials, comparing perineal and abdominal operations, rectopexy alone, resection alone and/or resection plus rectopexy could not find significant differences in terms of morbidity, mortality, improvement of incontinence or constipation, quality of life and recurrence. Therefore, without a clear-cut support by the literature, a pragmatic approach is necessary, applying common sense, experience and considering the availability of resources as well. Nevertheless, we may expect that definitive answers to many open questions about surgery of rectal prolapse may come from larger studies and longer follow-up.
This is an open access article under the terms of the Creative Commons Attribution License, which... more This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Haemorrhoidal disease (HD) shows high prevalence in western countries, reaching 4.4% per year in ... more Haemorrhoidal disease (HD) shows high prevalence in western countries, reaching 4.4% per year in the US. Topical preparations are the first-line treatments, which are readily available as “over-the-counter” (OTC) products, often containing a nonstandardised mixture of “natural” remedies, or anaesthetics or cortisol;those latter are not free from undesirable effects. The Zinc-L-Carnosine is a cytoprotective compound, promoting mucosal repair in the gastrointestinal tract and also in mucosal repair, following radiation injuries to the rectum as well as in ulcerative colitis. Our aim was to study the efficacy of Zinc-L-Carnosine in relieving acute symptoms of HD, testing a preparation in the rectal ointment, Proctilor®, in patients complaining of bleeding or thrombosed piles. In a multicentre open trial, 21 patients older than 18 years of age were enrolled. The symptoms of HD were graded according to the Haemorrhoidal Disease Symptoms Score (HDSS) in association with the Short Health S...
Background The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol... more Background The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. Methods A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. Results There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) ...
The syndrome of the so-called “acute abdomen” is sustained by several different pathologic entiti... more The syndrome of the so-called “acute abdomen” is sustained by several different pathologic entities. Among them, mesenteric ischemia is characterized by the worst prognosis, mainly due to diagnostic delay [1,2]. In fact, emergency laparotomy has the highest diagnostic accuracy, albeit does not represent an early, helpful tool against a mostly irreversible infarcted intestinal segment requiring resection. Therefore, timing in diagnosis is of utmost importance to reversing intestinal ischemia and for an early salvage of the intestine. Unfortunately, the biological indicators available are either nonspecific or develop too late to be detected (e.g. leucocyte count, L-lactate, CPK) [3]. The paper by Cekic et al. [4] investigates novel serological biomarkers of intestinal ischemia such as Ischemia-Modified Albumin (IMA) and the Signal peptide-CUB-EGF domaincontaining protein-1 (SCUBE-1). These may represent a fundamental aspect of deep clinical relevance to the field of abdominal, emergency surgery. In a recent systematic review and meta-analysis, Treskes et al. [5] reported a large amount of data on different serological biomarkers of acute intestinal ischemia. In a pooled estimate, they found a significant role for Intestinal Fatty Acid Binding Protein (I-FABP), D-lactate, alpha-Gutathione-S-Transferase (alpha-GST), and Ischemia-Modified Albumin (IMA) as predictors of acute mesenteric ischemia and a promising role for Citrulline. However, all of the markers investigated in the mentioned reports showed a certain degree of bias mitigating their role (false negative rates of 9-14% in I-FABP and IMA for instance) and thus potentially delaying laparotomy. In cases of complete mechanical bowel obstruction, the timing of operation is crucial to a successful surgical strategy. We currently rely upon several clinical, imaging, and biological markers, but they are far from being reliable indicators for early timing of laparotomy. The investigation by Cekic is a valuable contribution to the discovery of indicators for emergency surgery. However, similar to previous work, an undisputed conclusion is not yet reached. The presence of ischemic intestinal segments resulting from obstruction-induced changes deeply impacts the patient’s surgery; the operation can progress from a relatively safe procedure (cutting adhesions) to extensive resection surgery, sometime necessitating a second look with related morbidity and mortality. In this respect, intestinal ischemia represents the final, late complication of an unresolved bowel occlusion, especially in cases of “dileptic” mechanism leading to perforation. Similarly, a strangulated bowel implies an early mechanism of intestinal ischemia, worsening the clinical picture and leading to a necrotic intestinal segment. In these severe conditions, it is obvious that identifying early markers of intestinal ischemia, like those investigated by the authors, can play a helpful role. This may be particularly true in doubtful or ambiguous clinical cases. In the experiments conducted by the authors, the two markers IMA and SCUBE-1 rise sharply in the animals treated by cecum ligation compared to those undergoing shamoperation. In addition, the highest peak is observed between the fourth and sixth hour from the onset of experimental ligature of the cecum, i.e., from the start of the strangulation mechanism. This represents a common delay of patient observation from the appearance of symptoms. Unfortunately, the histopathology of the intestine sampled at those times already shows severe alterations that are suggestive of a non-viable bowel necessitating resection. Undoubtedly, given such a situation in the clinical setting, several physical signs and symptoms (peritonism, severe continuous pain), radiologic features (abdominal fluid, ischemia at CT scan), and biological markers (marked leucocytosis, metabolic acidosis, dehydration) will be detected, supporting the indications for emergency laparotomy and resection. In conclusion, the ideal early marker of intestinal ischemia should appear just after the occurrence of mechanical bowel obstruction with strangulated mesentery. In this respect, the alterations observed in intestinal samples from the animals in group 2, although characterized by a degree of not completely reversible changes, seem to suggest that a conservative approach may be attempted, provided that the patient is observed very early after onset of mechanical occlusion with strangulated bowel. I fear that this will be a very rare condition seldom encountered in routine clinical practice. On the other hand, a sharp increase in IMA and SCUBE-1 is suggestive of ischemic intestine and thus emergency laparotomy is indicated. This result may be helpful in those doubtful cases and it may find a place as a unique marker of intestinal ischemia, avoiding other costly diagnostic tools. Last but not least, when serum levels are below a cutoff level, they may be adopted as indicators able to…
Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associa... more Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associated comorbidities. The aim of the study is to evaluate the prognosis after laparoscopic or open cholecystectomy in these patients. 100 patients aged between 80 and 92 years (group 1) and 241 patients aged between 70 and 79 years (group 2), undergoing cholecystectomy for gallbladder disease, are the subject of the study. Types of disease and surgery and p.o. morbidity and mortality have been evaluated. The patients of group 1 have shown a significant greater incidence of p.o. morbidity (20%) than group 2 (2.3%) (chi2 = 39.5; p < 0.001), regardless to the type of cholecystectomy. Endoscopic sphincterotomy for lithiasis of common biliary duct seems an important risk factor (chi2 = 7.1; p < 0.001). In group 2, the morbidity rate after laparoscopic cholecystectomy was lesser than after open surgery (X2=5.3; p < 0.02). In both groups, postoperative hospital stay was longer after open ...
Octogenarians and nonagenarians with severe symptomatic and asymptomatic carotid disease: does ol... more Octogenarians and nonagenarians with severe symptomatic and asymptomatic carotid disease: does older age indicate "high risk" for carotid endarterectomy?
BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...
PURPOSE We present the outcomes and the recurrences of 848 patients with Pilonidal Disease (PD) t... more PURPOSE We present the outcomes and the recurrences of 848 patients with Pilonidal Disease (PD) treated by punch biopsy excision (PBE) and we weigh our results against the progressively obtained operative experience. BPE is a modified "merged" version of both the Bascom's "pit picking" procedure and of the Gips's procedure. It employs punch biopsies of different calibre, depending on whether treatment is in the natal cleft (calibre as small as possible) or lateral (larger calibre punches or even small incision). Sometimes this procedure is referred to as the "Bascom-Gips" procedure. METHODS Eight hundred and forty-eight consecutive patients with PD were treated from January 2011 until December 2016 [Sex: M=622 (73.4%) and F=226 (26.6%)] [mean age: 24.6 ± 28.99]. Age: median: 26.2 years: mean: 24.6 (range: 14-55) yrs., M=25.1 yrs., and F=24.8 years]. Of these 848 patients, 287 were operated in 2011-2, 301 in 2013-4, and 260 in 2015-6. The recurrence rates were recorded 12, 24 and 60 months after surgery both cumulatively, and examining the outcomes of the three biennia individually (years of treatment: 2011-12 or group A, 2013-4 or group B, 2015-6 or group C). RESULTS The mean operating time was 34 ± 24.45 min. Postoperative complications included early (<24 hours; n = 22 or 2.6%) and delayed postoperative bleeding (>24 hours; n = 26 or 3.1%). Postoperative fluid collections (<2 weeks) occurred in 83 / 848 patients (9.8%) and included haematoma (n= 25) and seroma (n=58). Full recovery was obtained after a mean of 21 ± 12.72 days and work/school/university activities were resumed after a mean of 4 ± 12.02 days. 12, 24, and 60-month follow ups were possible in 725 (85.5%), 682 (80.4%) and 595 (70.2%) out of 848 patients. An overall significant (ꭓ2 = 16.87, p = 0.0002) difference was found in the recurrence rates: 59 recurrences / 725 patients (or 8.1%) after one year, 89 recurrences / 682 patients (or 13.0%) after two years, and 98 recurrences / 595 (or 16.4%) after five years. However, when sub-grouping patients in three 24-month subsets, the recurrence rates showed a steady and progressive decrease in the three biennia 2011-2 (group A), 2013-4 (group B) and 2015-6 (group C) at 12, 48 and 60 month follow-ups. Recurrences after 12 months were: 29 / 225 (12.9%), 19 / 285 (6.7%), and 11 / 215 (5.1%) (ꭓ2 = 8.53, p = 0.014) in groups A,B and C respectively; after 24 months, 36 / 226 (15.9%), 31 / 242 (12.8 %), and 22 / 214 (10.2%) (ꭓ2 = 2.38, p = 0.30 N.S.) in groups A, B and C respectively; after 60 months, 38 / 194 (19.5%), 36 / 215 (16.7%), and 24 / 186 (12.9%) (ꭓ2 = 2.23, p = 0.32) in groups A, B and C respectively. CONCLUSIONS PBE is an effective, disease-targeted, minimally invasive, and inexpensive way to treat PD. Its results are influenced by the experience of the team involved, especially regarding early recurrences / failure of surgery. At least 5-year follow-ups are needed to ascertain the outcome of surgery for PD.
We report the results of the surgical treatment of anal fissures complicated by abscess or fistul... more We report the results of the surgical treatment of anal fissures complicated by abscess or fistula and formulate hypotheses about their nature. Among patients operated between 2012 and 2020 for anal fissure resistant to medical therapy, those affected by septic complications were selected for our inquiry. Surgical treatment consisted in the drainage of the sepsis, fissurectomy, posterior sphincterotomy and anoplasty. Intra-sphincteric fistulas were removed with the fissure, whereas low trans-sphincteric tracks, including horseshoe fistulas, were partially opened and curetted. Patients were followed on post-operative days 7–10 and then until healing. Pre- and post-operative Visual Analog Scale (VAS) and Cleveland Clinic Incontinence Score (CCIS) scores were compared. Recurrence rates of disease were recorded. We operated 988 patients and 55 of them showed local sepsis (5.5%) complicating anal fissures. There were 23 abscesses and 32 fistulas. Of these latter, 17 were intra or inter-sphincteric (2 anterior) and 15 low trans-sphincteric (6 horseshoes). Pre-operative VAS score was 7.6 ± 0.9 (mean ± sd), CCIS was 0.1 ± 0.5. Complete healing occurred after a median of 6 weeks (range 3–14 weeks). Mean VAS score dropped to 2.3 ± 0.6 at first follow-up visit and CCIS rose to 0.4 ± 0.2. After a mean of 56.4 months, 41 patients agreed to a visit and 14 were interviewed by phone. At office visit no disease recurrences were observed; pain and continence scores were within normal ranges in all patients. Abscess and fistula in anal fissures are not frequent and may represent a different disease from cryptoglandular fistulas. Surgical treatment achieves higher success than that reported for cryptoglandular fistulas.
A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme h... more A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme hyperextension of the back in a yoga position. At endoscopy a large lesion of the esophageal epithelium was detected, involving the middle third of the anterior wall of the esophagus. Other symptoms reported by the patient were dysphagia and odynophagia, depicting the typical features of intramural hematoma, also known as intramural dissection or intramural perforation of the oesophagus. The patient was managed conservatively and symptoms disappeared within a week. A barium swallow at six months reported normal findings. Different types of accidents occurring during yoga practice are reported in the literature, mainly involving musculoskeletal or nervous systems. Visceral lesions are exceptional and no similar cases have been reported in the literature. KEYWORDS: Acute chest pain, Esophageal lesion, Intramural hematoma, Management of esophageal lesion.
BACKGROUND Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study... more BACKGROUND Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study was to reach a consensus among experts as to the possible applications of telemedicine in the proctologic field. METHODS A group of 55 clinical practice recommendations was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Proctology Italian Working Group included 47 Italian Society of Colorectal Surgery nominated experts evaluating the appropriateness of each clinical practice recommendations based on published RAND/UCLA methodology in 2 rounds. RESULTS Stakeholder median age was 53 years (interquartile range limits 40-60), and 38 (81%) were men. Nine (19%) panelists reported no experience with telemedicine before the pandemic. Agreement was obtained on a minimum of 3 to 5 years of practice in the proctologic field before starting teleconsultations, which should be regularly paid, with advice and prescriptions incorporated into a formal report sent to the patient by e-mail along with a receipt. Of the panelists, 35 of 47 (74%) agreed that teleconsultation carries the risk of misdiagnosis of cancer, thus recommending an in-person assessment before scheduling any surgery. Fifteen additional clinical practice recommendations were re-elaborated in the second round and assessed by 44 of 47 (93.6%) panelists. The application of telemedicine for the diagnosis of common proctologic conditions (eg, hemorrhoidal disease, anal abscess and fistula, anal condylomas, and anal fissure) and functional pelvic floor disorders was generally considered inappropriate. Teleconsultation was instead deemed appropriate for the diagnosis and management of pilonidal disease. CONCLUSION This e-consensus revealed the boundaries of telemedicine in Italy. Standardization of infrastructures, logistics, and legality remain to be better elucidated.
Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic a... more Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic artery aneurysm. The authors report on two cases of spontaneous hematoma of the mesocolon and examine the relevant literature. The clinical presentation in our patients was, as indicated in the literature, non-specific, with the occurrence of acute abdomen (case 1) or mild abdominal pain (case 2). Only diagnostic imaging (contrast-enhanced CT scan) is capable of yielding an accurate diagnosis, specifying the size and location of the hematoma. A palpable mass or hemoperitoneum due to rupture should be regarded as late signs of presentation. Early diagnosis is of the utmost importance in order to avoid the by no means negligible mortality reported in such instances or ischaemic bowel wall complications.
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