Emergency surgery in the time of Coronavirus: the pandemic effect

BACKGROUND

The COVID-19 epidemic became a challenge for Emergency Departments (ED) and a remarkable reduction in surgical emergencies has been widely noticed. The aim of the present study was to evaluate the impact of the pandemic period in the need of surgical emergencies.

METHODS

Between January 1, and May 31, 2020 all the consecutive general surgery emergencies performed by the Unit Hospital Emergency Surgery of the Careggi University (Florence, Italy) were prospectively recorded and compared to the same period of 2019. Demographic and clinical data were recorded and analyzed.

RESULTS

The number of surgical procedures decreased only in the month of March 2020 (compared to 2019), while in April the total numer of emergency surgical procedures was similar. Only appendectomy, complicated hernia repair and colonic resection were significantly reduced (40%, 48% and 33% respectively). The number of small intestine excision, cholecystectomy and lysis of peritoneal adhesions remained stable throughout the entire period. No statistically significant differences were found considering age, sex, Emergency Surgery Score, mortality, ICU postoperative admission and time between admission and surgery, even when analyzed with multivariate analysis for every single surgical procedure, suggesting a comparable disease severity and comorbility patterns. Mortality in COVID patients was 25%, compared to 7% of no-covid patients.

CONCLUSIONS

The COVID-19 pandemic has caused major changes in daily clinical practice, especially in areas such as Emergency. This has led to a temporary reduction and changes in the flow of patients to the emergency room, with implications also for emergency surgical activities.

Emergency surgery in the time of Coronavirus: the pandemic effect

BACKGROUND

The COVID-19 epidemic became a challenge for Emergency Departments (ED) and a remarkable reduction in surgical emergencies has been widely noticed. The aim of the present study was to evaluate the impact of the pandemic period in the need of surgical emergencies.

METHODS

Between January 1, and May 31, 2020 all the consecutive general surgery emergencies performed by the Unit Hospital Emergency Surgery of the Careggi University (Florence, Italy) were prospectively recorded and compared to the same period of 2019. Demographic and clinical data were recorded and analyzed.

RESULTS

The number of surgical procedures decreased only in the month of March 2020 (compared to 2019), while in April the total numer of emergency surgical procedures was similar. Only appendectomy, complicated hernia repair and colonic resection were significantly reduced (40%, 48% and 33% respectively). The number of small intestine excision, cholecystectomy and lysis of peritoneal adhesions remained stable throughout the entire period. No statistically significant differences were found considering age, sex, Emergency Surgery Score, mortality, ICU postoperative admission and time between admission and surgery, even when analyzed with multivariate analysis for every single surgical procedure, suggesting a comparable disease severity and comorbility patterns. Mortality in COVID patients was 25%, compared to 7% of no-covid patients.

CONCLUSIONS

The COVID-19 pandemic has caused major changes in daily clinical practice, especially in areas such as Emergency. This has led to a temporary reduction and changes in the flow of patients to the emergency room, with implications also for emergency surgical activities.

The role of tibial nerve stimulation for enhanced postoperative recovery after colorectal surgery: a double-blind, parallel-group, randomized controlled trial

BACKGROUND

Postoperative ileus (POI) is the most common cause of prolonged hospital stay following abdominal surgery, despite an optimized enhanced recovery after surgery (ERAS) program. The aim of the study was to evaluate the role of postoperative transcutaneous electrical tibial nerve stimulation (TTNS) in the recovery of bowel function and in shortening hospital stay after colonic resection.

METHODS

Patients having elective laparoscopic colonic surgery within an ERAS program at our institution between June 2016 and June 2019 were enrolled and randomly assigned to a treatment protocol with TTNS or sham electrical stimulation. The primary endpoint was the time of recovery of gastrointestinal motility, measured as the first passage of stool. Secondary endpoints included: first passage of flatus, length of hospital stay, and complication rate related to the use of TTNS.

RESULTS

One hundred and seventy patients who had right hemicolectomy (median age 71 years (range 43-89 years); 47.5% women) and 170 patients who had left colectomy (median age 67 years range (37-92 years); 41.5% women) were enrolled. The only factor significantly affected by TTNS was time to first passage of flatus after right hemicolectomy (reduced from 46 to 33 h, p = 0.04). However, if only patients with low compliance to early oral nutrition (63 of 340; 18.5%) were considered, a statistically significant difference in time until first flatus (p < 0.01) and first bowel movement (p < 0.0001) and a shorter time until discharge (median 5 vs 7 days) were found in both left and right colectomies groups, respectively.

CONCLUSIONS

TTNS may have a positive effect on gastrointestinal tract motility and recovery from POI after colorectal surgery in a selected group, who has low compliance with an ERAS program, without increasing the risk of complications.

Role of transanal irrigation in the treatment of anterior resection syndrome

BACKGROUND

Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center.

METHODS

Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after  surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol.

RESULTS

Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended.

CONCLUSIONS

TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life.  Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed  6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus)

BACKGROUND

In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery.

METHODS

All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported.

RESULTS

Forty-five consecutive patients (median age 50; range 24-79) were included in the study. Median resected volume was 15 cm³ (range 12-19 cm³) with a median height of surgical specimen of 5.6 cm (range 4.5-10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12-30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline.

CONCLUSIONS

TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

Myoxinol ointment for the treatment of acute fissure

Myoxinol is a complex of oligopeptides obtained from the seeds of Hibiscus esculentus used in cosmetic as natural alternative to botulin toxin. The aim of the study was to evaluate the safety and effectiveness of local myoxinol for the treatment of acute anal fissure. All the consecutive patients with acute fissure treated from January to June 2014 underwent 30 days of topical treatment (twice/day) with a mioxinol based ointment. Pain, symptomatic relief, fissure healing and re-epithelization, 1-year recurrence rate, subjective satisfaction and need for further treatments were evaluated. During the study period 157 patients were eligible for data analysis (91 males: 58%; mean age 38 years: range 17-83). Median anal pain score was 7.1 pre-treatment and 1.7 and 0.9 after 30 days and 12 months from treatment, respectively (p: 0.0001). After the treatment period complete healing was achieved in 103 patients (65.5%), relevant improvement in 31 (20%) and no improvement in 21 patients (13.5%). Overall efficacy rate was 85.5%. A significant difference was reported considering patients with pre-treatment VAS between 1-5 and 6-10 (p: 0.004). Twenty-nine patients (18.5%) required further treatments. Hydrolyzed Hibiscus esculentus extract was proven to be an effective and well-tolerated topical treatment for acute fissure, with a high healing rate, a significant reduction of pain and a low 1-year recurrence rate.

Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up

BACKGROUND

Optimal surgical treatment for anal fistula should result in healing of the fistula track and preserve anal continence. The aim of this study was to evaluate Permacol™ collagen paste (Covidien plc, Gosport, Hampshire, UK) injection for the treatment of complex anal fistulas, reporting feasibility, safety, outcome and functional results.

METHODS

Between May 2013 and December 2014, 21 consecutive patients underwent Permacol paste injection for complex anal fistula at our institutions. All patients underwent fistulectomy and seton placement 6-8 weeks before Permacol™ paste injection. Follow-up duration was 12 months.

RESULTS

Eighteen patients (85.7%) had a high transsphincteric anal fistula, and three female patients (14.3%) had an anterior transsphincteric fistula. Fistulas were recurrent in three patients (14.3%). Seven patients (33%) had a fistula with multiple tracts. After a follow-up of 12 months, ten patients were considered healed (overall success rate 47.6%). The mean preoperative FISI score was 0.33 ± 0.57 and 0.61 ± 1.02 after 12 months.

CONCLUSIONS

Permacol™ paste injection was safe and effective in some patients with complex anal fistula without compromising continence.

Persistent anal and pelvic floor pain after PPH and STARR: surgical management of the fixed scar staple line

BACKGROUND

Persistent anal pain (PAP) after stapled procedures, be it hemorrhoidopexy (PPH) or stapled transanal rectal resection (STARR) may be hardly resolved by medical therapy. The typical objective finding in these patients is the staple line characterized by fixed scar to underlying layers.

METHODS

A total of 21 consecutive patients were operated for PAP after stapled procedure. The scarred staple line was excised and detached from layers below, the mucosal continuity reconstructed by single stitches. From January 2003 to December 2013 1500 patients underwent stapled procedure. Of these patients treated in our unit, 9 (0.6 %) were operated for chronic anal pain and 12 were referred to our center from other hospitals.

RESULTS

Fifteen (71.4 %) patients resolved and do not take any drugs for pain; an overall of 85.7 % (18/21) improved their clinical status. Mean time between the beginning of symptoms and the operation was 4.27 months (range 1-18 months). We divided the patients into three groups: before 3 months, between 3 and 6 months and after 6 months from the beginning of symptoms to the operation. The best results were in the first group with 100 % pain relief and satisfactory functional results.

CONCLUSIONS

The relief of PAP after stapled procedure, in which we recognize a scarred and fixed staple line, depends by the early recognition of this typical finding. The authors suggest the surgical treatment not later than 3-6 months after the onset of symptoms to achieve the best results.

Tailored prolapse surgery for the treatment of hemorrhoids with a new dedicated device: TST Starr plus

PURPOSE

The aim of the study was to assess the results of the stapled transanal procedure in the treatment of hemorrhoidal prolapse in terms of postoperative complications and recurrence rate using a new dedicated device, TST Starr plus.

METHODS

Patients affected by III-IV degree hemorrhoidal prolapsed that underwent stapled transanal resection with the TST Starr plus were included in the present study. Results of the procedure with perioperative complications, postoperative complications, and recurrence rate were reported.

RESULTS

From November 2012 to October 2014, 52 patients (19 females) were enrolled in the study. The main symptoms were prolapse (100 %) and bleeding (28.8 %). Transanal rectal resection was performed with parachute technique in 24 patients (46.2 %) and purse string technique in 23 patients (53.8 %). A mild hematoma at the suture line occurred in one patient (1.9 %). Postoperative bleeding was reported in three patients (5.7 %), in one of which, reoperation was necessary (1.9 %). Tenesmus occurred in one patient (1.9 %), and it was resolved with medical therapy. Urgency was reported in nine patients (17.1 %) at 7 days after surgery. Of these, three patients (5.7 %) complained urgency at the median follow-up of 14.5 months. Reoperation was performed in one patient (1.9 %) for chronic anal pain for rigid suture fixed on the deep plans. Occasional bleeding was reported in four patients (7.7 %). No recurrence of prolapse was reported at a median of 14.5 months after surgery, even if one patient (1.9 %) had a partial recurrent prolapse of a downstaged single pile.

CONCLUSIONS

TST Starr plus seems to be safe and effective for a tailored transanal stapled surgery for the treatment of III-IV degree hemorrhoidal prolapse. The new conformation and innovative technology of the stapler seems to reduce some postoperative complications and recurrence rate.

The technique of sacral nerve modulation

AIM

The aim of this review was to summarize current knowledge and recommendations regarding the technique of implantation of the electrode in performing sacroneuromodulation (SNM) and the available information on programming parameters and implantation algorithms.

METHOD

All English-language articles published from January 1985 to December 2013 that reported the SNM surgical technique and results were considered for inclusion. Data were considered useful for the present review only if related to: (i) peripheral nerve evaluation; (ii) temporary nerve stimulation; (iii) definitive impulse generator placement; and (iv) parameters programming.

RESULTS

The literature search revealed 193 potentially relevant studies from initial electronic search terms and eligibility criteria, and these studies were evaluated in detail. In total, 41 studies were included in the final analysis. Of the studies reviewed, the majority (n = 37) were prospective or retrospective case series. Only three randomized clinical trials were eligible for inclusion.

CONCLUSION

Although the technique seems to be standardized, several steps still need to be clarified in order to define the best way to perform the procedure and then to maximize the outcome.

Role of KRAS mutation as predictor of pathologic response after neoadjuvant chemoradiation therapy for rectal cancer

Individual patient response to neoadjuvant treatment is variable and reproducible biomarkers of response are needed. The role of the V-Ki-ras2 Kirsten rat sarcoma viral oncogene (KRAS) in rectal cancer remains equivocal. The aim of the current study was to evaluate the effect of KRAS mutation on outcomes following neoadjuvant chemoradiation therapy (CRT) for rectal cancer. A total of 76 stage II-III rectal cancer patients underwent preoperative CRT followed by surgery. In every patient tumor-related features and outcome results were considered for analysis and correlation with KRAS mutations. Forty-four patients (58%) obtained a downstaging after CRT, and in 7 patients (9%) a complete pathological response was found. Twenty-six (33%) mutations of KRAS were found in 26 patients. Nineteen mutations (73%) were located in codon 12, 6 in codon 13(23%) and 1 in codon 61. T-level downsizing and tumor downstaging showed no significant association with KRAS mutation status, except for mutation of codon 13(G13D). No correlation between cancer-associated mortality following CRT and surgery and KRAS mutation was observed. No correlation between pelvic recurrence and KRAS mutation was observed. KRAS mutation also failed to correlate with disease-free survival. No patients with a pCR had a local or distant failure. There appears to be no significant difference in pCR, tumor down-staging, T-downsizing or effects on cancer-associated mortality, overall survival and disease-free survival in patients with KRAS mutations except for patients with KRAS codon 13 mutations that seem to be resistant to neoadjuvant CRT and less likely to achieve a pCR.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results

The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series.

METHODS

Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study.

RESULTS

Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %).

CONCLUSIONS

The study confirms the oncological safety of laparoscopic TME in a long follow-up period.

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus

OBJECTIVE

The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery.

METHODS

All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded.

RESULTS

From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred.

CONCLUSIONS

The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.

Correlation between outcome and instrumental findings after stapled transanal rectal resection for obstructed defecation syndrome

OBJECTIVE

Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain symptomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders.

PATIENTS AND METHODS

All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome.

RESULTS

From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence.

CONCLUSION

Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient's satisfaction often does not match the objective functional outcome.

Colonic electrical stimulation for the treatment of slow-transit constipation: a preliminary pilot study

BACKGROUND

Electrical stimulation of the gastrointestinal tract is an attractive concept. In this article we report on a procedure for electrical colonic pacing due to intramuscular electrode placement for slow-transit constipation and some preliminary results.

METHODS

From January 2011 to December 2012, all consecutive patients affected by constipation and evaluated in our Pelvic Floor Center were prospectively assessed. Patients who underwent colonic electrical stimulation were evaluated for the present study.

RESULTS

In the study period, 256 patients were evaluated for constipation; 58% were identified as having obstructed defecation syndrome, 27.3% with irritable bowel syndrome or mixed forms, 4% with pelvic floor dyssynergia, and 10.5% (27 patients) as having slow-transit constipation. After failure of all the maximal conventional therapies, two patients, candidates for colectomy, agreed to undergo colonic electrical stimulation before a resective treatment. Both patients were females, aged 34 and 29 years, and were suffering from severe constipation since childhood. The follow-up was 19 and 6 months. The number of bowel movements per week increased from 0.3 to 3.5 in the first patient and from 0.5 to 2.5 in the second patient. Both patients no longer needed laxatives, enemas, or any other treatment. The hospital stay was 4 days, the mean operative time was 120 min, and no complications were reported.

CONCLUSIONS

Colonic pacing seems to be feasible and shows positive results. Further studies are required with a larger number of patients and a longer follow-up period to confirm the role of this promising treatment for slow-transit constipation.

Accuracy of transrectal ultrasound after preoperative radiochemotherapy compared to computed tomography and magnetic resonance in locally advanced rectal cancer

INTRODUCTION

The aim of the present study was to compare the restaging results obtained by transrectal ultrasound (TRUS), computed tomography (CT), and magnetic resonance imaging (MRI) performed after preoperative chemoradiation with pathologic staging of the operative specimen.

METHODS

From January 2008 to December 2009, all the consecutive patients with locally advanced rectal cancer that underwent neoadjuvant therapy at our department were evaluated. The results of diagnostic examinations and the definitive pathological examination were considered and compared.

RESULTS

Thirty-seven patients were included in the study (27 males, 73%), mean age was 65.5 years (range 45–82 years). In all the patients TRUS and CT and in 20 patients MRI were performed before and after the treatment. Concerning the depth of invasion after treatment TRUS agreed with histopathology in 25/37 patients (67.5%), CT agreed in 22/ 37 cases (59.5%), and MRI in 12/20 cases (60%). Considering only neoplasia with stage T3, TRUS agreed in 23/24 cases (96%), CT in 19 cases (79%), and MRI in 10/12 cases (83.5%). Considering the tumors that did not exceed the rectal wall (T0, T1, and T2), TRUS agreed with histology in 2/13 cases (15.5%),CTin 3/13 cases (23%), andMRI 2/8 cases (25%). Concerning the presence of positive lymph nodes TRUS agreed with histology in 28/37 cases (75.5%), while CT agreed in 21/37 cases (56.5%) and MRI in 11/20 cases (55%). The concordance between the techniques was found to be low.

CONCLUSIONS

Transrectal ultrasonography resulted as the most accurate method to determine neoplastic wall infiltration and lymph node involvement even after radiochemotherapy. In most cases, considering the poor correlation between the diagnostic procedures and the disagreement of the results, a restaging performed only with TRUS could be proposed, limiting the use of the other imaging methods to selected cases.

Sacral nerve modulation in the treatment of chronic pelvic pain

BACKGROUND

Chronic pelvic pain is a common condition that significantly compromises the quality of life of affected patients. Unfortunately, despite treatment procedures, the results are often ineffective and symptoms persist for years. For these reasons, the search for less aggressive treatment options with fewer negative consequences leading to minimally invasive techniques was conducted.

OBJECTIVE

The aim of the present study was to evaluate the efficacy of sacral nerve modulation in the treatment of chronic pelvic pain. Moreover, we aimed to identify potential predictors of positive results of sacral neuromodulation through the comparison between failed and successful patients.

PATIENTS

From January 2004 to December 2009, all consecutive patients suffering from chronic pelvic pain and tested for sacral nerve modulation in three pelvic floor dedicated centers were evaluated. Severity of symptoms were analyzed by a visual analog scale (VAS) RESULTS: Twenty-seven patients (2 males; mean age, 53 years) were tested for sacral nerve modulation in the screening period and were included in the present study. The mean duration of pain was 51 months (range, 10-132 months). The mean preoperative VAS was 7.8 (range, 5-10). Previous pelvic surgery was reported in 18 patients (66.5%). Sixteen patients (59%) fulfil the successful criteria and were definitively implanted. The mean follow-up was 37 months (range, 12-71 months). The mean preoperative VAS was 8.1 (range, 6-8) and decreased to 2.1 ± 1.2 at 6-month follow-up (p < 0.0001), to 2.1 ± 1.1 at 12 months (16 patients), to 2.0 ± 1.2 at 24 months (13 patients), to 2.3 ± 1.4 at 36 months (9 patients), to 2.1 ± 1.5 at 48 months (5 patients), and to 1.9 ± 1.3 at 60 months (3 patients).

CONCLUSIONS

Sacral neuromodulation proved to be effective in the treatment of some patients affected by chronic pelvic pain, and the effect persists over time. A positive screening phase and a positive response to gabapentin or pregabalin showed to be predictors of a successful response. Multiple localizations of pelvic pain and pain occurred after stapler surgery seem to be negative factors for the success of the treatment.

Sacral nerve modulation in the treatment of chronic pain after pelvic surgery

AIM

The aim of the study was to evaluate the efficacy of sacral nerve modulation for chronic pelvic pain after pelvic or anal surgery for benign disease.

METHOD

From January 2004 to December 2009, 17 (14 female; age 56 years) consecutive patients suffering from chronic pelvic pain underwent evaluation for sacral nerve modulation in three pelvic floor units.

RESULTS

The previous surgery included stapled transanal rectal resection (five), hysterectomy (four), haemorrhoidectomy (two), stapled haemorrhoidopexy (one), fistulectomy (one), urethral sphincterotomy (one), appendicectomy (one), discectomy (one) and laparoscopy for endometriosis (one). Eight (47%) patients fulfilled the criteria for definitive implantation and were followed for a mean of 39 months. Using a visual analog pain score, pain levels fell from 8.2 preoperatively to 1.9, 2.1, 2.0 and 1.8 at 6, 12, 24 and 36 months, respectively. Age < 60 years and duration of symptoms of < 24 months were good predictors and stapling was a poor predictor of success.

CONCLUSION

Sacral nerve modulation seems to be effective over time in some patients with chronic pain related to previous surgery.

Early complications after stapled transanal rectal resection performed using the Contour® Transtar™ device

AIM

This study evaluated the early results (with particular reference to complications) of stapled transanal rectal resection (STARR) carried out using the CCS-30 Contour® Transtar™ device. The procedure was performed in a single centre on patients with obstucted defecation caused by rectocele or rectal intussusception.

METHOD

From July 2007 to February 2009, 133 patients were treated. Preoperatively, all underwent clinical examination, transanal ultrasonography, anorectal manometry and cinedefaecography. Obstructed defaecation syndrome was assessed using the Cleveland Clinic Constipation Score (CCC-S). Early postoperative complications and those occurring within 6 months were recorded.

RESULTS

The median follow-up period was 19 (range 12-30) months. The mean ± standard deviation preoperative CCC-S of 19.4 ± 7.1 decreased to 10.1 ± 9.0 postoperatively. The early complication rate was 15.7% and included rectovaginal fistula (n = 1), rectal perforation (n = 1), posterior dehiscence (n = 4), further surgery for retained staples (n = 2), postoperative bleeding (n = 2) and postoperative impaired continence (n = 11).

CONCLUSIONS

STARR using the Contour Transtar device seems to be effective for treating obstructed defaecation. However, serious complications may occur.

Transanal resection of rectal lipoma mimicking rectal prolapse: description of a case and review of the literature

Submucosal lipomas of the large bowel are uncommon. Occasionally, they occur in the rectum and may cause aspecific symptoms; presentation with rectal prolapse is very unusual and may lead to a misdiagnosis of simple mucosal prolapse. The paper describes an additional case of a prolapsing rectal mass that led to diagnosis and surgical treatment of a rectal lipoma under local anesthesia.

Clinical relevance of transperineal ultrasound compared with evacuation proctography for the evaluation of patients with obstructed defaecation

AIM

Dynamic evacuation proctography (DEP) is still considered the gold standard diagnostic procedure for posterior compartment pelvic disorders. The study aimed to assess the value of dynamic transperineal ultrasound (DTPU) compared with DEP in patients with obstructed defaecation syndrome (ODS).

METHOD

In a prospective observational study, 54 consecutive female patients referred with symptoms of ODS between January and June 2009 were studied by clinical evaluation (including Wexner score), perineal ultrasound and defaecography. The tests were analysed by two experienced investigators unaware of the opinion of the other.

RESULTS

DEP revealed a rectocoele in 35 (64%), intussusception in 27 (50%) and enterocoele in 10 (18.5%) patients. DTPU revealed a rectocoele in 32 (59%), intussusception in 23 (42%) and enterocoele in 11 (20%) patients. The degree of agreement of the two techniques calculated using the Cohen kappa method was 0.69 for rectocoele, 0.74 for intussusception and 0.86 for enterocoele. In patients with grade 2-3 rectocoele, the agreement was 0.88. There was no significant difference between the two techniques in the measurement of the anorectal angle or in the detection of dyssynergic contraction of the puborectalis. DTPU was better at identifying multiple diagnoses and associated pelvic floor alterations.

CONCLUSION

The degree of concordance between the two techniques is good. DTPU is accurate for asymptomatic patients with ODS and can be considered an alternative to DEP in the assessment of such patients.

Familial colorectal cancer: a concept revisited

OBJECTIVE

The family history of patients with colorectal cancer (CRC) shows an increased risk of disease although evident inherited syndromes are demonstrable in only a small percentage of patients. The purpose of this study was to identify factors that might suggest an inherited component in the transmission of CRC.

METHOD

The study monitored 880 consecutive patients between 1980 and 2005 treated for CRC.

RESULTS

Familial adenomatous polyposis (FAP) was found in only one patient, and a classical mutation of hereditary nonpolyposis colon cancer was found in only two patients. The risk assessment was possible mainly because of factors such as early onset CRC, the presence of multiple primary tumours and a high risk family history. Considering these 36 more patients were suspected to be high risk and referred for further genetic testing. At least one first-degree relative with CRC was reported in 140 patients. In 49 patients, CRC was diagnosed before 50 years of age. Multiple primary tumours, colonic or extra colonic, synchronous or metachronous were found in 136 patients.

CONCLUSION

Our study suggests that if only patients with identified mutations are taken into consideration, then the percentage of evident hereditary colon cancer is very low, but this percentage quickly increases if we make marginal adjustments to the identifying criteria. It seems that it is the physician's clinical suspicion, more than the fulfillment of rigid criteria, which plays a fundamental role in the timely identification and a subsequent focused treatment of patients with hereditary CRC.

Accuracy of endoanal ultrasound in the follow-up assessment for squamous cell carcinoma of the anal canal treated with radiochemotherapy

BACKGROUND

Radiochemotherapy has largely replaced surgery in the treatment for squamous cell cancer of the anal canal. Transanal ultrasonography is well documented as an important investigation method in the management of anal carcinoma. This study aimed to evaluate the accuracy of endoanal ultrasound in the study of the postradiation findings and to distinguish between postradiation fibrosis, residual tumor, and local recurrence.

METHODS

The study enrolled 16 consecutive patients with biopsy-proven squamous carcinoma of the anal canal between 2003 and 2006. All the patients underwent a pretreatment and at least four posttreatment endosonographies, according to the follow-up period. All the patients were treated with the same radiochemotherapy protocol.

RESULTS

Nine patients had stage uT2 disease; none had uT3 disease; and seven had uT4 disease. There was no evidence of residual tumor in the T2 group after treatment. In the T4 patients after treatment, ultrasound demonstrated tumor regression or abnormalities considered to be radiation-induced changes rather than residual diseases. Only for three patients was a posttreatment biopsy performed to evaluate recurrence (two uT2 and one uT4). Surgical treatment of recurrence was performed for two uT4 patients.

CONCLUSIONS

Endoanal ultrasound is a safe and effective method for evaluating and following anal cancer before and after treatment. Experience and evaluation during the period of the ultrasonographic abnormalities could give a clear idea concerning the evolution of the anal tumors treated with radiochemotherapy.