Jacopo Martellucci

Bowel dysfunction is a common and debilitating condition affecting patients with endometriosis. Despite the extent of surgery, symptoms may persist or arise, often overlapping with low anterior resection syndrome (LARS) or irritable bowel syndrome (IBS) typical features. This review aims to summarize the multifactorial pathophysiology and current therapeutic options for postoperative bowel dysfunction after endometriosis surgery. A structured narrative review was conducted through a comprehensive search for studies published between 2000 and 2025. Inclusion criteria focused on postoperative functional outcomes and treatments (medical, rehabilitative and interventional) effectiveness. The available evidence is limited and largely extrapolated from related conditions such as LARS and neurogenic bowel dysfunction. The complex pathophysiology of postoperative dysfunction involves preoperative visceral hypersensitivity, surgical disruption of pelvic autonomic nerves, reduced rectal compliance, and pelvic floor dyssynergia. While dietary interventions (e.g., low-FODMAP diet) and pharmacological treatments (laxatives, antidiarrheals, or neuromodulators) serve as first-line therapies, they are often insufficient for severe symptoms. Emerging evidence supports the use of transanal irrigation (TAI) for mechanical emptying and sacral neuromodulation (SNM) for refractory sensorimotor disorders. Functional rehabilitation, including pelvic floor physiotherapy and manual therapy, represents a further opportunity to influence specific symptoms. Postoperative bowel dysfunction in endometriosis management requires a transition from rigid treatment protocols to a multidisciplinary, symptom-oriented approach. The support of specialized nursing, physiotherapy, and advanced interventions like TAI and SNM is essential. Future prospective studies using standardized outcome measures are needed to better define these therapeutic pathways and improve patient quality of life.

BACKGROUND: Functional constipation is a chronic GI disorder that significantly impairs quality of life. OBJECTIVE: To evaluate the beneficial effects of transanal irrigation after 12 and 24 months of treatment in patients with functional constipation. DESIGN: Multicenter, prospective, observational study. SETTINGS: Thirteen gastroenterology centers across Italy. PATIENTS: A total of 216 adults diagnosed with functional constipation were enrolled. INTERVENTION: A transanal irrigation system was used to perform bowel irrigation. Patients completed validated questionnaires at baseline and at 1, 6, 12, and 24 months after the procedure. MAIN OUTCOME MEASURES: The primary end points were to assess improvement in patient satisfaction and quality of life related to bowel function, as well as the safety of the procedure. Secondary outcomes included constipation severity, symptom occurrence, treatment discontinuation rates, and reasons for dropout. RESULTS: Mean satisfaction scores increased from 2.9 ± 2.4 at baseline to 6.5 ± 2.0 in 1 month and remained higher through 24 months ( p < 0.001). The mean quality-of-life total score improved from 2.7 ± 0.6 to 2.0 ± 0.7 in 1 month and remained at about 1.9 thereafter ( p < 0.001). Constipation score severity decreased (Wexner score 17.9 ± 5.8 to 12.5 ± 5.2 at 1 month; maintained to 24 months; p < 0.001), and mean constipation-related symptoms declined from 3.3 to 1.0 per patient at 24 months. Of 175 patients prescribed irrigation, discontinuation occurred in 10.3% at 6 months, 9.1% at 12 months, and 6.3% at 24 months; technical difficulties were uncommon and absent at 24 months, and no serious adverse events were reported. LIMITATIONS: The nonrandomized design may have introduced bias. Outcomes were assessed using validated but subjective self-reported questionnaires, and the study population was unbalanced for sex and comorbidities, although these factors did not significantly affect the primary results. CONCLUSIONS: This study provides the first evidence to support the effectiveness and safety of long-term transanal irrigation in improving bowel function, symptoms, and quality of life in patients with functional constipation across the long term. See Video Abstract . IRRIGACIÓN TRANSANAL EN EL ESTREÑIMIENTO FUNCIONAL: RESULTADOS A LARGO PLAZO DE UN ESTUDIO NACIONAL ITALIANO: ANTECEDENTES: El estreñimiento funcional es un trastorno gastrointestinal crónico que afecta significativamente la calidad de vida. OBJETIVO: Evaluar los efectos beneficiosos de la irrigación transanal tras 12 y 24 meses de tratamiento en pacientes con estreñimiento funcional. DISEÑO: Estudio multicéntrico, prospectivo y observacional. ÁMBITO: Trece centros de gastroenterología en Italia. PACIENTES: Se incluyeron 216 adultos diagnosticados de estreñimiento funcional. INTERVENCIÓN: Se realizó irrigación transanal mediante un sistema de irrigación transanal. Los pacientes completaron cuestionarios validados al inicio del estudio y a los 1, 6, 12 y 24 meses. PRINCIPALES MEDIDAS DE RESULTADO: Los objetivos primarios fueron evaluar la mejora en la satisfacción del paciente y la calidad de vida relacionada con la función intestinal, así como la seguridad del procedimiento. Los objetivos secundarios incluyeron la gravedad del estreñimiento, la aparición de síntomas, las tasas de abandono del tratamiento y los motivos de abandono. RESULTADOS: La puntuación de satisfacción aumentó de 2,9 ± 2,4 al inicio a 6,5 ± 2,0 al mes y se mantuvo más alta durante 24 meses (p < 0,001). La puntuación total de calidad de vida mejoró de 2,7 ± 0,6 a 2,0 ± 0,7 al mes y alrededor de 1,9 a partir de entonces (p < 0,001). La gravedad de la puntuación de estreñimiento disminuyó (puntuación de Wexner de 17,9 ± 5,8 a 12,5 ± 5,2 al mes; se mantuvo hasta los 24 meses; p < 0,001), y los síntomas relacionados con el estreñimiento promedio disminuyeron de 3,3 a 1,0 por paciente a los 24 meses. De 175 pacientes a los que se les prescribió irrigación, la interrupción ocurrió en el 10,3% a los 6 meses, el 9,1% a los 12 y el 6,3% a los 24; Las dificultades técnicas fueron poco frecuentes y no se presentaron a los 24 meses, y no se notificaron eventos adversos graves. LIMITACIONES: El diseño no aleatorizado podría haber introducido sesgos. Los resultados se evaluaron mediante cuestionarios autoadministrados validados pero subjetivos, y la población del estudio no estaba equilibrada en cuanto a sexo y comorbilidades, aunque estos factores no afectaron significativamente los resultados principales. CONCLUSIONES: Este estudio proporciona la primera evidencia que respalda la eficacia y seguridad de la irrigación transanal a largo plazo para mejorar la función intestinal, los síntomas y la calidad de vida en pacientes con estreñimiento funcional a largo plazo. (AI-generated translation )

Aim: This study aimed to evaluate the global perspectives of healthcare professionals on LARS, including awareness, use of diagnostic tools, management strategies, resource access and multidisciplinary involvement, and to provide a contemporary international snapshot that identifies gaps in care and informs future consensus‐building and education. Method: A cross‐sectional, international online survey was distributed to healthcare professionals involved in the care of patients following rectal cancer surgery. The survey assessed awareness of LARS, use of validated diagnostic tools, treatment approaches, access to multidisciplinary services and availability of advanced therapeutic options. Responses were analysed descriptively. Results: A total of 238 healthcare professionals from 46 countries participated; most were surgeons (79.0%). While 86.6% reported informing patients about LARS risk, only 17.6% reported using POLARS score. Access to specialized services such as pelvic floor physiotherapy or multidisciplinary support varied widely. Initial management commonly included dietary modifications (81.1%) and antidiarrhoeal medications (73.5%), while advanced therapies, such as pelvic floor physical therapy (41.6%), transanal irrigation (32.8%) and sacral neuromodulation (28.6%), were unavailable or underutilized. Conclusion: Global inconsistencies in LARS care highlight the need for provider education, standardized pathways, wider use of validated tools and improved access to multidisciplinary interventions. Involving patient representatives will be essential to ensure consensus reflects patient priorities and optimizes quality of life. Originality Statement: This study provides the most comprehensive contemporary global overview of Low Anterior Resection Syndrome care, capturing real‐world variation in awareness, assessment, management and resource access across 46 countries and identifying critical gaps to inform international consensus, education and equitable survivorship care.

Aim: The aims of the study were to: (1) update a systematic review on the efficacy of transanal irrigation (TAI) in patients with chronic constipation (CC) and/or faecal incontinence (FI); (2) provide guidance on the position of TAI in the treatment pathway of CC and FI; and (3) discuss knowledge gaps and areas of future research. Method: A collaborative of 11 experts (gastroenterologists, colorectal surgeons, and clinical scientists) from eight European countries was established. The expert group was divided into three main groups, with each group leading a specific section (systematic review, treatment pathway, and knowledge gaps). A previously published systematic review on TAI was updated by conducting an additional search on 12 April 2025. Studies on TAI in specific subgroups (neurogenic bowel dysfunction, low anterior resection syndrome) were excluded. Results: Sixteen studies involving 1567 (range 16–507) patients were included. Only one underpowered randomised trial was performed, which demonstrated that high‐volume TAI may be more effective than low‐volume TAI in patients with CC. Most other studies (observational) showed improvement in symptoms and/or quality of life to some extent, with a large variation in outcomes used. Treatment discontinuation was reported in 3–57% of patients. The position of TAI in the treatment pathway of CC and FI was proposed, and 13 knowledge gaps were provided. Conclusion: TAI may be an effective treatment in patients with CC and/or FI. There is a need for randomised controlled trials to study its efficacy and current knowledge gaps.

Low anterior resection syndrome (LARS) significantly impacts quality of life after rectal cancer surgery. Transanal irrigation (TAI) is a potential treatment, but long-term outcome data are limited. This study aims to evaluate the efficacy and safety of TAI in LARS patients after more than 5 years of follow-up. From April 2015 to December 2019, consecutive patients with LARS following low anterior resection for rectal cancer, trained in TAI at Careggi University Hospital, were prospectively collected. Patients with LARS scores > 30 or those failing conservative management were included. TAI was performed using the Peristeen® device, with a standard protocol of 400-600 ml irrigation 3-4 times/week. Primary outcomes were maintenance of TAI benefits and patient satisfaction (VAS). After an appropriate training and evaluation period, 35 patients were referred to TAI. While interruptions in the first year were mainly related to technical problems, ineffectiveness, or the onset of other clinical problems, afterward, patients tended to discontinue treatment only in the event of death (6 patients) or clinical well-being (5 patients). At the last follow-up control, with a median follow-up of 89 months, 15 patients (43%) still used TAI treatment. The median VAS satisfaction score for bowel control was 8.2. TAI demonstrates sustained benefits in LARS patients over 5 years, with significant symptom improvement and high patient satisfaction. Further studies are needed to identify predictors of long-term success.

Background: Left colon cancer obstruction treatment is a debated topic in the literature. Stent placement is effective as a bridge-to-surgery strategy, but there are some concerns about the oncological safety for the reported higher risk of local and peritoneal recurrence. This study aims to compare the surgical and oncological outcomes of patients treated with stent followed by elective surgery with those treated with primary resection. Methods: This is a retrospective observational study. We included patients of both sexes, ≥18 years old, with a histological diagnosis of intestinal adenocarcinoma, and admitted to our hospital for left colon cancer obstruction demonstrated by CT scan without metastasis or perforation. They were treated through primary resection (PR) or stent placement followed by elective surgery (SR). The two groups were compared for general characteristics, surgical outcomes, and oncological outcomes (metastasis and local recurrence) at 30 days, 90 days, 1 year, and 3 years. Post-operative quality of life (QoL) was also investigated. Results: The SR group showed a shorter hospital stay, a lower post-operative mortality, a lower stoma rate at 1 year, and a higher number of minimally invasive procedures. Oncological outcomes were not different compared to the PR group. The SR group demonstrated better QoL in two out of six items on the EQ-5D-5L test. Conclusions: Stent placement as a bridge-to-surgery strategy is feasible and provides better surgical outcomes in terms of post-operative complications, surgical approach, stoma rate, and QoL. Oncological outcomes were not reported differently, but further studies should be conducted to better evaluate this aspect.

Background This study aims to establish a consensus-based standard protocol for transanal irrigation (TAI) in patients with low anterior resection syndrome (LARS) and functional constipation. Methods The Delphi method was utilized to reach a consensus among clinicians and nurses expert in the field of colorectal surgery and gastroenterology. To address various uncertainties concerning technical aspects, difficulties, and prescription of TAI, two questionnaires were developed and analyzed in two rounds. A binary approach was employed, setting a consensus threshold of 75% agreement. Results In the first round, nurses achieved consensus on all statements, while clinicians required a second round to reach consensus, particularly regarding prescription and technical aspects. Clinicians reached consensus on prescribing TAI as a second-line treatment for LARS and functional constipation, following the failure of conservative measures such as dietary and lifestyle interventions. Timing considerations for patients with LARS encompass avoiding TAI within 1 month of stoma closure and waiting a minimum of 3 months. For functional constipation, TAI is recommended for slow transit constipation, emphasizing its preference over surgical options. Consensus was also reached on the choice of catheter for patients with LARS, training requirements for patients and caregivers, preparation of the patient’s intestine before TAI, and recommended irrigations. Conclusions This consensus study successfully developed a standardized TAI protocol for LARS and functional constipation. It provides comprehensive guidelines for prescription and technical aspects, addressing the challenges encountered by healthcare professionals. The protocol aims to enhance patient care, improve treatment outcomes, and contribute to the advancement of TAI.

Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons’ daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.