Adolfo Renzi

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) on the diagnosis and management of obstructed defecation syndrome (ODS), with the purpose of guiding physicians in the selection of the most appropriate treatment option. A panel of experts was appointed by the Board of the SIUCP to develop key questions addressing the main topics related to the management of ODS and to perform an accurate literature search for each topic, in order to provide evidence-based answers and to summarize them in structured statements. All clinical questions were discussed by the expert panel over multiple rounds using the Delphi approach, and consensus among the experts was achieved for each statement. The questions were formulated according to PICO (patients, intervention, comparison, outcome) criteria, and the statements were developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In patients with ODS refractory to first-line medical therapy, rehabilitation may be considered as a therapeutic option, particularly in cases of dyssynergic defecation, whereas a surgical approach may be indicated in patients with a high symptom score and an Oxford prolapse grade system score ≥3 on defecography (using magnetic resonance imaging or another modality). Surgical options include stapled transanal rectal resection and ventral mesh rectopexy, eventually combined, respectively, with pelvic organ prolapse suspension and sacrocolpopexy in the presence of multicompartment pelvic prolapse. A transverse perineal support procedure may be considered in the presence of excessive perineal descent. In patients with recurrent symptoms after surgery, transanal irrigation may represent a useful therapeutic option.

Purpose: To evaluate the safety and long-term efficacy of stapled transanal rectal resection (STARR) combined with the transverse perineal support (TPS) procedure in the surgical treatment of obstructed defecation syndrome (ODS) associated with internal rectal prolapse and excessive perineal descent (PD).Methods: This multicenter observational case-control study involved 7 European centers. During the initial study period, patients underwent STARR alone (group 1), while in the subsequent period, patients received STARR combined with TPS (group 2). All patients were followed clinically at 6, 12, 36, and 60 months, and were offered radiological evaluation between 3 and 5 years postoperatively.Results: The median postoperative ODS score was similar between groups at 6 months (6 [range, 2–15] vs. 5 [range, 2–13]; P=0.16, Mann-Whitney U-test), but at 36 months, it was significantly lower in group 2 compared to group 1 (11 [range, 5–16] vs. 5 [range, 2–15]; P<0.001, Mann-Whitney U-test), with stable results maintained through 5 years. The success rate followed a similar trend. Postoperative maximum PD during straining remained unchanged in group 1, whereas it significantly decreased compared to preoperative values in group 2.Conclusion: The addition of TPS to STARR in the surgical treatment of ODS associated with internal rectal prolapse and excessive PD appears to significantly improve long-term success rates and correct descending perineum.

Background: Sphinkeeper™ (SK) implantation has emerged as a minimally invasive option for patients with fecal incontinence (FI) who fail to respond to conservative therapies. While preliminary outcomes have been encouraging, robust mid-term data remain limited. This study aimed to evaluate the safety, efficacy, and quality-of-life outcomes of SK implantation in a large, multicenter European cohort. Materials and methods: This retrospective cohort study included patients with FI who underwent SK implantation between 2017 and 2022 across seven tertiary referral centers in Europe. Eligible patients had failed pharmacological and pelvic floor rehabilitation therapies and completed at least 3 years of follow-up. Primary outcomes included changes in the Cleveland Clinic Incontinence Score (CCIS), Vaizey score, weekly incontinence and soiling episodes, and the ability to postpone defecation. Secondary outcomes assessed changes in the fecal incontinence quality of life (FIQoL) scale. All patients underwent standardized clinical, ultrasonographic, and manometric evaluations preoperatively and at 3 months postoperatively. Results: A total of 111 patients (61.2% female; median age 59.4 years) were included. Median CCIS decreased from 12 (range: 6–18) at baseline to 7 (1–10) at 12 months, with sustained improvement at 3 years ( P < 0.0001). Vaizey scores and weekly incontinence episodes significantly declined, while the ability to postpone defecation improved from 8 to 18 seconds ( P < 0.001). All FIQoL domains showed significant enhancement by 12 months and remained stable through 36 months. No major complications were reported, and implant positioning was confirmed as adequate in 91.9% of cases. Conclusion: SK implantation is a safe and effective treatment for refractory FI, offering durable improvements in continence, urgency control, and quality of life over a 3-year follow-up period. These findings support its role as a viable minimally invasive alternative in the contemporary management of FI.

Purpose: This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.Methods: This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.Results: When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).Conclusion: The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.

Purpose: Postoperative pain is a major concern for patients undergoing ultrasound scalpel-assisted hemorrhoidectomy, potentially exacerbated by delayed wound healing. This study aimed to evaluate the impact of an intimate cleansing gel containing chlorhexidine, hyaluronic acid, and other anti-inflammatory agents (Antroclean Fisioderm) on postoperative pain, itching, and wound healing in patients who had undergone this procedure. Methods: This multicenter observational case-control study involved a cohort of consecutive adult patients who underwent hemorrhoidectomy using an ultrasound device. The study compared 2 different postoperative wound management strategies over 1 month after surgery: washing with warm water twice per day (control group) versus a 2-minute topical application of intimate cleansing gel (Antroclean Fisioderm) followed by a warm water wash (intervention group). Results: The median postoperative pain score was significantly lower in the intervention group than in the control group at each follow-up point (P<0.01). The percentage of patients reporting anal itching was also significantly lower in the intervention group than in the control group at each follow-up point (P<0.01). All patients in the intervention group achieved complete wound healing 4 weeks after surgery, compared to 88 (82%) in the control group (P<0.01). No adverse events were reported. Conclusion: The topical application of intimate cleansing gel (Antroclean Fisioderm) twice daily for 1 month following ultrasound scalpel-assisted hemorrhoidectomy appears to be associated with faster healing, reduced pain, decreased itching, and improved quality of life, without any adverse effects. Further larger and prospective randomized trials are recommended to confirm these findings.

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Purpose: To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery. Methods: The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings. Results: A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference ( P < .0001; Fisher’s exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate. Conclusion: The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.

Severe and persistent dysphagia (PD) due to a stenosis of the esophageal hiatus is a serious and rare complication after antireflux procedures. In the case report presented here, the treatment of dysphagia, which arose eight weeks after surgery and progressively worsened, required a new laparoscopic approach. The re-intervention undertaken allowed us to identify the cause of the dysphagia, a tight hiatal stenosis, and to treat it successfully.