MANAGEMENT OF MALIGNANT COLON AND RECTAL POLYPS (T1) AFTER ENDOSCOPIC POLYPECTOMY: A RETROSPECTIVE MULTICENTRIC OBSERVATIONAL STUDY. POST-1 PROJECT
- Saadeh, D. Parini, M. Zizzo, J. Sancho-Muriel, L. Lorenzon, L. Turati, R. Tutino, A. Mellano, G. Gallo, G. Rizzo, M. Morino, M.E. Allaix, P. Conti,R. Scilletta, M. Zuolo, R. De Luca, M. Frasson, M. Scarpa, T. Meggiato, G. Del Favero, E. Facci
Background: The widespread colonoscopy screening for colorectal cancer led to an increased incidence of T1 endoscopically excised polyps. Despite these findings, the management of T1 colorectal polyps is still controversial, varying from surgical resection to endoscopic follow up, due to different risk factors such as histological features and early lymph node involvement. The aim of this study is to analyze the different pathological criteria, in order to identify possible predictors of lymph node metastasis.
Material and Methods: In this multicenter retrospective study, the clinical data of 569 patients who underwent endoscopic polypectomy for malignant colorectal polyps T1 were retrieved from 11 hospital in Italy and Spain from 2010 to 2015. The patients were later divided into two groups: those who underwent endoscopic polypectomy (EP) and patients who underwent complementary surgery (CS). According to the literature, 6 histopathological criteria were tested as predictors of lymph node involvement: tumor differentiation grade G3-G4, lymphatic invasion, vascular invasion, tumor budding, submucosal invasion depth>1000 µM (or sm2-3 Kikuchi classification) for sessile polyps and Haggitt level 4 for pedunculated polyps, lateral margin involvement (lateral healthy tissue <1mm). Univariate and multiple logistic regression analysis were performed to identify possible predictors of nodal metastasis in T1.
Results: 220 patients (38,7%) underwent only EP while 349 patients (61,3%) underwent CS. Among CS, 10,0% (35/349) had lymph node metastases. At logistic regression analysis the presence of vascular invasion was the only independent predictor of nodal metastasis (OR 2.51, 95%CI 1.12-5.65; p=0.02) (see Table).
Conclusions: In these preliminary findings, only vascular invasion out of the six pathological factors tested revealed to be an independent predictor of nodal involvement in CS group. The still ongoing POST-1 clinical trial will test the accuracy of these findings.
IMPACT OF PROCTOLOGIC SURGERY ON ANAL INTERCOURSE: A PROSPECTIVE STUDY
Sturiale A, Fabiani B, Menconi C, Cafaro D, Martellucci J, Naldini G
Background The percentage of heterosexual population that experienced and are used to have anal intercourse ranges from 20% to 35% in USA. This practice raises up to 95% in high-risk people, including lesbian, gay, bisexual and transgender. Because of the lack of data in literature about the effect of proctologic surgery on anal sex, this study aims to analyse if this type of surgery has an impact on sexual behaviour in both genders.
Methods From March 2016 until February 2018, an anonymous questionnaire was submitted to all patients aged>18, undergone proctologic surgery in two surgical unit of tertiary referral centres, independently from the gender. The exclusion criteria were incomplete healing and less than 3-months follow-up.
Results 929 patients answered the questionnaire. The overall preoperative anal intercourse was 22.5%. Male anal intercourse among men was 16.7% while the female anal intercourse among women was 28.9%. The overall postoperative anal intercourse was 11.8%. The rate of postoperative anal intercourse after surgery among those people who have this preoperative habit is 52.6% with a 47.4% of abandon. The main cause of abandon was the fear of pain without any real attempt to the intercourse in 43% of cases, the second cause was the experienced pain in 35% of cases and 22% did not answered.
Conclusion Anal sex is a widespread habit between both genders, especially in high-risk population. Proctologic procedures may have an impact on this hedonistic practice but there are only few reports with tips and advice about problems after this type of surgery. This is an initial report showing how most of the patients changed their sexual behaviours after surgery. Hence, nowadays the surgeon has the duty to treat the diseases and even to inform the patient about the possible consequences of proctologic surgery and its influences on anal intercourses.
PREOPERATIVE NEAR INFRARED REGION IN VIVO IMAGE ACQUISITION AFTER ADMINISTRATION OF I.V. INDOCYANINE GREEN CONTRAST FOR MALIGNANCIES DETECTION
- Franceschin, R. Cahill University College of Dublin
Preoperative near infrared region in vivo image acquisition after administration of I.V. Indocyanine green contrast for malignancies detection. An experimental protocol towards automatic recognition of malignant lesion. Indocyanine green (ICG) is a cyanine compound that displays fluorescent properties in the near infrared region (NIR). It is employed for several different indications like oral surgery, hepato-biliary surgery, breast and colorectal surgery. In colorectal surgery it is especially used to avoid leaks and to detect positive lymph nodes. Recently, thanks to its stability and distribution, it is also tested to deliver drug directly inside the tumour.
The rationale of this investigation protocol is that if the distribution of the dye is different between the normal and the neoplastic tissue because of the alteration of the arterial flow, the resulting image in the near infrared field should be different as well. Assuming this is true, a software build ad hoc, should be able to decide by itself if the lesion, visualised directly with the camera, (laparoscopic or endoscopic vision) is malignant or not, based on the different gradient of contrast in the NIR image due to a different wash out time of the dye. In our observations, under direct vision of the rectal mucosa, few minutes after the administration of the ICG by I.V. (0.5 mg/kg IV bolus) the normal mucosa uptake all the dye and start to be visible in the NIR vision. In contrast the malignant lesion start to be visible in the NIR only after a variable time. 30 mins (ending time for the image acquisition) after the administration of the dye, the normal tissue is completely without contrast and is not more visible in the NIR image. Instead the malignant lesion has still the contrast in the interstitial space, and therefore is still visible in the NIR. After the surgery we have taken 3 samples from the specimen: positive control, negative control, tumour control. Thanks to the biopsies histology report, we have build the relation between the biopsies and the images previously recorded. Thanks to the comparability between NIR images and histology characterisation, with a collaboration between software engineers and the medical physics service, we are building a software which should be able to recognise by itself, during the images acquisition, the neoplastic lesion from the normal tissue.
A NATIONWIDE SURVEY UPON INTERNET AND SOCIAL MEDIA USE AMONG PATIENTS WITH COLORECTAL DISEASE
Sturiale A, Gallo G, Pellino G, Pata F, Moggia E, Campennì P, Milone M, Martellucci J (on Behalf of the You-SICCR Committee)
Introduction ISMAEL survey (Internet and Social Media Among colorectaL patients) aims to evaluate the impact of internet and social media on patients affected by colorectal and proctologic diseases. The study was designed to define the use of these tools as information sources, in order to develop a new contemporary and scientifically-based communication strategies for patients.
Materials and Methods From March to July 2018 an anonymous questionnaire of 18 items will be administered to all the patients referred to the outpatient clinic of the participating centers affiliated to the Italian Society of Colorectal Surgery. A minimum of 200 questionnaire were requested to join the study. Each center created a team (up to 3 investigators, 1 senior and 2 young under 40 years), to which will be guaranteed the authorship.
Results Currently more than 40 referral centers affiliated to the Italian Society of Colorectal Surgery have joined the survey with an estimated number of questionnaires around 8000. After 100 days from the beginning of the study 1527 questionnaires were already uploaded on a dedicated platform (https://docs.google.com/forms/d/1KssYJz4Y2ILAgx0Gor4dk3e4TV2yQ_5gZ86RElOsn6M/viewform?ts=5aec1810&edit_requested=true Google form – Google LLC) with an homogeneous distribution from North to South.
Conclusion Internet and social media are raising as a source of information for medical doctors, surgeons as well as patients. Understand how they are used by the patients to get information about diseases, possible treatments and to know the specialist who treat such specific problems is key point to create network on medical and scientific issues.
LONG-TERM RESULTS OF A NEW ARTIFICIAL ANAL SPHINCTER IN TREATING FECAL INCONTINENCE
Veronica De Simone, Francesco Litta, Angelo Parello, Ugo Grossi, Carlo Ratto
UOSA Proctologia Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome
Fecal incontinence (FI) significantly affects patients’ quality of life (QoL). Treatment of FI is still controversial. Correct selection of an effective procedure is crucial. A new artificial anal sphincter was devised with the aim to surround the anal canal with specifically designed self-expandable prostheses. The long-term results in patients (pts) treated for FI are reported.
SphinKeeper (SK, THD SpA, Correggio, Italy) prostheses (length: 25 mm; diameter: 3 mm) are hydrophilic and self-expandable, changing,when immersed in body fluids, dimensions (length: 22 mm; diameter: 7 mm) and becoming soft with shape memory. SK implant was performed in lithotomy position, under local anesthesia. Ten 2-mm perianal skin incisions were made equidistant each other. Under digital guidance, the dispenser cannula was inserted into the intersphincteric space reaching the upper part of the anal canal. Endoanal ultrasound (EAUS) confirmed the correct position. Then, the delivery system provided the automatic deployment of 10 prostheses along the anal canal circumference. Follow up (FU) was scheduled at 1 week, 1, 3, 12 months, and once a year, providing clinical assessment (includingFI severity scores), EAUS and anal manometry (ARM).
Forty-one pts (9 men, 32 females; median age: 58 years, range 20–75) were submitted to SK implant. Mean procedure duration was 40 min (range 30–45). None intra-postoperative complication was registered, (including sepsis). No patient complained of anal pain/discomfort. For 19 pts FU duration was at least 12 months (range 12-15). Compared with baseline, reduction in mean episodes of soiling (from 8.4 to 3.6, p=0.0014), incontinence to gas (from 22.2 to 9.0, p=0.0024), liquid (from 6.0 to 1.8, p<0.0001), and solid stools (from 3.4 to 1.5, p=0.065) was achieved. In 10 pts (52.6%) a reduction of >75% episodes of FI events was accounted; 6 pts (31.6%) regained full continence. FI severity scores improved significantly: Wexner score, from 11.8 to 6.2, p=0.0004; Vaizey score, from 14 to 7.7, p<0.0001; AMS score, from 78.8 to 42.9, p=0.0098.If compared to baseline, ability to defer defecation for >5 minutes concerned a significantly higher number of pts following the SK implant (21.1% vs. 52.7%, p<0.001). At ARM, resting pressure did not change significantly but squeeze pressure improved (from 102.277.2 to 120.465.3, p=0.02) and the anal canal functional length increased (from 1.61.0 to 1.90.4, p=0.27).
This study demonstrates the long-term efficacy of the SK implant in treating FI pts. Also soiling and incontinence to gas resulted significantly improved. The mechanisms of action of SK implant must be better elucidated; however, this study showed an improved pts’ ability to defer defecation, anal canal functional length, and squeeze pressure. Moreover, safety of SK implant was confirmed. This procedure can be considered a valid therapeutic option in FI
THE USE OF A MODIFIED RHOMBOID MUCO-CUTANEOUS ADVANCEMENT FLAP FOR ANAL STENOSIS
Gaetano Gallo1,2, Michela Campanelli1, Giuseppe Clerico1, Alberto Realis Luc1, Mario Trompetto1 1. Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy 2. Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
INTRODUCTION. Anal stenosis is one of the most symptomatic proctological disturbance (excessive straining, painful evacuation, bleeding after defecation) which depends on a series of various diseases (IBD, tuberculosis, cancer), treatments (Radiotherapy) or more frequently is a complication of anal/perianal surgeries (above all after haemorrhoidectomy). A certain percentage of patients complaining of anal stenosis can be successfully treated by a simple anal dilatation or by a careful local incision but the majority of severe cases needs a plasty to restore an almost normal anal canal. Many shapes of mucosal and mucocutaneous flaps are used for these anoplasties (house, V-Y, rhomboidal flaps) depending on the local condition or more frequently on the preference or experience of the surgeon. The aim of this study is to evaluate the role of our modified rhomboid mucocutaneous flap for anal stenosis.
MATERIAL AND METHODS. From January 2002 to September 2015 we have performed 50 modified rhomboidal flaps, 4 of which bilateral (mean age 58y, range 33-82y, 27 females and 23 males). All patients were carefully examined with digital rectal examination. We categorize the severity of the stenosis using the topografic classification of Milsom. Patients were operated in lithotomy position using an epidural anesthesia and the average time of hospitalization was 2 days.
RESULTS. The mean operation time was 30 min (range 25-45 min) for the monolateral flap and 50 min (range 45-65 min) for the bilateral flap. The mean follow up has been 84 months (range 9-168 months). No major complications occurred being the healing by secondary intention the most frequent postoperative discomfort. The large majority of patients (92%) are satisfied with the results, having solved the problem of pain, bleeding and defecation with faeces spaghetti-like.
CONCLUSIONS. The use of a modified rhomboid mucocutaneous flap is a good option for the treatment of patients complaining of anal stenosis and needing surgery premise that the preoperative evaluation of the stenosis is critical to success.
INNATE IMMUNITY AND CROHN’S DISEASE RECURRENCE AFTER SURGERY
Saadeh L, Angriman I, Kotsafti A, Mescoli C, Odorizzi T, Scarpa M, Cavallin F, Rugge M, Bardini R, Castagliuolo I, Scarpa M
Background Crohn Disease (CD) is a chronic inflammatory disease affecting the gastrointestinal tract with a patchy and transmural involvement. CD complications or unresponsiveness to medical therapy are managed with surgery but recurrence rate is high and burdensome. Re-operation is often required because of the fibrotic stenosis of the anastomosis. This study aims to analyse the relationship between innate immunity mediators and ileal wall fibrosis and to define possible molecular predictors of clinical and endoscopic recurrence.
Methods Mucosal samples were obtained from both healthy and inflamed ileum of 56 consecutive patients undergoing ileo-colonic resection for CD. Ileal mucosal samples of 14 patients undergoing surgery for cancer were obtained as control tissues. Data on clinical, endoscopic, and surgical follow-up were collected. Clinical recurrence has been defined as HBI≥8 (moderate-to-severe activity) while endoscopic recurrence has been defined as Rutgeerts’s score ≥3. A pathologist evaluated the fibrosis grade with a specific score. CD68, CD163 and iNOS expression was evaluated with immunohistochemistry through a semi-quantitative scale. TLR2, TLR4, TLR5, HBD1, HBD2, HBD3, HD5, and HD6 mRNA expression was quantified through RT-PCR. Concentrations of BDNF, Eotaxin-1, ICAM-1, IL-1β, IL-1alpha, IL-1ra, IL-12p40, IL-12p70, IL-15, IL-17, IL-23, MMP-3, SCF, VEGF were determined with ELISA. Statistical analysis was carried out with non-parametric tests.
Results Fibrosis grade showed a direct correlation with IL-17 concentration (r = 0.37; p = 0.04) and inverse correlation with HBD1 (r = -0.34; p = 0.01), TLR4 (r = -0.41; p < 0.01), and IL-12p70 (r = -0.37; p = 0.01) levels. HBD1 and TLR4 accurately indicated severe fibrosis (AUC 68%; p = 0.02 e AUC 72%; p < 0.01 respectively). During the follow-up, 30% of patients (17/56) developed moderate-to-severe clinical recurrence, while 21% of the patients (12/56) developed endoscopic recurrence. Clinical recurrence-free interval is inversely correlated with expression of CD68 (r = -0.335; p = 0.01) and CD163 (r = -0.341; p = 0.02) and iNOS expression is inversely correlated with endoscopic recurrence-free interval (r = −0.46; p = 0.02). Clinical recurrence-free directly correlated TLR2 (r = 0.36; p = 0.01), TLR5 (r = 0.42; p < 0.01), IL-17 (r = 0.42; p < 0.01), IL-23 (r = 0.39; p = 0.01) levels.
Conclusion Pro-inflammatory cytokines perpetuate inflammation and were associated to intestinal fibrosis. HBD1 and TLR4 may be accurate molecular markers of severe fibrosis. M1 macrophages seem to play an important role in the re-activation of the inflammation after surgery.
PELVIC HEMATOMA FOLLOWING STAPLED HEMORRHOIDOPEXY: A RARE COMPLICATION TREATED WITH PERCUTANEOUS ANGIOEMBOLIZATION
Francesco Ferrara, Paolo Rigamonti, Giovanni Damiani, Maurizio Cariati, Marco Stella
Introduction: Stapled transanal mucopexy for hemorroids, also called Procedure for Prolapsed Hemorroids (PPH) or hemorrhoidopexy, has been introduced as an alternative method to the Ferguson and Milligan-Morgan techniques. However this procedure is not free from complications, some of which have been described as serious. One of the most described complications is bleeding, that, in some cases, can be very important. We describe a case of a female patient with a post-operative huge pelvic hematoma following PPH, successfully treated with percutaneous angioembolization.
Materials and methods: A 76-year-old woman was referred to our Unit for hemorrhoidal prolapse complaining recurrent ano-rectal bleeding and pelvic discomfort. She had past history of arterial ipertension and chronic constipation. At consultation a IV degree muco-hemorrhoidal prolapse was diagnosed, according to Goligher’s classification. After colonoscopy, which showed no abnormalities in the whole colon, indication to surgery has been placed. Procedure for Prolapsed Hemorrhoids (PPH) was offered and accepted by the patient. Operation was carried out with PPH-03 stapler kit as usual, with no intraoperative complication. At the end of the procedure the rectal suture was 4 cm above the dentate line and it was complete. Additional stitches were placed on the suture line and finally no bleeding points were noted. Then postoperative endoanal sponge was left.
Results: Few hours later the patient started to complain of abdominal pain and pelvic discomfort. On clinical examination the abdomen was diffusely painful, with signs of abdominal rigidity on the lower quadrants, as acute abdomen. No rectal bleeding nor other abnormalities were noted. Since the pain did not regress after strong analgesic therapy, an urgent abdominal and pelvic contrast-enhanced CT scan was performed. The exam showed a giant peri-rectal and retroperitoneal pelvic hematoma, with signs of active bleeding. A subsequent selective arteriography showed huge bleeding from superior haemorrhoidal artery, treated with super-selective embolization. The procedure was successful and immediately after the patient showed a symptomatic improvement. The subsequent hospital stay was uneventful and she was discharged on post-operative day 9, after a control CT scan which showed partial regression of the hematoma with no signs of active bleeding. At the 30-day postdischarge follow-up, the patient was completely pain free with no signs of pelvic discomfort. Ano-rectal examination showed regular stapler line with no prolapse recurrence and a new control CT scan revealed regression of the pelvic hematoma.
Conclusions: Severe complications may occur after PPH and one of the most important is local bleeding. In our case no signs of external active bleeding were noted. Prompt diagnosis with CT scan allowed to offer efficacious non-operative treatment with angioembolization, avoiding the need of reoperation for a potential serious complication
TREATMENT OF SYMPTHOMATIC HAEMORRHOIDAL DISEASE WITH INJECTION OF POLIDOCANOL 3% FOAM: OUR EXPERIENCE ON 46 PATIENTS
- Minafra, P. Lobascio, R. Laforgia
The objective of our study is to analyze the effectiveness, safety, results and quality of life of the treatment for the second-third degree hemorroids using sclerotherapy. This retrospective study was for 46 patients treated in our clinic from March 2017 to May 2018. All patient underwent polidocanol 3% foam injection using Blonde-Blanchard modified technique. Data were collected from the patients’ files. The patients were asked to return to outpatient clinic for follow up at 1,4,12,24 weeks. 91% of patients are males in a range of ages between 30 and 70 ys. Symptomatic recurrence was detected in 10 patient after 1 year.; 2 patients had pain and thrombosis the day after procedure.Concluding, sclerotherapy with polidocanol 3% foam is a simple, safe and effective method for treating symptomatic II – III degree hemorrhoids improving patients’quality of life or as bridge to surgery symptom-free.
The objective of our study is to analyze the effectiveness, safety, results and quality of life of the treatment for the second-third degree hemorroids using sclerotherapy. This retrospective study was for 46 patients treated in our clinic from March 2017 to May 2018. All patient underwent polidocanol 3% foam injection using Blonde-Blanchard modified technique. Data were collected from the patients’ files. The patients were asked to return to outpatient clinic for follow up at 1,4,12,24 weeks. 91% of patients are males in a range of ages between 30 and 70 ys. Symptomatic recurrence was detected in 10 patient after 1 year.; 2 patients had pain and thrombosis the day after procedure.Concluding, sclerotherapy with polidocanol 3% foam is simple, safe and effective method for treating symptomatic II – III degree hemorrhoids improving patients’ quality of life or as a bridge to surgery symptom-free.
INJECTION OF ADIPOSE TISSUE DERIVED STEM CELLS (MYSTEM® EVO TECH): A NEW SPHINCTER PRESERVING TREATMENT FOR COMPLEX TRANSSPHINCTERIC ANAL FISTULAS
- Minafra, P. Lobascio, R. Laforgia, A. Delvecchio
Introduction: Adipose tissue derived stem cells (ADSCs) are multipotent and can differentiate into various cell types. ADSCs have been tested for Crohn’s fistulae with good results. We used ADSCs autologous transplantation for a complex transphinteric fistula: a sphincter-preserving technique to avoid the risk of fecal incontinence.
Presentation of case: We present a case of a 77 years-old male patient with left posterior lateral perianal abscess on 6cm long fistula tract and posterior external opening without internal opening. The surgical procedure was performed when the fistula had stopped discharging pus. MYSTEM® EVO Technology was used to obtain stem cells. They were injected outside (directed toward hipotetical I.F.O) and inside the fistula tract. The external opening was closed by adsorbable stich. The patient underwent a F-U (at 7-30-180 POD) demonstrating a complete healing of fistula.
Discussion: adipose tissue is an excellent source of adult stem cells, because of plasticity features which represent a powerful source for several future applications. One of revolutionary impact in stem cells-based therapies is going to develop in the management of Crohn’s fistula, for their anti-inflammatory and immunomodulatory capacities.
Conclusion: ADSCs are a promising new sphincter preserving treatment option for high or complex transsphincteric anal fistulas, and MYSYSTEM® EVO Technology is potentially useful for this application.
3D ENDOANAL ULTRASOUND: DIAGNOSIS AND FOLLOW-UP OF ANAL FISTULAS IN CROHN’S DISEASE
- Orlandi, A. Massella, A. Variola, M. Fortuna, P. Bocus, A. Geccherle
Background: Perianal Crohn’s disease (PCD) requires a multidisciplinary approach. As an optimal management of the disease, it is critical to have a complete study of fistula, including clinical assessment
of external opening and digital rectal exploration (DRE), endoscopic evaluation and Magnetic Resonance Imaging (MRI) measurements to define fistula’s anatomy and The presence of abscesses.
Methods: 3D-Endoanal Ultrasound (3D-EAUS) shows a good concordance with surgery in detection of primary and secondary fistulas and has a high sensitivity and specificity for the internal opening
diagnosis In our study we aimed to test the role of 3D-EAUS in the management of Crohn’s disease perianal fistulas.
Results: 55 patients (patients) with complex PCD underwent surgery: 13 patients were treated using video-assisted anal fistula treatment (VAAFT) technique combined with advanced flap repair and closure of internal opening, 16 patients were treated with lay open surgery and 26 patients underwent fistulectomy and seton placement. One month after surgery all the patients received Infliximab (IFX) therapy. During the induction period patients underwent proctological visit and 3D-EAUS. On maintenance IFX therapy we performed only a DRE and anoscopy. Due to detection of abscess, an absolute contraindication to IFX, ultrasound examination has been crucial in stopping the biologic therapy in 3% of patients.
Conclusions: 3D-EAUS is a cost-effective, useful and simple technique for the monitoring of PCD patients undergoing surgery and successively treated with IFX.
IMPACT OF FISTULOTOMY AND PRIMARY SPHINCTEROPLASTY ON CONTINENCE AND PATIENTS’ SATISFACTION: LONG-TERM RESULTS Francesco Litta, Angelo Parello, Veronica De Simone, Ugo Grossi, Carlo Ratto UOSA Proctologia Fondazione Policlinico Agostino Gemelli IRCCS Rome
INTRODUCTION Aim of this retrospective study was to evaluate safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS), and evaluate its impact on postoperative continence status and patients’ satisfaction.
METHODS Between June 2006 and May 2017, 203 patients (139 males; mean age: 48.7 years) affected by cryptoglandular anal fistulas underwent FIPS. All patients were evaluated by standardized telephone interview. Main outcome measures evaluated were: fistula healing, continence status, and patient’s satisfaction (by VAS scale).
RESULTS Fistulas treated were intersphincteric in 58 patients (28.6%), and transphincteric in 145 (71.4%, 60 low, 85 medium-high). In 103 patients (50.7%) fistulas were complex. At a mean FU period of 55.9±30.9 months (range, 12-143), the healing rate was 92.6% (188 patients). Preoperatively, 8 patients (3.9%) were affected by post-defecation soiling, and one patient by gas incontinence. Postoperatively, 26 patients (12.8%) complained of “de novo” continence impairment, mainly consisting of post-defecation soiling (20 patients, 9.8%); the overall CCFIS did not significantly change (preoperative, 0.04; at FU, 0.49). At the univariate analysis patients affected by a recurrent (p=0.002), complex (p=0.012), with secondary tracts (p=0.004), with previous setons drainage (p=0.0001), were at higher risk of incontinence; at the multivariate analysis the only significant factor was the fistula complexity (p=0.050). The mean VAS patients’ satisfaction rate was 9.3+1.6; patients affected by a transphincteric (p=0.011), complex (p=-0.0001), with secondary tracts fistula (p=0.041), or with previous setons drainage (p=0.008), and postoperative continence impairment (p=0.0001) had a lower satisfaction rate. At the multivariate analysis the only factor associated to a lower satisfaction rate was the postoperative onset of incontinence (p=0.0001).
CONCLUSIONS FIPS should be considered a valid therapeutic option for selected anal fistulas, giving a good healing rate, and providing high patients’ satisfaction. However, a risk of post-operative minor fecal incontinence exists, and it should be considered and discussed with patients.
L’emorroidopessia con tecnica HPS
Valerio Ranieri, Ilaria Benzoni, Cremona
Recently, the ligation of the distal branches of the haemorrhoidal artery under doppler guidance, possibly associated with hemorrhoidopexy, has been used as an alternative to hemorrhoidectomy or mucoprolaxectomy with stapler for the treatment of 2nd and 3rd degree hemorrhoids respectively for less postoperative pain and lower incidence of major complications. According to some studies, hemorrhoidopexy without doppler guidance achieves overlapping or greater results in terms of distant relapses.The dearterialising hemorrhoidopexy with HPS technique represent a valid tool, available to specialist surgeons in that field, with excellent results both in complications and recurrence rate.The surgical technique is simple and easily reproducible and the anatomical landmarks on which to dose the hemorrhoidopexy easily recognizable.We present a single-operator case series, collected between 2013 and 2018, consisting of 145 cases, with a 2.26% recurrence rate and a 2.75% surgical complication rate.”
An APP in proctology: Innovative solutions to improve the life of the patient and the surgeon
- Passannanti , F. Gaj
Technological progress has opened numerous paths and possibilities for a different approach to clinical practice. Our application, available for PC, Tablet and smartphones, aims to improve the assistance provided to the patient and facilitate the work of health professionals. The first section of the APP is addressed to the doctor, specializing in particular. Here are collected some valuable information regarding the management of the patient: how to write the medical record; objective examination (with particular attention to the exploration of the perianal and rectal region). The most common surgical techniques are explained, to provide the young doctor with basic knowledge.The second section is aimed at nursing staff. Useful information are given about, for example, the instrumentation necessary for a specific surgery or the description of the correct positioning of the patient on the operating table. There is also useful information to the ward nursing staff about the patient’s post-operative management.The third section is addressed mainly to the patient. It contains some images and videos that the doctor can use to explain the anatomy of the anal and perianal regions and some pathologies, allowing a greater degree of understanding by the patient, thus encouraging compliance. The last section of the APP is dedicated to sending pre-filled documents to the patient. In a single step, it is possible to send forms and information sheets concerning all the phases of the treatment. For example: pre-hospitalization procedure or post-surgery suggestions. Even informed consent can be sent via email with a single click. This APP is proposed as a 360°aid to the participants involved in the welfare process, placing the patient’s wellbeing at the center, and with the further goal of supporting and facilitating the work of all health professionals, while taking into consideration the economic factor, not negligible in any health initiative.
Transanal Minimally Invasive Surgery for rectal tumors (TAMIS): initial experience.
Autori: Andrea Lauretta, Angelo Danilo Antona, Renato Cannizzaro, Antonino De Paoli, Claudio Belluco, Giulio Bertola
Introduction: Transanal minimal invasive surgery (TAMIS) is alternative to transanal endoscopic microsurgery (TEM) for the treatment of rectal neoplasms. This technique allows safe transanal local excision of the lesions of the mid and low rectum with a reproduceable approach. The authors report the initial experience with TAMIS.
Methods: Between December 2016 and March 2018 patients undergoing TAMIS had their data collected in an institutional permanent rectal tumors database. The procedure was performed adopting the single incision laparoscopic surgery port (SILS™ Port, Covidien) and traditional laparoscopic instruments were used. Only lesions of the mid and low rectum within 12 cm from the anal verge were treated by TAMIS. All data were retrospectively analyzed.
Risultati: Nineteen patients underwent TAMIS. The mean age was 65 years (range 22-82). The mean distance between the lesion and the anal verge was 6 ± 2.1 cm. All but three cases had the rectal wall defects sutured. The length of the procedure was 87 ± 40 min (range 205 – 30 min). The mean hospital stay was 4.1± 2.4 days. There was one case of intraoperative perineal emphysema and four postoperative complications: anal pain in one patient suffering from anal fissure, two cases of fecal urgency spontaneously resolved and one case of acquired Factor XII Deficiency. Histology documented 10 cases of rectal cancer, seven adenoma with high grade dysplasia and two hyperplastic polyps. Resection margins were involved in three cases (15.7%). The mean follow up was 10 months.
Conclusioni: TAMIS is a new method to perform local excision safely and in a reproducible manner. The learning curve is not long since it is performed by traditional laparoscopic instruments. TAMIS treatment of rectal cancer following complete clinical response after neoadjuvant chemoradiation should be accurately evaluated and performed only within clinical trial context.
Human papillomavirus vaccination and squamous cell anal cancer: how does the screening change?
E.Stocco1, A.Infantino1, G.Moise2, C.Colli3, E.Vaccher4, O.Schioppa4, D.Giacomazzi5, S. Sulfaro6, A.Camporese7
Chirurgia Generale, San Vito al Tagliamento (PN)1 Centro MTS , Dermatologia, ASS2 Isontina2
Centro MTS, ASUI, Trieste3CRO Aviano Malattie Infettive, Trieste 5Anatomia Patologica, Pordenone 6Microbiologia, Pordenone 7
Human papillomavirus (HPV) is a sexually transmitted pathogen, persistent infection with high-risk genotypes causes nearly 90 percent of anal cancers. The incidence of anal cancer in the general population has increased over the last 30 years. An increased incidence has been associated with female gender, infection with HPV, lifetime number of sexual partners, genital warts, cigarette smoking, receptive anal intercourse and infection with human immunodeficiency virus (HIV). Since 2015, a Regional Group of local expertise has been established in Friuli Venezia Giulia (FVG) to screen for anal high-grade squamous intraepithelial lesions (HSIL) among patient populations that are at increased risk of anal cancer.Selected high risk individuals are submitted to High Resolution Anoscopy (HRA). Focused biopsies on typical suspicious patterns are sent for hystopathological analysis. HSIL are treated througth HRA-guided cautery and patients followed up. We have evaluated 188 high risk subjects: 58% (109/188) HIV positive; 65% (122/188) MSM. Twenty-five percent have been vaccinated with Gardasil. The number of treatments for HSIL decreased from an average of 0,75±0,74 to 0,125±0,34 cauterizations per patient during a mean follow up of 11±7 months (p=0,001).Our data seem to confirm the reduction of HSIL lesions in vaccinated population. A longer follow up and a greater number of patients is demanded to obtain more significant data.
APPENDECTOMY AND ULCERATIVE COLITIS: ROLE OF INNATE IMMUNITY IN THE INFLAMMATORY RESPONSE OF THE APPENDICULAR AND COLONIC MUCOSA
Saadeh L, Angriman I, Scarpa M, Mescoli C, Kotsafti A, Cavallin F, Rugge M, Bardini R, Castagliuolo I, Scarpa M
Background Ulcerative colitis (UC) pathogenesis involve both gut-associated lymphoid tissue and enteric microflora. Several studies suggested that appendectomy at a young age reduce the risk of UC onset. Moreover, other studies showed that the appendix may also be somehow implicated in UC pathogenesis but the exact mechanism remain unclear. The aim of this study was to analyse the inflammatory response in the appendix and in the colon to determine its role in UC.
Methods From November 2016 to May 2018, 39 patients have been enrolled: 14 patients with UC, 9 patients with acute appendicitis, and 16 patients with CRC.
Patients were enrolled consecutively at the time of surgery when appendicular wall samples were sampled. Then, cytomorphometric analysis was performed to study the activation state of different kind of cells populations forming part of the GALT: M2 macrophages, dendritic cells and T lymphocytes. Statistical analysis was performed with the non parametric tests.
ResultsThe cytomorphometric analysis showed a statistically significant increase of the M2 CD163+/CD68+/CD86+ activation rate, which are located in the basal lamina of the mucosal samples derived from patients with UC compared to patients with acute appendicitis (p=0.02) and compared to patients with CRC (p=0.005). Moreover, The cytomorphometric analysis showed a statistically significant increase of the dendritic cell activity CD1a+/HLA-DR+/CD86+ activation rate, inpatients with UC compared to patients with acute appendicitis (p=0.04).
Conclusion These preliminary data showed an activation of M2 macrophages and dendritic cells in the appendix of UC patients suggesting a relationship between appendicular inflammatory response and UC. Further data on the local microbiota will shed light on the interplay between chronic inflammation in the appendicitis and UC activity.
AUTOLOGOUS, MICRO-FRAGMENTED AND MINIMALLY MANIPULATED ADIPOSE TISSUE AS AN INNOVATIVE APPROACH FOR THE TREATMENT OF COMPLEX ANAL FISTULAS: A PROSPECTIVE OBSERVATIONAL STUDY
Sturiale A, Fabiani B, Menconi C, Giani I, Cafaro D, Toniolo G, Naldini G
Introduction The aim is to evaluate the complex anal fistula healing rate treated with the association of advancement flap and autologous, micro-fragmented and minimally manipulated adipose tissue injection.
From May 2015 to December 2017, twenty-five patients out of 30 expected according to the power analysis, were enrolled. Inclusion criteria: complex anal fistula confirmed by pelvic magnetic resonance or 3D 360° transanal ultrasound, fistula already drained with a seton from 4-6 weeks, first sphincter saving procedure. Exclusion criteria: multiple fistula tracts, abscess, inflammatory bowel disease, HIV, HBV or HCV infection, recto-vaginal fistula, therapy with anticoagulants, steroids or immunomodulants, previous pelvic radiotherapy, personal history of neoplasia within 5 years from the diagnosis, pregnancy, uncontrolled diabetes, coagulopathy or connective diseases Technique: The harvested fat from the lateral abdominal wall was processed in the processing kit (Lipogems®). After curettage of the fistula tract, the internal opening was closed through 3/0 PDS stiches with mucosal flap above it and a subsequent injection of the processed adipose tissue around the fistula tract and internal opening.
Follow-up was scheduled at 7 days, 1-3-6-12 months after surgery. Fistula healing was defined as the closure of internal and external openings without any discharge.
Results: Twenty-five patients underwent the procedure. The mean operative time was 55 minutes. Mean follow-up was 9 months. Recurrence rate was 20%. Globally, only one case of abscess and four cases of persistent discharge without closure of the internal and external openings were observed. No intraoperative or post-operative complications were recorded.
Conclusion: Autologous, micro-fragmented and minimally manipulated adipose tissue injection is a safe, feasible and effective procedure to promote complex anal fistula healing. Preliminary results of this novel technique are very promising, although a larger number of patients is required to draw any conclusion about long-term results compared with the other sphincter saving procedures.
DIATHERMY EXCISIONAL HAEMORRHOIDECTOMY: STILL THE GOLD STANDARD
Gaetano Gallo1,2, Michela Campanelli1,3, Alberto Realis Luc1, Giuseppe Clerico1, Mario Trompetto1
1Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
2Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
3Department of General Surgery, University of Modena and Reggio Emilia, Modena, Italy
Introduction. Haemorrhoids are a common, multifactorial benign but bothersome condition. Their ideal treatment should be minimally invasive, painless, safe and effective with minimal costs. Patients with grade III-IV hemorrhoidal prolapses or having failed conservative and outpatient treatments can be considered for excisional hemorrhoidectomy.
Materials and Methods. In our Department all patients with III or IV degree symptomatic haemorrhoids undergo an open diathermy excisional haemorrhoidectomy under spinal anesthesia, with removal of the three classical piles.
To reduce bleeding and allow a precise anatomical dissection, with the identification of both the internal and external sphincters, the excisional haemorrhoidectomy begins with the injection of 10-15 cc of Adrenaline dissolved in 250 cc of saline.
Three v-shaped incisions are then placed on the mucocutaneous border, leaving a skin bridge in between to avoid anal stenosis. No ligation of the vascular pedicle is applied and no contemporary internal sphincterotomy is performed. Discharge is planned the day after surgery and a recommended oral dose of ketorolac tromethamine of 10 mg every 4-6 hours, not exceeding 40 mg per day and not exceeding 5 postoperative days according to the indications for short-term management of moderate/severe acute postoperative pain, plus stool softeners is administered.
Patients are followed up by the same surgeon who have performed the procedure and are scheduled for a control visit at the first postoperative day (T1), at 7 to 10 days (T2), 20 days (T3), and 40 days after discharge (T4). Follow-up assessment includes a clinical external evaluation at T1, clinical evaluation with rectal digital exploration at T2, clinical evaluation and proctoscopy at T3 and T4. Postoperative pain is evaluated using a visual analog scale (VAS) for pain in which 0 indicates no pain and 10 the worst possible pain.
Conclusions.: Open excisional hemorrhoidectomy remains the gold standard technique despite the risk of postoperative bleeding and associated sequaelae such as anal stenosis and fecal incontinence.
Furthermore, due to the extent of dissection and the presence of incisions below the dentate line, post-operative pain can be severe, and may delay return to normal post-operative activities.
Despite hemorrhoidectomy with energy-based devices seems to cause less immediate post-operative pain we think that the diathermy excisional haemorrhoidectomy, if carried out by an experienced surgeon, must be still considered the gold standard because its more precise dissection bring to the best respect for the anatomy of the anal canal.
ANAL FISTULA REPAIR: TREATMENT WITH DERMAL MATRIX PLUG
Rosanna Curinga, Andrea Legnaro, Michele Longo, Francesco Pietrangeli, Luigi Losacco
Introduction: This study was designed to evaluate the outcomes using a matrix plug for the correction of anal fistulas repair. The three dimensional structure ensure the stability of the device, the sharp edges of the wedge provides the incorporation into the host tissue with lower inflammatory responses and primary stability.
Methods: The study was conducted at the Unit of Coloproctology, Rovigo Hospital, from January 2014 to September 2017 and comprimes data of 21 patients, 9 male and 12 female treated for anal fistula repair with plug (Pressfit). The median age was 53 years (range:29-80 years). Patients were previously treated with a loose seton to promote drainage of the fistula (range 3-12 months). After removed seton and courettage, plug is inserted the larger part in the internal opening that will be sutured; then close the internal orefice with a small mucosal flap. The truncated pyramid frustum creates an intimate contact to promote tissue regeneration. Results: Only complex anal fistula were enrolled in the study. Mean operative time was 30 min. No major complications, active sepsis or mortality were observed. Success rate with a mean follow up of 21 months (range:1-46 months) was 67% of patients. The mean recurrence was 23%. Fourteen of 21 fistulas (67%) were successfully treated. Mean time for recurrence was 3-4 months. Two recurrent patients were successfully treated with a new plug procedure, and five were treated with fistulectomy. No patient experienced any change incontinence.
Conclusion: Fistula plug treatment with dermal matrix is a safe and viable surgical option that should be offered to anal fistula patients. The procedure is safe, simple and has low risk of morbidity. A longer follow-up period and a larger sample size remain to be explored
Anal massage in the treatment of anal fissures, a valid alternative?
- Passannanti, F. Gaj
Anal fissure is a very common pathology but the choice of the most appropriate treatment still remains difficult, due to the risk of recurrences associated with conservative treatment and that of serious complications associated with surgical treatment. For this reason, we have implemented a new type of treatment: anal self-massage The treatment takes place in the introduction of the index finger into the anal canal (with the use of gel containing lidocaine) for 10 minutes a day for the first 2 days of treatment; for a further 5 days the patient is instructed to perform circular motions, for 10 minutes, 2 times a day. The duration of treatment was 7 days. The gel is used exclusively for lubricating and pain relieving. This type of treatment has been studied in the past by comparing it with the use of anal dilators, showing good results. We evaluated the effectiveness of this treatment by recruiting another 50 patients, all affected by posterior anal fissure. Patients were evaluated at the time of diagnosis, at the end of treatment, at 3 months and 6 months. At the time of diagnosis, the patients were instructed about the type of treatment and were given a booklet specifically designed to make clear, and more acceptable, the treatment modalities. In fact, this type of treatment, suffers a lot of socio-cultural influences, errors / difficulties in their execution. The results of the study showed that, at 6 months from treatment in 76% of patients an improvement in the symptoms of the fissure was observed, with an associated relapse rate of 24%.
The study data confirm the effectiveness of treatment by anal massage, accompanied by the already known advantages in terms of treatment duration and costs.
LOW LAPAROSCOPIC VENTRAL RECTOCOLPOPEXY (LLVR) FOR RECTAL PROLAPSE: PERSONAL EXPERIENCE IN OVER 70 PATIENTS
- Giacomel, E. Stocco, R. Bellomo, F. Galanti, A. Lauretta A. Infantino
PelviPerineology Unit-SICCR; Department of General Surgery – Santa Maria dei Battuti Hospital, San Vito al Tagliamento (PN), Italy
Background: LLVR is an effective procedure for the treatment of external and internal rectal prolapse with low postoperative morbidity and mortality rate. The aim of this study is to confirm the safety and feasibility of this procedure in elderly patients.
Methods: Two hundredfiftythree patients with symptomatic rectal intussusception or overt rectal prolapse were operated on and the data on perioperative complications, post-op hospital stay were prospectively collected and analysed comparing the group ≥ 70 years with <70 yrs group.
Results: Group A: 67 (26.5%) patients with mean age of 74.8 ± 3.9, and group B: 186 (73.5%) patients with mean age of 54.5 ± 9.7years No statistical difference In the mean operating time was demonstrated between group A and group B: 101.61 ± 32.5 min vs 104.3 ± DS 36.7 min respectively. No mortality in both groups. Early (within 30 days) postoperative complications were observed in 5.9% and 5.3% respectively: necessitating reoperations in 2 (ileal perforations and abdominal wall hematoma) in group A and 1 (hernia in trocar site) in group B.
The mean post-op hospital stay was 4.03±1.8 days vs 3.8±1.5 days, for the group A and B.
The mean follow up was 16.6 ±12.2 months. In group A preoperative fecal incontinence (FI) was recorded in 23/67 (34.2%) patients while postoperative FI was reported in 15 patients (22.3%), with an improvement of a mean CCIS: 11.8 ±5.6 and 4.1 ± 5.6 ( p <0.001).
We observed a similar improvement in the younger group: 65 (34.9%) patients preop vs 34 (18.3%) patients postop, with mean CCIS respectively 8.7±4.5 vs 3.9± 5.3 (p < 0.001).
The ODS (Altomare) score improved significantly: Group A 14.5±5.2, vs 7.3± 6.1 (p<0.001) pre and postoperatively, respectively. Similarly, ODS resulted improved in group B: 13.7 ± 4.5 vs 6.2 ± 5.4 (p< 0.001).
Conclusions: LLVR is safe and effective for prolapse and associated symptoms also in the elderly population.
SOLO IN ITALIANO
LESIONI OSTETRICHE (OASIS) DI ALTO GRADO: LA NOSTRA ESPERIENZA SULLA RIPARAZIONE SFINTERIALE CON TOSSINA BOTULINICA
- Stocco, G. Giacomel, A. Infantino
In caso di danno sfinterico grave da OASIS la tecnica ricostruttiva comunemente accettata è l’overlap sfinterico, i cui risultati a breve termine sono molto buoni (il 74% migliora la continenza a 3 mesi) ma si riducono nel lungo termine. Per questo sono state introdotte alcune varianti tra cui l’impianto di protesi biologiche e l’iniezione di tossina botulinica. Nella nostra esperienza l’introduzione della Tossina Botulinica sembra migliorare i risultati funzionali dopo overlap.
CASO DI TUMORE CISTICO RETRORETTALE: ASPORTAZIONE LAPAROSCOPICA
- Maiello, R. Perinotti, M. Pozzo,R. Polastri
Nuovo Ospedale degli Infermi di Biella
È descritto il caso di una giovane di 18 anni con dolore anale acuto senza segni di suppurazione perianale con tumefazione estrinseca retrorettale tesoelastica associata a febbre, che alla RMN pelvica è risultata lesione di 9 cm di diametro a margini regolari, polilobata e plurisettata comprimente il retto. È stata sottoposta a drenaggio transrettale e terapia antibiotica con risoluzione dell’evento acuto. Dopo due mesi è stata sottoposta a controllo RMN ed intervento di asportazione laparoscopica della lesione e di un tassello di parete rettale e di muscolatura del pavimento pelvico fusi con la lesione, sutura della parete rettale. Il decorso è stato con piccola deiscenza della sutura rettale risoltasi spontaneamente. L’esame istologico è risultato amartoma cistico retrorettale. La paziente a sei mesi di distanza è asintomatica e la RMN di controllo è negativa.
I tumori retrorettali sono patologie rare, con un’incidenza stimata di 1/40000. Tra questi, gli amartomi retrorettali sono i più frequenti. Più frequenti nel sesso femminile 3-4:1, si possono presentare a tutte le età, ma più spesso tra la quarta e la sesta decade.
Nella maggior parte dei casi sono asintomatici, quando presenti i sintomi prevalenti sono l’infezione (fino al 50%), il dolore anale e pelvico, mentre la degenerazione neoplastica è rara (7%).
La corretta diagnosi preoperatoria è molto diffcile, le indagini più significative sono TC e RM pelvica. L’asportazione laparoscopica è una valida tecnica, alternativa alla via transrettale per la ottima visione dei piani pelvici per risparmiare le fibre nervose e la possibilità di posizionare un drenaggio nella pelvi.
LA VALUTAZIONE MORFO-FUNZIONALE DEL PAVIMENTO PELVICO PRE E POST INTERVENTO IN PAZIENTI CON ENDOMETRIOSI PROFONDA CANDIDATE A CHIRURGIA RESETTIVA
Orlandi S., Clarizia R., Geccherle A., Andreoli R., Bocus P., Ceccaroni M.
|L’endometriosi è una patologia caratterizzata dalla proliferazione di tessuto endometriale in sede ectopica, associata comunemente a dolore pelvico cronico ed infertilità ma che può arrivare a ingenerare, in casi di infiltrazione profonda, danno d’organo (stenosi intestinale, stenosi ureterale, compromissione ovarica con menopausa precoce, compressione nervosa).
L’endometriosi profondamente infiltrante (DIE), è una condizione clinica, in cui l’endometriosi può interessare organi e tessuti di tutto il corpo ed è quasi sempre responsabile di un’importante sintomatologia dolorosa. L’endometriosi profonda è la forma più severa di malattia, pur non essendo progressiva, ed è presente nell’1% delle donne in età riproduttiva. Per endometriosi profonda si intende l’interessamento del setto retto-vaginale con infiltrazione del tessuto peritoneale che riveste gli organi pelvici superiore a 5 mm. Il sintomo più frequente, a causa della ricca innervazione delle strutture interessate, è il dolore legato al ciclo mestruale che si associa spesso ad altri sintomi invalidanti a carico dell’intestino e delle vie urinarie, con notevole compromissione della qualità di vita. I sintomi riferiti sono generalmente: dismenorrea, dischezia, dispareunia, dolore pelvico cronico, rettorragia, diarrea cronica.
Il nostro studio ha come obiettivo la valutazione morfo-funzionale del pavimento pelvico in pazienti candidate a chirurgia resettiva intestinale per endometriosi profonda posteriore e come questo possa influire la strategia di trattamento e di recupero nel postoperatorio.
La valutazione pre e postoperatoria comprende l’esecuzione di manometria anorettale con THD Anopress e sonda Sensyprobe, l’ecografia transanale a 360°, la somministrazione di score funzionali come il Constipation Scoring Sistem di Wexner,il Fecal Incontinence Grading Scale, l’ODS score di Altomare ed il PAC- QOL, la visita proctologica con DRE e l’esecuzione di rettoscopia rigida in un unico accesso al momento del prericovero.
I dati preliminari mostrano come lo studio del pavimento pelvico proposto può indirizzare la scelta terapeutica e la strategia di recupero funzionale nel postoperatorio.
LINEE GUIDA PER ENTEROSTOMIE ED UROSTOMIE
|G. Rizzo, M. Barbierato, A. Bondurri, F. Cattaneo, F. Ferrara, C. Forni, D. Parini, F. Pata, G. Roveron, A. Tafuri, M. Veltri|
|Premessa ed obiettivo: il confezionamento e la gestione delle stomie enteriche ed urologiche rappresentano un aspetto fondamentale nella presa in carico dei pazienti che vengono sottoposti a chirurgia colo-rettale ed urologica maggiore. Per questo motivo è necessaria una presa in carico ottimale, sia dal punto di vista della tecnica chirurgica, sia per quanto riguarda l’assistenza infermieristica specialistica, nel pre e post-operatorio. In letteratura esistono poche linee guida su questo argomento, ed in particolare in Italia, nessuna è stata accreditata dalle maggiori Società Scientifiche chirurgiche ed ancor meno validata a livello Ministeriale.
Obiettivo dello studio è elaborare, sulla base delle evidenze scientifiche, delle Linee Guida Nazionali condivise sulla presa in carico multidisciplinare chirurgica ed infermieristica delle enterostomie ed urostomie,
Materiali e metodi: su iniziativa e proposta della Società degli Infermieri Enterostomisti (AIOSS) è stato creato un gruppo di lavoro multidisciplinare denominato MISSTO (Multidisciplinary Italian Study group for STOmas), che include chirurghi generali e colo-rettali, urologi, enterostomisti. E’ stato chiesto il patrocinio delle maggiori Società Scientifiche Italiane chirurgiche ed urologiche (SIC, ACOI, SICCR, SIUCP, SICO, SIU), e di varie Società di pazienti stomizzati (AISTOM, FAIS, AMICI), con la richiesta di individuare un “collaboratore esperto” per Società.
Risultati: i risultati finali del Gruppo di lavoro MISSTO verranno presentati in occasione dei più importanti Congressi di Chirurgia Italiani e pubblicati su una rivista internazionale indicizzata. Le Linee Guida complete, grazie al patrocinio ottenuto dalle Società Scientifiche, verranno successivamente proposte per una validazione a livello Ministeriale. I risultati verranno anche condivisi sui Social Network (Linkedin e Twitter), che sempre di più si stanno dimostrando un mezzo di divulgazione scientifica serio ed ampiamente frequentato dai professionisti della Sanità, dai pazienti e dalle Associazioni che li rappresentano.
Conclusioni: il Gruppo Multidisciplinare MISSTO è nato con l’obiettivo di elaborare delle Linee Guida Nazionali sul confezionamento e la gestione delle Enterostomie ed Urostomie, con il patrocinio delle Società Scientifiche Chirurgiche interessate. Questo Gruppo di lavoro appena formato si propone anche come punto di partenza per successivi studi multicentrici, che abbiano come soggetto degli aspetti specifici ed ancora dibattuti sul confezionamento delle Stomie.
EPSIT – I MIEI PRIMI 14 CASI. ESPERIENZA PERSONALE, OUTCOME, LINEE GUIDA
Introduzione: La EPSiT (Endoscopic Pilonidal Sinus Treatment), tecnica introdotta dal dottor Meinero P. prevede l’utilizzo dello strumentario VAAFT (Visual Assisted Fistula Treatment) e rappresenta al momento una delle innovazioni nel trattamento chirurgico del sinus pilonidalis.
Materiali e Metodo: da dicembre 2017 ad agosto 2018 abbiamo arruolato 14 pazienti in un database prospettico; i pazienti sono stati tutti operati da un unico operatore con metodica EPSiT. Alla dimissione tutti i pazienti sono stati istruiti sulla necessità di medicare giornalmente il tramite fistoloso con un lavaggio di 20 cc di soluzione fisiologica. I controlli medici sono stati eseguiti con scadenza bisettimanale. I dati sono stati raccolti e sottoposti ad analisi statistica.
Risultati: abbiamo operato 13 pazienti maschi ed 1 donna con un’età media di 30.1 anni; il tempo operatorio medio è stato di 40.6 minuti senza assistere ad alcuna complicanza né precoce né tardiva. L’intervento è stato ben tollerato con una satisfaction rate del 98%. L’aderenza complessiva alle medicazioni domiciliari è stata buona e l’healing rate è stato del 86% (tempo medio di guarigione 33 giorni) con 2 recidive, entrambe parziali, su un follow-up di 10 mesi.
Conclusioni: la EPSiT è una metodica semplice e “safe” che riduce nettamente il discomfort post-operatorio dei pazienti operati di fistola sacro coccigea. I primi risultati della letteratura ed anche quelli del nostro gruppo di lavoro sono molto incoraggianti anche se necessitano di un follow-up sensibilmente più lungo.