Results of neoadjuvant Short-course Radiotherapy followed by Transanal Endoscopic Microsurgery for T1-T2 N0 extraperitoneal rectal cancer


Simone Arolfo, Alberto Arezzo, Alberto Bullano, Marco Ettore Allaix, Umberto Ricardi, Fernando Munoz, Paola Cassoni, Giovannino Ciccone, Mario Morino


To assess in a pilot study short-term outcomes of neoadjuvant short-term radiotherapy (RT) followed by Transanal Endoscopic Microsurgery (TEM) for T1-T2 N0 extraperitoneal rectal cancer.

Summary Background Data

Recent studies suggest that neoadjuvant RT followed by TEM is safe and has similar results to abdominal rectal resection for the treatment of extraperitoneal early rectal cancer


Transanal Endoscopic Microsurgery under Spinal Anesthesia: preliminary results of a pilot study

Simone Arolfo, Alberto Arezzo, Alberto Bullano, Gerardo Cortese, Marco Ettore Allaix, Mario Morino


Transanal Endoscopic Microsurgery (TEM) was introduced in clinical practice by Gerhard Buess in 1983. It allows a full thickness excision of rectal benign lesions and early rectal cancer with excellent oncologic and functional outcomes. High costs of instrumentation and technical difficulties, as the improvements of endoscopic excision technique (Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection) limited the diffusion of TEM. Today the major advantage advocated by flexible endoscopists is the avoidance of general anesthesia. Loco-regional anesthesia had been traditionally reserved to patients unfit for general anesthesia, in particular due to severe chronic cardiopulmonary disease, although its use in healthy patients is also supported proving the advantage of quicker recovery and reduced metabolic responses to surgical stress. Combining a minimal-access operation with segmental anesthesia may further enhance the advantages of a real surgical dissection provided by TEM, over flexible endoscopy that forces to long lasting sedations. The purpose of the study is to assess the feasibility and safety of undertaking TEM under epidural anaesthesia versus general anaesthesia.


Patients who underwent TEM under spinal anesthesia (SA) were matched with an historical series of patients who underwent TEM under general anesthesia (GA), comparable for age, sex, tumor location and size and patient’s positioning in the operatory room. Primary end-point was feasibility and safety; secondary endpoints were post operative pain at operatory room discharge (ORD VAS) and during the first post operative day (FOD VAS) measured by Visual Analogue Scale (VAS), need of opioids (during and after the operation), post operative nausea or vomiting (PONV), urinary retention (UR). Means were compared by a 2 tailed t-test for paired samples; differences considered significant if p<0.05.


No intraoperative complication occurred in the SA group and operative time was not significantly different (61 min in SA vs 87,75 min in GA; p=0.07). Mean ORD VAS significantly was lower in SA group (1.5 vs 0.3; p=0.004), while mean FOD VAS was similar in both groups (0.5 vs 0.8; p=0,315). Patients under SA did not need intraoperative opioids, while patients under GA required a continuous intravenous infusion of remifentanil during the operation. Mean total tramadol need was 160 mg in SA group vs 47,5 mg in GA group (p=0.008). PONV occurred only in 1 patient in GA group, while 4 patients developed urinary retention in GA group vs 1 patient in SA group.


TEM under epidural anaesthesia can be undertaken safely and effectively with additional health benefits compared with TEM under general anaesthesia, despite a greater incidence of urinary retention.

Effects of curative colorectal cancer surgery on exhaled volatile organic compounds (VOCs) and potential implications in clinical follow-up.

Di Lena M, Porcelli F, Travaglio E, Longobardi F, Tutino M, Depalma Norma, Tedesco G, Sardaro A, Memeo R, De Gennaro G, Altomare DF.

Dept of Emergency and Organ Transplantation, Dept of Chemistry, University Aldo Moro of Bari, Bari, Italy


Background: Colorectal cancer (CRC ) has been proved to induce metabolic derangements detectable by high through-output techniques in exhaled breath showing  as a specific pattern of volatile organic compounds (VOCs) which could be used as potential tool for mass screening.

The aim of this study was to determine whether the VOCs pattern in CRC patients could be modified by curative surgery and eventually used in the oncologic follow up.

Material and methods: 48 CRC patients entered the study from July 2012 to June 2013.  Thirty-two of them (M/F:0.5 ; mean age 68y)  attended the oncologic follow-up (mean follow-up 24 months) and were found disease-free. Breath samples were collected under similar environmental conditions into 3-litre Tedlar ® bags, using a standard breath sampler and processed offline by thermal-desorber gas chromatography–mass spectrometry.

Results: 34 VOCs were selected by U-test to build a Probabilistic Neural Network (PNN) model. A training phase was set up and cross-validated using the leave-one out. PNN model showed an excellent discriminant performance identifying  disease-free subjects from patients before surgery, with a sensitivity of 100 %, a specificity of 95.8%, and an accuracy of 97.5% (Area under receiver operating characteristic curve (AUC):  0.994).


Exhaled VOCs pattern from CRC patients is clearly modified by cancer removal confirming the tight relationship between tumor metabolism and exhaled VOCs. PNN analysis provides a high discriminatory tool to identify patients disease-free after curative CRC resection suggesting promising  applications in secondary prevention and screening of CRC recurrences.



*G. Portale, V. Fiscon, G. Migliorini, F. Frigo

General Surgery, ULSS 15, Cittadella (PD)


Hartmann’s procedure, originally designed for neoplastic obstructions, has been used more extensively since then and current indications include also complicated diverticulitis, traumatic colonic lesions, volvulus and perforated recto-sigmoid tumors. So there has been recently a growing number of patients undergoing a Hartmann  procedure and, subsequently, waiting for their continuity to be restored. But, reestablishing continuity after a Hartmann procedure (Hartmann’s reversal) is considered a major surgical procedure and carries serious risk of both morbidity and mortality.

In this video we present the restoration of intestinal continuity after Hartmann’s procedure, with minimally-invasive approach. The first step of the technique involves mobilization of the colostomy site. This is excised at the mucocutaneous junction circumferentially, untill the peritoneum is entered. The edge of the stoma is revised to take away excessive scar tissue. An appropriately sized anvil of a circular stapler is then inserted into the colonic lumen and secured with a pursestring reabsorbable suture. The colostomy site is now used as port site for the establishment of pneumoperitoneum and a trocar or an hand-assist device can be placed for the camera. Three operative trocars are used: a 12-mm trocar in the right lower quadrant, a 10-mm in the right upper quadrant and a 10-mm in the umbilicus. With the patient in a steep reverse Trendelenburg position, the rectal stump is identified. This step can be facilitated by a suture thread placed at the first surgery (Hartmann) or by transanally inserting a circular stapler, Hegar, dilators or a rigid sigmoidoscope at Hartmann’s reversal. Lysis of adhesions is performed with sharp scissor dissection and minimal use of electric current to prevent any injury to the bowel. It is also important to minimize the risk of vascular injury during pelvic dissection, in a subsequent step of the procedure. In case the rectal stump is too long and includes a few folding of the distal sigmoid colon, the latter can be excised using a linear stapler and the specimen brought out through the colostomy site where the hand-assist device can been placed. Subsequently, with the patient in Trendelemburg position, mobilization of the left colon proximal to the colostomy and take down of the splenic flexure is accomplished, by freeing the lateral attachments, to ensure a tension-free anastomosis with the rectal stump. An end-to-end colorectal anastomosis is created with an appropriately sized endoluminal circular stapler, possibly avoiding a stapler with diameter less than 28-29 mm. The pelvic cavity is filled with saline solution and the air leak test is done by insufflating the air in the rectum while visualizing the anastomosis. The stoma wound is left partially open.

*presenting author (< 40 years)


  1. S. Pipitone Federico , E. Gibin, M. Ferronato, , I. Destefano , M. Scaglia

Divisione Universitaria Chirurgia Generale Dir prof M. Nano,  A.O.U. S. Luigi Gonzaga Orbassano (TO)

Introduzione : la gestione dell’ incontinenza fecale (FI) è una sfida per la sua alta prevalenza, l’ eterogeneità eziologica e la frequente mancanza di specifiche competenze [i]. Le tecniche impiegate da molti anni per il trattamento dell’incontinenza fecale presso l’Ambulatorio di  coloproctologia dell’ A.O.U  San Luigi di Orbassano TO sono la stimolazione del nervo tibiale posteriore (PTNS) e l’agopuntura (ACU), con risultati promettenti.

Obiettivo: studio clinico randomizzato valutativo dell’efficacia di PTNS e ACU nel trattamento dell’ incontinenza.

Materiali e Metodi  da ottobre 2013 a giugno 2014 sono stati valutati 39 pazienti consecutivi  (6 M E 33 F) affetti da FI refrattaria a trattamento conservativo, previa valutazione clinica, ultrasonografica e manometrica. Questi pazienti sono stati casualmente suddivisi in 2 gruppi : gruppo 1(16F, 3M) , gruppo 2 ( 17F, 3M) che sono stati valutati per composizione, genere,età, score di FI,  risultando sovrapponibili. Il gruppo 1 è stato trattato con agopuntura (ACU) , il gruppo 2 con neurostimolazione del tibiale posteriore (PTNS). Prima dell’ inizio del trattamento, dopo 5 sedute e a ciclo concluso (10 sedute) ciascun paziente ha compilato il Cleveland Clinic Incontinence Score (CCIS), l’ American Medical System (AMS), il Gastrointestinal quality of life (Qol) (GICLI) ed il diario delle evacuativo e minzionale per 2 settimane.

Analisi statistica: i dati pre, durante e post-trattamento per ogni gruppo sono stati analizzati da un software brevettato, presentando una distribuzione normale.

Abbiamo calcolato media e deviazione standard per le variabili numeriche, mediana e range interquartile per quelle categoriche, il miglioramento >50%  dopo 15 giorni di trattamento per incontinenza fecale ed urinaria.

Per confrontare i trattamenti, abbiamo utilizzato T-Test ed il Wilcoxon Mann-Whitney per le variabili numeriche, il Chi quadro per le categoriche. Un p value <0.05 è stato considerato significativo.

RisultatiNon si osservano differenze significative fra i due gruppi pre-, durante e dopo il trattamento comparando i 3 scores, eccetto che per GICLI3 , indice della qualità di vita post-trattamento, a favore di ACU (p=0.01).

Confrontando i valori pre- e post-trattamento di ogni singola tecnica, l’ AMS mostra una differenza statisticamente significativa sia per ACU (p=0.0001) sia per PTNS (p=0.0063) così come CCIS (ACU p=0.0261, PTNS p=0.0012), mentre GICLI  per ACU riporta una p=0.1 e per PTNS una p=0.97.

Venti pazienti ( 26/39, 53%) mostrano un miglioramento della sintomatologia>50% per FI dopo 15 giorni di trattamento, 8 dopo ACU (8/19, 44.4%) e 12 dopo PTNS (12/20, 60%), senza differenza significativa fra i due gruppi (p=0.33).

Ventisei pazienti ( 26/39, 66.6% ) presentano un’ associazione di FI ed UI (incontinenza urinaria); 15 ( 15/39, 39.47% ) mostrano un miglioramento della sintomatologia>50% per UI, 7 dopo ACU ( 7/19, 38.9%) e 8 grazie a  PTNS ( 8/20, 40% ), senza differenza significativa fra i due gruppi ( p=0.97).

Discussione: In letteratura pochi studi si occupano di trattamenti conservativi alternativi per FI( neuro modulazione sacrale, stimolazione del nervo tibiale posteriore o agopuntura ) [ii].

ACU è ormai accettata a livello mondiale e consiste nell’ inserzione di piccoli aghi stimolati manualmente lasciati in sede 20 minuti [iii] [iv] [v]. PTNS è una neuro modulazione periferica minimamente invasiva che modifica il processo di neurotrasmissione [vi]  .

Nel nostro studio, AMS e CCIS migliorano significativamente dopo ogni trattamento, ma non Qol come mostrato da GICLI; ciò è in accordo con i risultati di Tjandra et al. sulla stimolazione sacrale [vii].

Non si osservano differenze significative fra i due gruppi durante e dopo il trattamento confrontando i tre scores, eccetto che per GICLI post-trattamento: ACU mostra un punteggio superiore in termini di QoL.

Abbiamo valutato il miglioramento dei sintomi >50% per FI e UI attraverso i diari delle evacuazioni tenuti per 2 settimane; il 53% dei pazienti ha ottenuto un miglioramento grazie a trattamento conservativo, il 60% dopo PTNS rispetto al 40% dopo ACU. Sembra infatti che la stimolazione elettrica arrechi un miglioramento più rapido rispetto alla manuale con ACU. Ciò può apparire in contrasto col dato precedente, presentando ACU uno score GICLI3 superiore; tuttavia, i diari settimanali sono strumenti meno oggettivi rispetto ai questionari. Il 39% dei pazienti ha avuto un miglioramento di UI dopo 15 giorni di trattamento, simile fra i due gruppi ( 38.9% per ACU e 40% per PTNS ).

PTNS ed ACU sono tecniche relativamente semplici, minimamente invasive e a basso costo. Tuttavia, prima di intraprendere uno studio più grande, bisogna valutare la disponibilità di specialisti formati in materia , di strumentario e di tempo dedicato necessari [viii].

[i] Boyle DJ, Murphy J. Et al. “Efficacy of sacral nerve modulation for the treatment of fecal incontinence “, Dis Colon Rectum 2011; 54:1271-8.

[ii] Hotouras A., Murphy J. et al. “ Prospective clinical audit of two neuromodulatory treatments for fecal incontinence: sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS)”, Surg. Today 5 may  2014 (Epub ahead of print).

[iii] Anderson S., Lundeberg T. “ Acupuncture- from empiricism to science: functional background to acupuncture effects in pain and disease “, Med Hypotheses Sep.1995; 45: 71-281

[iv] Hulten L., Angeras U. et al. “ Sacral nerve stimulation (SNS), posterior tibial nerve stimulation (PTNS) or acupuncture for the treatment for fecal incontinence: a clinical commentary “, Tech Coloproctol 2013; 17:589-592

[v] Scaglia M., Delaini G. et al. “ Fecal incontinence treated with acupuncture-a pilot study”, Auton Neurosci 145:89-92.

[vi] Van der Pal F, Heesakkers JPFA et al. “ Current opinion on the working mechanism of neuromodulation in the treatment of lower urinary tract dysfunction”, Curr Opin Urol 2006; 16:261-267

[vii] Tjandra JJ, Chan MK, Yeh CH, Murray-Green C “Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study”,Dis Colon Rectum. 2008 ;51: 494-502

[viii] Thin NH, Horrocks EJ et al. “ A systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence”, Br J Surg 2013; 100:1430-1447.



Luca Grasso, M.D., Paolo Tonello*, M.D., Giulio Di Benedetto, M.D.,  Giuseppe Benedetto., Simone Arolfo, M.D., Alberto Bullano, M.D., Lisa Rapetti, M.D., Mario Morino, MD, Massimiliano Mistrangelo, MD, PhD


Digestive and Colorectal Surgical Department, Centre of Minimal Invasive Surgery, University of Turin, Città della Salute e della Scienza Hospital, Italy.

*Department of Surgery, Koelliker Hospital, Turin Italy


Purpose. Perineal Stapled Prolapse Resection (PSP) for external rectal prolapse is a new surgical technique, proposed by Scherer and Coll in 2008. Initial enthusiasm accompanied first positive results. More recent reports oppose those results reporting a large incidence of recurrences.

Methods. We performed a Literature review regarding PSP in the treatment of complete external rectal prolapsed. Duplicated data and abstracts were excluded from the study. Number of patients, intraoperative and postoperative results, complications and recurrences were evaluated.

Results. 8 papers were found in international Literature. Considering duplication of the data only 7 papers including 127 patients were analysed. All patients presented as complete external rectal prolapse. The largest series report 56 patients. The longitudinal section of the prolapse was performed at 3 o’clock in 3 studies, at 9 o’clock in 1 study, and at 3 and 9 o’clock in the other 3 studies (in these series the initial cases were sectioned only at three o’clock as described by Scherer). A median of 6 cartriges were used for the surgical procedure. Intraoperative complications occurred in 6 patients (4.7%): 2 conversions to an Altemeier due to a staple line disruption probably related to a rather thick prolapsed; 4 additional handsuture for an insufficient stapled line. Mean operative time (reported only in 6 papers) was 36.4 minutes. Postoperative major complications were observed in 5 patients (3.9%): 1 pelvis sepsis and 4 bleedings (surgical hemostasis). Minor complications occurred in 15 patients (11.8%): 3 postoperative bleedings not requiring a surgical procedure, 2 systemic inflammatory reactions, 2 urinary retentions, 3 urinary infections, 1 peritonitis in a patients with peritoneal dialysis, 1 granuloma, 1 medical disease and 2 not specified diseases. No mortality was observed. Median hospital stay was 5 days. During follow up of 21.1  months 16 patients recurred (12.6%). Regarding functional results the studies are not comparable, considering different scores of evaluation of ODS and fecal incontinence and for the absence of available data. A reduction of median ODS score was reported in two study and a general improvement of incontinence was observed in all studies but one (Ram and Coll) even if in few cases new incontinence occurred postoperatively. Conclusions. PSP is a new surgical procedure for external rectal prolapse. It is easy, fast and a safe procedure. Early functional results are good in many series, even if recent papers report a high incidence of recurrence. A total 12.6% of recurrence could be accepted considering the incidence of other perineal procedures like Delorme (0-38% of recurrence) or Altemeier (0-16%). The cost of the procedure is high and it is tenable only if hospital stay and the incidence of recurrence are low respect other procedures. Long term functional results must be investigated further.

Internal Delorme’s procedure for obstructed defecation syndrome: a Multicentric study.

Campennì  Paola* MD, Terrosu Giovanni* MD, Carducci Palma* MD, Cian Enrico**MD, De Carli Gianluigi** MD, Mancino Gennaro **MD, Digito Francesco *** MD, Iorio Santo*** MD, Snidero Daniele SnideroSnidero *** MD, Risaliti Andrea *MD


Department of General Surgery, University Hospital of Udine, Udine, Italy (*)

Department of General Surgery, Santa Maria del Prato Hospital, Feltre, , Italy  (**)

Department of General Surgery, Sant’Antonio Hospital, San Daniele , Italy  (***)

Address corresponders :

PaolaCampennì, MD

Department of General Surgery

Azienda ospedaliero-universitaria di Udine

Piazzale Santa Maria della Misericordia 15

33100 Udine Italy

tel. +39 0432 559557

fax: +39 0432 559564




Obstructed defecation is identified as a subset of functional constipation. A wide range of pelvic floor abnormalities  including Rectal Prolapse (RP), rectocele, rectal intussusception and mucosal prolapse have been demonstrated to have a causative association with the obstructed defecation syndrome.

The first  therapeutic approach is medical, but in case of clinical failure, surgery may be considered. Surgical treatment of Obstructed Defecation Syndrome (ODS)  is not well standardized and many different operative approaches have been described. The aim of the present study is to evaluate the long-term results of Internal  Delorme’s Procedure (IDP) for  Obstructed Defecation Syndrome.


From October 2007 to September 2013, 145 patients with ODS refractory to non-operative therapy  were submitted to a Delorme Procedure, performed in three different Colorectal Units (Udine, Feltre and San Daniele). All patients were studied as sequent: clinical examination, anoscopy, defecography. Functional results were evaluated by Cleveland Clinic Costipation Score (CCCs), Obstructed Defecation Score (ODs), Patient Assessment of Constipation – Quality of life Score (PAC-QoL) questionnaire before and after surgery at 6 months, 12 months, least follow-up.  Statistical  analisys of data was performed with R (v.3.0.1) with p-value considered statistical significant <0.005.


Oneundredfortyfive patients ( 131 women  14 men) with a mean age of 59 (range 23-86) were enrolled in our study with mean follow-up 4.3 years (range 6month-6 years).

Eighty-five patients presented  ODS associated with Internal Rectal Prolapse, 84 with rectocele and 51 with intrarectal intussusception. Clinically, the obstructive defecation was characterised by incomplete evacuation sensation (84.1%), prolonged straining (75.9%), in addition to the symptoms evaluated by the Cleveland score. In all patient spinal anesthesia was performed with mean operation time  108 min (range 45-190 min). Mean hospital stay was 4.7 days (range 2-11 days). No intraoperative complication occurred.  Postoperative complications occurred with an overall incidence of 22.6% (33 cases): suture dehiscence in 2 cases (1.3%),  proctalgia in 2 (1.3%),  stenosis in 25 (17.1%), bleeding in 4 (2.6%). Urgency was reported in 38 patients and spontaneously resolved in 17 within six months. 133 patients (91%) showed a good overall results after Delorme procedure. The analisys of CCCs, Ods, , PAC-QoL Score questionnaire indicated a significant improvement by comparing preoperative and postoperative data.  At diagnosis median CCCs was 15, median Ods was 17 and median PAC-QoL was 3.3. The postoperative median CCCs was 4 ; median Ods was 5 and PAC-QoL was 1.1. (p>0.001). A clinical relapse was recorded in 2 cases (1.3%).


The Delorme procedure for treatment of rectal outlet obstruction can be performed with minimal morbidity, short hospital stay and overall high patient satisfaction. This surgical approach seems to be associated with good long-term clinical outcomes improving quality of life and functional scores in patients with rectal outlet obstruction.

Title: Initial experience of the treatment of rectal adenomas and rectal tumors by transanal endoscopic operation.


Authors: A. Sartori, F. Nicolì


Department of General Surgery,San Valentino Hospital, Via Togliatti 1 Montebelluna, Italy




Introducion: transanal endoscopic microsurgery was introduced in 1989 by Buess  Actually transanal endoscopic resection is  an alternative to traditional surgical treatment of adenomas and rectal tumors. The aim of the study is to describe our initial experience of transanal endoscopic operation (TEO; Karl Storz, Germany).

Methods: according to the protocol all patients was classified  by endorectal ultrasound, magnetic resonance, endoscopic exam and medical visit.

In a prospective analysis we examined data on 10 patients operated between 1 january 2013 to 31 december 2013. In this collective, we also examined parameters concerning perioperative management, local recurrences.

Results: the median follow-up was 14 months (range 7-18). No 30-day perioperative mortality occurred. No conversion to laporoscopic or laparotomy  intervention was reported. One patient was reoperated by conventional surgery (laparoscopic TME). No further recurrences was observed in the follow-up.

Conclusions:  TEO is a safe procedure to treat adenomas and rectal cancer T1 in selected patients. This study was limited by the small sample size but the short-term outcomes and the results of follow-up of are encouraging.


KEY WORDS: Rectal cancer; Local excision; Transanal endoscopic microsurgery; Local recurrence.

We planned a consecutive series of 25 patients with extraperitoneal T1-T2 N0 M0 rectal adenocarcinomas who should undergo 5 Gy per 5 days (25 Gy), followed by TEM 4-10 weeks later. Results in terms of safety, efficacy and acceptability had to be compared to different historical groups with similar rectal cancer stage and treated in different ways.


The study was interrupted after 14 patients underwent 25 Gy RT followed by TEM an average of 7 weeks (range, 4-10) later. While no perioperative complication was observed, four weeks after surgery 7 patients (50%) presented a complete dehiscence of the suture, in 2 cases associated with an enterocutaneous fistula in the sacral area, 1 of whom required a colostomy. Quality of life at 1 month assessed through EORTC QLQ-C30 decreased of 17.0 (iqr -42,-11), compared to 9.5 (iqr -11,-5) after TEM following 46 Gy radiotherapy (P=0.0277), 7.5 (iqr -9.5,-5) after TEM alone (P=0.0004) and 15.0 (iqr -24,-11) after anterior resection or abdomino-perineal rectal resection (P=0.604) for similar stage of disease. With an average follow-up of 10 (range, 3-26) months, we observed one local recurrence at 6 months who required an abdomino-perineal resection.


Short-term RT followed by TEM for T1-T2N0 rectal cancer is burdened by a high rate of painful dehiscence of the suture line and enterocutaneous fistula, significantly higher than TEM alone and TEM following long-term RT, which forced us to stop the study.

Internal Rectal Prolapse and Rectocele in female patients:  alterations of the Enteric Nervous System

Bondurri Andrea1, Vicario Erika1, Zerbi Pietro2, Maffioli Anna1, Danelli Piergiorgio1

1 Chirurgia Generale
Dipartimento di Scienze Biomediche e Cliniche “Luigi Sacco” Università degli Studi di Milano
2 Anatomia Patologica
Dipartimento di Scienze Biomediche e Cliniche “Luigi Sacco” Università degli Studi di Milano

Le indicazioni chirurgiche nella stipsi grave rimangono molto ristrette, per lo più tese a correggere morfologicamente il prolasso rettale interno e/o il rettocele associati alla sindrome da ostruita defecazione (ODS). Recenti studi hanno dimostrato la presenza di alterazioni del sistema nervoso enterico (SNE) nella stipsi grave idiopatica (inertia colica) e nel prolasso rettale. Il  nostro studio aveva come obiettivo la valutazione del SNE nei preparati istologici di pazienti sottoposti a STARR o Delorme interna per ODS e il confronto con preparati istologici ottenuti da pazienti sottoposti a resezione anteriore di retto (RAR) per altre patologie.


E’ stato effettuato uno studio caso-controllo includendo campioni provenienti dal retto distale di pazienti donne, operate tra il 2009 e il 2014. Il primo gruppo comprendeva 10 casi operati di STARR o Delorme Interna per ODS associata a prolasso mucoso interno e rettocele. Il secondo gruppo comprendeva 10 casi operati di RAR per patologia neoplastica. I campioni sono stati processati per l’esame istologico convenzionale con Ematossilina-Eosina; per lo studio morfologico dei gangli con colorazione di Nissl; e per l’esame immunoistochimico con anticorpo anti S-100, positivo negli elementi gliali e nelle cellule di Schwann. E’ stato calcolato il rapporto tra lo spessore della muscolatura circolare e quella longitudinale. Nel plesso mioenterico sono state quantificate l’area totale delle fibre nervose; l’area totale del plesso nervoso; l’area totale dei gangli; il numero totale dei gangli e il numero dei neuroni per ganglio. Nel plesso sottomucoso è stata quantificata l’area totale del plesso nervoso. L’elaborazione statistica è stata effettuata con l’analisi univariata e multivariata secondo i modelli di Kaplan-Meier e Cox.


Nelle pazienti operate di STARR o Delorme interna, il numero di neuroni per ganglio e l’area totale dei gangli sono risultati ridotti rispetto ai controlli (p<0,05). Il numero totale dei gangli è risultato aumentato (p<0,05). Il rapporto tra la muscolatura circolare e quella longitudinale è risultato minore nei casi rispetto ai controlli (p<0,05). Non si sono invece dimostrate differenze statisticamente significative negli altri parametri valutati.


Questo studio dimostra la presenza di alterazioni del  SNE nella popolazione affetta da ODS associata a prolasso rettale interno e rettocele; in particolare la presenza di un numero maggiore di gangli ma con contenuto neuronale minore e di minori dimensioni, e una diminuzione relativa dello strato muscolare circolare.

La nascita di un’Unità Interdisciplinare per le disfunzioni del Pavimento Pelvico

Bondurri Andrea, Vicario Erika, Maffioli Anna, Danelli Piergiorgio

Chirurgia Generale
Dipartimento di Scienze Biomediche e Cliniche “Luigi Sacco”
Università degli Studi di Milano

Le disfunzioni del pavimento pelvico (che comprendono, tra le altre patologie, il prolasso utero-vaginale, l’incontinenza urinaria, il prolasso rettale, l’incontinenza fecale, la stipsi, le anomalie dello svuotamento vescicale, il dolore cronico) costituiscono nel loro insieme una patologia che colpisce una quota compresa tra il 20 e il 30% dei soggetti di sesso sia femminile che maschile, con significative ricadute in termini di costi individuali, sociali e sanitari.

Il pavimento pelvico rappresenta un distretto corporeo le cui anomalie funzionali e anatomiche non possono che coinvolgere sul piano diagnostico, terapeutico (riabilitativo e/o chirurgico) e idealmente anche preventivo, diverse figure professionali che includono il ginecologo, l’urologo, il chirurgo colo-rettale, il neurologo, il terapista del dolore, lo psichiatra, il gastroenterologo, il radiologo, il dietista, il fisiatra ed il fisioterapista.

L’Azienda Ospedaliera “Luigi Sacco” – Polo Universitario, si è proposta nel febbraio 2014, in armonia con le indicazioni delle principali Società Scientifiche nazionali ed internazionali, di costituire una Unità Interdisciplinare del Pavimento Pelvico al fine di garantire ai pazienti una ottimale gestione diagnostico terapeutica sia in termini di efficienza che di efficacia. Le Unità Operative di Ostetricia e Ginecologia, Chirurgia, Urologia, Neurologia, Anestesia e Rianimazione, Recupero e Riabilitazione funzionale hanno identificato al loro interno le figure professionali per costituire il gruppo di lavoro, che da allora si è riunito una volta al mese.

Marzo 2014

Ogni Unità Operativa ha presentato i propri settori di attività, le capacità diagnostiche e terapeutiche. Si è costituito un gruppo di lavoro sulla Neuromodulazione Sacrale, per la valutazione collegiale di indicazioni, costi e rimborsi della procedura.

Aprile 2014

L’Unità Operativa di Radiologia ha presentato risorse e potenzialità diagnostiche oltre alle caratteristiche della nuova RM. Si sono confrontate le diverse cartelle ambulatoriali e schede anamnestiche.

Maggio 2014

E’ stato presentato uno studio sull’Urge Incontinence femminile e i relativi criteri di inclusione. Si è deciso di procedere nei lavori basandosi sulle necessità del paziente, e quindi per aree sintomatologiche/patologiche: dolore, incontinenza urinaria, incontinenza fecale, ritenzione (urinaria e fecale), prolasso.

Giugno 2014

Si è discusso del dolore cronico, e in particolare delle possibilità terapeutiche del Centro della Terapia del Dolore. Si è affrontata anche la problematica degli esiti degli abusi sessuali. Si è deciso di allargare i lavori alle Unità Operative di Psichiatria, Dietologia e Nutrizione Clinica, Gastroenterologia.

Settembre 2014

Si sono condivise indicazioni e percorsi per la Riabilitazione del Pavimento Pelvico, attualmente gestita in Riabilitazione per le problematiche urinarie femminili, in Urologia per quelle urinarie maschili e in Chirurgia per quelle proctologiche.


Un Servizio dedicato alla diagnosi e cura delle disfunzioni del pavimento pelvico necessita di alcune elementi di base. Il primo e principale è l’interesse e la capacità di gestire una tipologia di pazienti che può rappresentare sfide impegnative. Il secondo è la disponibilità nella propria istituzione o in centri limitrofi di adeguati mezzi diagnostici. Il terzo è la creazione di un autentico approccio multidisciplinare: integrazione di competenze, percorso indispensabile per affrontare in modo completo ed efficace malati e malattie complesse.

Hai ricevuto un Abstract per Relazione

il signor Francesca Da Pozzo ha inviato un file 20140912212756_abstract rovigo TEO.docx tramite il sito web

la sua mail:

F.Da Pozzo MD, A. Braini MD, A. Stuto MD
II Unit Surgery, “S.M.A.” Hospital, Pordenone

Rectal Resection with Total Mesorectal Excision (TME) is nowadays the standard of care for rectal turmors. However local excision of early low risk stage (T1s-T1 with G1 or SM1) could be a safe alternative. Recent literature datas support this minimally invasive approach. Transanal Endoscopic Microsurgery (TEM), introduced by Buess, is a minimally invasive procedure for removal rectal lesions that need dedicated tools. TEM, a three-dimensional viewing endoscopic system, is a safe procedure in terms of low recurrence rate and correct oncological outcome but suffer from high cost and long learning curve . New technologies were recently introduced to avoid these problems and to improve outcome in treatment of rectal lesions that could be safely treated by transanal excision. In fact a two-dimensional transanal endoscopic operation (TEO), with the introduction of high-definition vision, achieves results that are comparable to those of the classical TEM. We present our experience in transanal excision on using TEO. We propose TEO for benign rectal lesions and malignant rectal lesions at early stages as Tis or T1 Rectal Tumor located from 2 to 15 cm from the anal verge. In all the cases nodal involvement was exclude by Transanal Ultrasound and MRI. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and using standard laparoscopic instruments .In selected patients we also propose TEO in case of T3N0 with a complete or nearly complete (less than 20% of Residual Cancer Cells at re-staging) response at neo-adiuvant therapy (performed within a controlled study protocol). In 8 months experience we performed 10 TEO procedures, 5 for benign rectal polips, 4 for Tis or T1 uNo and 1 for complete neoadiuvant RT-CT response cases. No mayor intraop or post-op complications were showed. In all we performed antibiothic profilaxis . Hospital discharge was from day 2 to day 4 with 1 case of readmission for pain and minor rectal wounds problem. In our early experience TEO is a safety and feasible technique for selected early stage rectal tumors or for benign rectal lesions. The technique is easy to perform and require a short learning curve expecially for surgeons with laparoscopic skills. High-definition vision of TEO system permit high quality excision comparable with TEM but with lower costs .

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Hai ricevuto un Abstract per Relazione

il signor Francesca Da Pozzo ha inviato un file 20140912214247_abstract algoritmo rovigo.docx tramite il sito web

la sua mail:

F. Da Pozzo M.D., A. Braini M.D., A. Stuto M.D.
II Unit Surgery, “S.M.A.” Pordenone, Italy
Refractory constipation is a frequent clinical finding in patients suffering from Obstructed Defecation Syndrome (ODS). ODS is a complex and multifactorial disease, more common in women. Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings, however in a low percentage of cases this clinically findings are associated with other morphological disorders as enterocele, sigmoidocele or complex floor disease (urogenital prolapse). When conservative treatment failed surgery is needed to improve symptoms in patients suffering from ODS.
Nowadays the most used and studied surgical approach for ODS are Stapler Transanal Rectal Resection (STARR), a transanal technique, and Laparoscopic Ventral Rectopexy (LVR), with a transabdominal approach. Data from literature are not clear on indications for one procedure or the other. These two surgical options, in our experience, are not equivalent in use but are complemntary technique in order to improve patient’s outcome and, at the same time, to reduce post-op complications as post-op urgency.
On the basis of the need for a concept treatment options in patient suffering from ODS we propose a clear decision-making algorithm specifically focusing on the role of STARR and LVR based on clinical symptoms and dynamic imaging.




Autori : A. Donfrancesco, A. Basso, A. Cuviello, M. Chiarello , G. Calabrese & C.Finco

Primo autore : dott Andrea Donfrancesco   d.n   27.03.1978  Frosinone

Istituzione: Regione Veneto, ULSS5 Ovest Vicentino, UOC Chirurgia Arzignano  ( direttore :dr Cristiano Finco  )

Introduzione :La prevalenza della malattia diverticolare colica è del 35-50%.Il 15-25% dei pazienti sviluppa una diverticolite acuta: la perforazione colica può essere la prima manifestazione della malattia.

Il trattamento delle diverticoliti perforate è dibattuta; l’anastomosi primaria, con o senza ileostomia temporanea, sembra essere associata a minori tassi di morbilità e mortalità rispetto alla resezione secondo Hartmann.

Il lavaggio e drenaggio laparoscopico è stato utilizzato con successo come alternativa alle tecniche chirurgiche tradizionali con un tasso di complicanze molto basso. 

Scopo dello studio Valutare l’efficacia del lavaggio e drenaggio laparoscopico nel trattamento d’urgenza delle diverticoliti perforate.                

Materiali e Metodi La nostra casistica comprende 34 pazienti,21 M e 13 F,età media 58 anni (22-82) , con diverticolite allo stadio di Hinchey IIb (12pts) –III ( 21pts)  IV ( 1pts) .

In tutti i pazienti è stato eseguito un lavaggio della cavità peritoneale di 3-5 litri di soluzione fisiologica ed il posizionamento di drenaggi multipli; nel 44% dei casi è stata eseguita la raffia della perforazione oltre al lavaggio.

Risultati Il trattamento è stato efficace per 31 pazienti (91.2%). Negli altri 3 Pts ( 8.8%) è stato necessario eseguire  nel postoperatorio un intervento  chirurgico resettivo ( 2 emicolectomie sx open- 1 Hartmann open) per inefficacia del trattamento laparoscopico . Non vi è stata mortalità. Ad un intervallo medio di 4.5 mesi ( 3-6) dal drenaggio laparoscopico 17 pts ( 54.9%) sono stati sottoposti ad emicolectomia sinistra VLS, 3 pts  ( 9.7%) ad emicolectomia sinistra laparotomica con  mortalità postoperatoria nulla ed assenza di fistolizzazioni anastomotiche . Quattro pts ( 12.9%)  non sono stati operati  a causa di un’ elevata comorbidità e 8 ( 25.8%) sono in attesa di intervento.

Conclusioni La nostra casistica conferma l’efficacia di questo approccio chirurgico per le diverticoliti acute Hinchey IIb e III, con tassi di mortalità e morbidità molto bassi, evitando una laparotomia, il confezionamento di una stomia, riducendo le infezioni di ferita, i laparoceli e la disabilità post-operatoria.I pts con elevata comorbidità ricevono un trattamento terapeutico definitivo. La maggioranza dei pazienti viene sottoposta ad intervento radicale di emicolectomia sx ad un intervallo medio di 4.5 mesi dall’evento acuto .


Autori : B.Luongo, , A. Cuviello, M. Chiarello , C.Finco

Primo Autore : dr.ssa Barbara Luongo  d.n 31.8.1976 Napoli


Istituzione: Regione Veneto, ULSS5 Ovest Vicentino, UOC Chirurgia Arzignano

( direttore :dr Cristiano Finco  )


La chirurgia del prolasso rettale esterno consta di innumerevoli procedure chirurgiche.In sintesi l’orientamento della letteratura  internazionale è che nel paziente giovane si preferiscono le procedure  di Rettopessi (laparoscopica/open)  con o senza resezione  che garantiscono un minor numero di recidive a fronte di una generale tendenza al peggioramento della stipsi preoperatoria . Nel paziente anziano, l’orientamento in Europa è quello trattare i prolasso con la tecnica di  Delorme  oppure Resecare il  Prolasso  con la tecnica della scomposizione , mentre negli USA si preferisce la resezione rettosigmoidea transperineale sec Altemeier. In entrambe le procedure il rischio di recidiva si aggira attorno al 38%.

Case Report

Nel presente video si presenta il Caso di una paziente di 81 anni affetta da prolasso rettale esterno sintomatico , malattia diverticolare del colon , importante comorbidità cardiovascolare  ( infarto miocardio e fibrillazione striale parossistica ) , ASA 3 . Viene posta indicazione al trattamento del prolasso per via perineale .

Diagnosi clinico-strumentale : prolasso rettale esterno, Constipation Scoring System  (Aghacan- Wexner) 14/30 .Incontinence score (Wexner ) 8/20. Manometria anorettale : pressione a riposo 45 mmhg . In  contrazione : valori nella norma.

Ecografia endorettale : non evidenti difetti sfinterici . Perineografia : non enterocele

Tecnica: Paziente in posizione litotomica . Introduzione anuscopio dedicato . Fissaggio dello stesso al perineo .Esteriorizzazione del prolasso con manovra di Parks .Il prolasso è di 7 cm circa. Confezionamento “ paracadute  con 6 punti   che vengono raggruppati  lateralmente ad ore 3 ed ore 9. Introduzione della suturatrice CPH 36 SMS. Si recuperano i punti attraverso le due finestre laterali della  suturatrice e si procede alla sua chiusura . Si esegue la resezione . Apertura e rimozione della suturatrice. Ottima emostasi che non richiede nessun punto. Il pezzo asportato misura 12cm (larghezza)   x 7 cm  ( altezza) per una superficie di 84 cmq  , 23 ml volume .

Il follow- up a 6 mesi dimostra l’assenza di recidive e il recupero della continenza .

Conclusioni. Il video presenta , a nostra conoscenza , il primo caso in letteratura  di resezione di prolasso rettale completo con suturatrice circolare al alto volume. Il risultato tecnico immediato  , l’assenza di recidive ed il controllo della sintomatologia nel breve periodo ( 6 mesi) supportano l’efficacia del device. L’utilizzo della suturatrice  CPH 36SMS  in questa paziente conferma i dati della letteratura sperimentale con questo strumento. L’utilizzo del device a nostro avviso deve essere limitato ai prolassi  esterni di lunghezza inferiore ai 6-7 cm con pareti del retto  plastiche in grado di essere contenute agevolmente nella testina .

Il condiloma gigante (cosiddetto Tumore di Buschke Lowenstein) è una rara condizione clinica
benigna ma ad alto rischio di recidiva e potenziale trasformazione maligna, correlata al
papillomavirus umano (HPV), spesso a trasmissione sessuale, il cui trattamento è ancora oggetto
di discussione, anche se prevale l’approccio chirurgico.
Portiamo il caso di un uomo di 49 anni, affetto da cirrosi HBV correlata, senza altre patologie in
anamesi ad esclusione di epilessia, e sierologia negativa per HCV e HIV, portatore di condiloma
gigante ano-perineale di 22 x 10 cm.
Il paziente è giunto alla nostra attenzione per ematochezia ricorrente da circa un anno, aggravate
nell’ultimo mese da discomfort anale e problemi alla defecazione, in assenza di prurito o perdite di
altra natura.
Oltre all’esecuzione di visita proctologica e anoscopia, ha eseguito un’endoscopia anale che ha
dimostrato interessamento della lesione vegentante fino alla linea pettinea, senza infiltrazione dei
piani muscolari; una pancolonscopia sostanzialmetne negativa e una TC torace-addome con MDC
anch’essa negativa.
Con il paziente in posizione ginecologica e anestesia spinale, si è proceduto ad eseguire
un’incisione circolare a lama fredda sulla cute macroscopicamente indenne, a circa 5 mm dalla
lesione vegetante. Il derma è stato dissecato con forbice dal tessuto sottocutaneo, in modo da
ottenere un cilindro mucocutaneo comprendente in toto la lesione, eseguendo un’escissione
radicale circonferenziale della stessa (che si approfondava nel canale anale fino alla linea
La sezione è stata completata con pinza a ultrasuoni (Enseal®) e l’emostasi con pinza bipolare.
La lesione è stata dissociata senza problemi dal muscolo sfintere esterno, arrivando a ridosso di
quest’ultimo, preservandolo in toto.
Si è proceduto quindi a ricostruzione diretta del difetto ano-perineale con punti staccati mucocutanei
in Novosyn 2/0.
Il paziente è stato dimesso in terza giornata post-operatoria in buone condizioni cliniche generali.
L’esame istologico ha confermato trattarsi di Tumore di Buschke Lowenstein, e la successiva
tipizzazione e test molecolare (Tecnology Micro Array) ha dimostrato la presenza di HPV di tipo 6,
a basso rischio di trasformazione maligna.
Il controllo dopo un mese ha mostrato una buona cicatrizzazione della ferita chirurgica. L’alvo è
stato sempre regolarmente canalizzato. A tre mesi non si sono verificate complicanze, in particolar
modo né stenosi del canale anale, né ectropion, soiling o episodi di incontinenza. A sei mesi non vi
sono segni di recidiva locale.
Questo tipo di approccio chirurgico, sia alla luce della tipizzazione che per la semplice metodica
realizzativa, ci sembra, in casi selezionati, il più idoneo a far coincidere la radicalità oncologica con
i buoni risultati di natura funzionale; riducendo sicuramente i tempi operatori, se comparati con
quelli che richiedono la ricostruzione con lembo; sia i tempi medi di degenza che le complicanze
peri e post-operatorie.

Luca Pomba, Benito Ferraro, Emanuele Migliori, Genny Mattara, Pierluigi Pilati
U.O.C. Chirurgia Generale – Ospedale Sant’Antonio, Azienda ULSS n.16, Padova

Controversies exist in indication of elective colonic resection for uncomplicated diverticulitis.
Elective resection is not routinely recommended and prophylactic resection after one or more
episodes of acute diverticulitis should be performed on a case-by case basis. The assessment of
quality of life in patients with diverticular disease could be an interesting tool with tailored
approach. DV-QoL is a brand new questionnaire for investigation on quality of life in patients with
symptomatic uncomplicated diverticular disease. So far, DV-QoL has not been validated in Italian
language and it has been never used to evaluate results of therapy in surgical patients.
Main goals of the study were: to validate in Italian DV-QoL and to evaluate the application of this
questionnaire to surgical patients; to estimate the variation of quality of life in patients with
uncomplicated diverticulitis after surgical or conservative treatment with SF-36 and DV-QoL; to
assess the improvement of QoL in surgical patients with colonic stenosis and/or two or more
hospitalization for acute diverticulitis (risk factors); to evaluate clinical satisfaction in surgical
patients after surgery.
All consecutive patients who underwent surgical operation for uncomplicated diverticulitis or were
hospitalized for acute uncomplicated diverticulitis in three centers (Padua, Trieste, Udine), in period
from 2008 to 2015, were enrolled. Healthy volunteers were enrolled to validate DV-QoL in Italian
language. Clinical data were collected retrospectively from medical records. SF-36 and DV-Qol
Clinica Chirurgica III, Dipartimento di Scienze Chirurgiche Oncologiche e Gastroenterologiche, Università
degli Studi di Padova
Chirurgia Generale, Dipartimento di Chirurgia Generale, AOU Santa Maria della Misericordia, Udine
Gastroenterologia, Dipartimento di Scienze Chirurgiche Oncologiche e Gastroenterologiche, Università degli
Studi di Padova
Chirurgia Generale, Dipartimento Universitario Clinico di Scienze Mediche Chirurgiche e della Salute,
Azienda Sanitaria Universitaria Integrata di Trieste
Biostatistica, Epidemiologia e Sanità Pubblica, Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari,
Università degli Studi di Padova
1 3 1 4 2 1 1
were administered by telephonic interviews with reference to quality of life before and after surgical
or conservative treatment. DV-QoL validation was performed with analysis of Pearson’s correlation
with SF-36, comparing results in healthy population. SF -36 and DV-QoL scores before and after
conservative or surgical treatment for uncomplicated diverticulitis were compared using T-test and
Ninety-seven operated patients and 44 patients with conservative treatment were enrolled and
satisfied the inclusion criteria of the study. Forty-four healthy volunteers served as controls. Italian
DV-QoL correlated significantly with overall scores and subscales of SF-36 (p<0.0001). Surgical
patients had worse scores before treatment with respect to patients treated conservatively (mean :
21.12 surgical VS 15.41 conservative, p= 0.0048) but better scores after treatment (mean: 6.90
surgical VS 10.61 conservative, p= 0.0186). Covariance analysis confirmed that differences
between DV-QoL scores pre-treatment (basal) and post treatment (final) were significantly higher
in surgical (p=0.0002) with respect to non-surgical patients. DV-QoL improvement after surgery
was not statistically different between patients with risk factors (colonic stenosis and /or 2 or more
of previous attacks of diverticulitis) and those without risk factors. 95% of surgical patients were
satisfied after their surgical treatment.
DV-QoL appears to be a useful questionnaire for evaluation of quality of life in patients with
uncomplicated diverticulitis and it can be also applied to surgical patients. In clinical practice DVQoL
could be useful as complementary tool in assessment of patients referred to surgery in
addition to clinical and instrumental feature and guideline recommendation. Surgical treatment of
uncomplicated diverticulitis could improve quality of life, even in absence of colonic stenosis and
repeated previous attacks. Prospective studies to confirm this result are required.

A. Bressan1, M. Vecchiato2, E. Vincenzo Savarino3, A. Turoldo4, A. Frigo5, L. Marini1, M. Della
Coletta3, G. Da Dalt1, N. De Manzini4, R. Petri2, S. Merigliano1, L. Polese1

Faecal Incontinence; posterior tibial nerve stimulation
Background: Percutaneous tibial nerve stimulation (PTNS) has been proved to be a first line
treatment in urinary incontinence, due to its characteristics of minimal invasiveness, low cost and
easy access in outpatient clinics. In a previous multicentre study we also demonstrated the efficacy
of PTNS in the treatment of faecal incontinence, using a 12-month protocol. The aim of this study
was to determine whether a 9-week protocol could be eventually used as a maintenance treatment
for faecal incontinence of low-medium grade of severity.
Material and methods: The PTNS protocol included 12 sessions in the first 6 weeks (twice a
week), and 3 final top down sessions. The clinical outcomes were assessed using the Cleveland
Clinic Incontinence score, the FIQoL questionnaire and the weekly FI episodes. All outcomes were
compared at baseline and following the treatment using the U-Mann Whitney test. Further analysis
between this protocol and the 12-month protocol were also performed.
A total of 6 patients entered the study. One of them was lost in follow-up, due to a
possible side effect of the percutaneous nerve stimulation (reporting a worsening of migraine
attacks after the sessions). The Cleveland Clinic Incontinence score fell from 10  16 at baseline to
9  13 after treatment (P = 0,1437). Improvements were also seen in the quality of life (84  90,75
at baseline versus 85,25  95 at 9 weeks). A total of 30% of patients had a 50% decrease in
incontinence episodes, which perfectly correlates with the results obtained by the 12-month
protocol (33,3% at 6 weeks).
Conclusions: Percutaneous nerve tibial stimulation has a good potential in faecal incontinence as
a maintenance treatment in the outpatient setting. A 9-week protocol can be an efficient alternative,
increasing patients’ compliance.

Depalma N., Giuliani G., La Torre F.
Department of Emergency Surgery, Policlinico Umberto I, Roma

More than 100 surgical procedures have been proposed for the treatment of
complete external rectal prolapse. Since 2008 Scherer proposed a new perineal procedure called
Perineal Stapled Prolapse Resection. The aim of the study is to value results, complications,
recurrences and functional results of this technique.
Material and Methods.
We performed a multicenter study analyzing a prospective database
including consecutive patients. The study was conducted by five specialized colorectal surgical
teams. Inclusion criteria were all patients with an external complete rectal prolapse, which were not
suitable for an abdominal surgical procedure. The choice of the surgical procedure (abdominal or
perineal) was performed by surgeon’s practice. No variations from usual habits were performed in
relation to this study. Exclusion criteria were patients younger than 18 years, patients who refused
the surgical procedures and patients with a prolapse thickness major than 1.5 cm (that actually is
considered over the capacity of the stapler). Functional results were valued through Altomare ODS
score scale and Wexner incontinence score performed pre and postoperatively.
Follow up was conducted with a proctological examination every week for 1 month and with a rigid
proctoscopy every 3 months for the first year, and then twice annually thereafter.
All patients gave their written informed consent after being informed of the benefits and risks of the
procedure. They were also informed about the lack of published long-term follow-up data and of
possible late complications associated with the technique.
27 patients were submitted to Perineal Stapled Prolapse Resection. Preoperative median
Wexner incontinence score was 10 (range 5-20), while median ODS score was 12 (range 5-22).
Laparoscopic assistance was performed in 3 patients (11.1%). Median number of cartriges used
was 6 (range 4-9). Median operative time was 48 minutes (range 30-100 min). Early complications
occurred in 6 patients (22.2%), while late complications occurred in two patients (7.4%). Mean
hospital stay was 5 days (range 3-21 days).
After a median follow up of 25 months a recurrence rate of 14.8% was observed. Postoperative
Wexner incontinence score was 5 (range 0-18). ODS postoperative score was: 5 (range 4-10). The
difference were statistically significant.
Perineal Stapled Prolapse Resection is an easy, fast and a safe procedure. Early
functional results are good. 14.8% of recurrence compares with other perineal procedures like
Delorme (0-38% of recurrence) or Altemeier (0-16%). The cost of the procedure is high and it is
tenable only if hospital stay and the incidence of recurrence are low respect other procedures.
Long term functional results must be investigated further. A limitation of this study was the small
number of patients and the follow up lower than 3 years. Considering the low incidence of this
pathology and the number of surgical procedures disposable for the treatment of complete rectal
prolapse an International Registry should be advised to obtain an adequate evaluation of this
procedure, to assess indications, complications, recurrences and functional results also in
comparison with other procedures.

Lisa Rapetti, M.D., Massimiliano Mistrangelo, MD, PhD, Paolo Tonello1, MD., Riccardo Brachet
Contul2, MD., Giovanni Arnone3, M.D., Roberto Passera4, PharmD, PhD, Giada Pozzi, MD,
Roberto Borroni1, MD, Elena Mazza, M.D., Mauro Pozzo5, MD, Maurizio Roveroni2, M.D., Mario
Morino, MD., Roberto Perinotti5, MD.
Department of Surgical Sciences, Centre of Minimal Invasive Surgery, University of Turin, Città
della Salute e della Scienza di Torino Hospital, Chief Prof Mario Morino.
1Department of Surgery, Koelliker Hospital, Turin
2 Department of Surgery, Aosta Hospital
3 Department of Surgery, Martini Hospital
4 Nuclear Medicine Department, University of Turin, Città della Salute e della Scienza Hospital,
5 Department of Surgery, Biella Hospital

Perineal Stapled Prolapse Resection (PSP) for external rectal prolapse is a new surgical
technique, proposed by Scherer and Coll in 2008. Initial enthusiasm accompanied first positive
results. More recent reports oppose those results reporting a large incidence of recurrences.
We performed a Literature review regarding PSP in the treatment of complete external
rectal prolapsed. Duplicated data and abstracts were excluded from the study. Number of patients,
intraoperative and postoperative results, complications and recurrences were evaluated.
15 papers were found in international Literature. Considering duplication of the data only
10 papers including 176 patients were analysed. All patients presented as complete external rectal
prolapse. The largest series report 64 patients. The longitudinal section of the prolapse was
performed at 3 o’clock in 3 studies, at 9 o’clock in 1 study, and at 3 and 9 o’clock in the other 6
studies (in these series the initial cases were sectioned only at three o’clock as described by
Scherer). A median of 6 cartriges were used for the surgical procedure. Intraoperative
complications occurred in 15 patients (8.5%): 2 conversions to an Altemeier due to a staple line
disruption probably related to a rather thick prolapsed; 1 conversion to a ventral rectopexy due to
the impossibility to pull out the prolapse; 5 additional handsuture for an insufficient stapled line and
the remaining were possible small intestine adherence. Mean operative time (reported only in 7
papers) was 40.3 minutes. Postoperative major complications were observed in 7 patients (3.9%):
1 pelvis sepsis, 1 suture dehiscence treated with a colostomy and 5 bleedings (surgical
hemostasis). Minor complications occurred in 22 patients (11.4%): 5 postoperative bleedings not
requiring a surgical procedure, 2 retrorectal hematoma treated conservatively, 2 systemic
inflammatory reactions, 2 urinary retentions, 3 urinary infections, 1 peritonitis in a patients with
peritoneal dialysis, 2 granulomas, 1 rectal abscess, 1 medical disease, 1 persistent pain and 2 not
specified diseases. No mortality was observed. Median hospital stay was 5 days. During follow up
of 23 months 40 patients recurred (22.7%). Regarding functional results the studies are not
comparable, considering different scores of evaluation of ODS and fecal incontinence and for the
absence of available data. A reduction of median ODS score was reported in four study and a
general improvement of incontinence was observed in all studies but one (Ram and Coll) even if in
few cases new incontinence occurred postoperatively. Conclusions. PSP is a new surgical
procedure for external rectal prolapse. It is easy, fast and a safe procedure. Early functional results
are good in many series, even if recent papers report a high incidence of recurrence. A total 22% of
recurrence is high considering the costs of the procedure even if could be accepted considering
the incidence of other perineal procedures like Delorme (0-38% of recurrence) or Altemeier (0-
16%). The cost of the procedure is high and it is tenable only if hospital stay and the incidence of
recurrence could be reduced respect other procedures. Long term functional results must be
investigated further.

Lisa Rapetti, M.D., Paolo Tonello*, M.D., Luca Grasso, M.D., Valentina Testa, M.D., Lucia Idda,
M.D., Giuseppe Benedetto, M.D., Simone Arolfo, M.D., Marco Ettore Allaix, M.D., PhD., Elettra
Ugliono, M.D., Mario Morino, MD, Massimiliano Mistrangelo, MD, PhD
Surgical Science Department, Centre of Minimal Invasive Surgery, University of Turin, Città della
Salute e della Scienza Hospital
*Department of Surgery, Koelliker Hospital, Turin

Chronic pelvic pain associated to the Bladder Pain Syndrome (BPS) is a typical example of
neuropathic pain, involving peripheral and central mechanisms of sensitization. Although
neuropathic pain responds to antidepressants, anticonvulsants and opioid agonists, these drugs
are often ineffective or can induce severe adverse effects. Hence, to manage this disturbance
other safe and effective therapeutic options are need. In these settings, cortical stimulation has
emerged as a novel approaches for pain relief. Specifically, a non-surgical technique modulating
cortical excitability and inhibiting pain perception is repetitive transcranial magnetic stimulation
(rTMS) applied to the motor cortical areas. Standard TMS coils (such as the figure-of-8 coil) permit
to stimulate only superficial cortical regions of the human brain. A newer cooled coil, the Hesed
(H)-coil allows deep brain stimulation without significantly increasing fields induced in superficial
cortical regions. The H-coil can therefore be used to stimulate the motor cortex concerning the
pelvic area, a region that lied deep in medial motor area sections folding into the brain medial
longitudinal fissure. To date, no studies have used rTMS with an H-coil to stimulate the motor
cortex as therapy for resistant neuropathic pain in BPS patients.
In the present pilot study, we investigated whether modulation of excitability of the motor cortex
with rTMS in patients with BPS could result in modifications of neuropathic pain and urinary
disturbances. Twelve patients with BPS were enrolled. Diagnosis of neuropathic pain was
confirmed with the Douleur Neuropathique en 4 questions (DN4) questionnaire. All patients were
resistant to standard therapies for neuropathic pain taken for at least six months. The patients
received two weeks of rTMS sessions, with three weeks-break between the two weeks of
In each patient, the rTMS sessions were delivered with a H-coil for 5 consecutive days, lasting 20
minutes and consisting of 30 consecutive trains of 50 stimuli delivered at 20 Hz, at 100% of resting
motor threshold, separated by intertrain intervals lasting 30 s. The patient’s clinical condition was
evaluated before treatment began, immediately after it ended, 3 weeks later, and every 3 weeks in
a follow up lasting 126 days (18 weeks). At baseline patients was submitted to DN4 and
sensitization scale. At various time-points, all patients underwent to the following assessments:
Visual Analogue Scale (VAS) for pain and Neuropathic Pain Symptom Inventory (NPSI) to assess
changes in pain; Overactive Bladder Questionnaire (OABq), O’Leary Sant questionnaire and postvoiding
bladder ultrasound to assess changes in urinary disturbances; Short Form-36 Health
Survey (SF-36) and Beck depression inventory (BDI) to evaluate changes in the quality of life. The
Minnesota Multiphasic Personality Inventory (MMPI) and a urodynamic examination with
cystoscopy were performed at baseline, at the end of the two rTMS sessions and three months
later. Data were analyzed using the one way ANOVA and Fisher post hoc test.
Twelve women were enrolled (mean+SD: 53.0+14.3 years). Two of them did not terminate the
study because of a flare of their pathology in the screening phase. The delay between the onset of
symptoms and the inclusion in the study was 18+9.5 years. At the enrollment, the DN4 was
6.3+0.8 and the sensitization scale score was 78.8+23.9. The bladder residue significantly
improved after the rTMS (p=0.03). The OABq score reduced significantly after the rTMS (p=0.05).
Also the NPSI score reduced after the rTMS (p=0.004). The VAS, the O’Leary Sant questionnaire,
the SF-36, and the MMPI did not changed after the rTMS. The BDI score reduced but not
significantly. The effect on the OABq and the NPSI tests persisted at least for 3 weeks.
This study shows that the rTMS of the brain motor cortex related to the pelvic area changes both
the subjective perception of the pain and the objective measurement of bladder voiding. In a
previous study the efficacy of rTMS on chronic drug-resistant neuropathic pain associated to other
syndromes was already demonstrated (Onesti E et al, 2013). Our results are consistent with the
recent characterization of brain white matter micro structural abnormalities in women with BPS,
suggesting a brain neuropathological contribution to chronic pelvic pain (Farmer MA et al, 2015). In
our research, a placebo effect could be ruled out because a long latency between the treatment
and the effects was demonstrated, such as previously evidenced (Onesti E et al, 2013). Also the
frequency, urgency and incontinence symptoms, such as reported in OABq, improved. Moreover,
depression did not improved before the changes in painful and urinary parameters, meaning that
the change of psychic disease did not cause the clinical improvement reported.
Deep H-coil rTMS applied to the motor cortex could be provide pain and urinary disturbances relief
in patients with BPS. The interpretation of this results is limited by the small sample size, and more
data are certainly need to confirm this preliminary report and to better understand the mechanisms
by which rTMS may modulate pain and urinary disturbances in BPS patients.
Farmer MA, et al. Brain white matter abnormalities in female Interstitial Cystitis/Bladder Pain
Syndrome: A MAPP network neuroimaging study. J Urol 2015;194:118-26. doi:
Onesti E, et al. H-coil repetitive transcranial magnetic stimulation for pain relief in patients with
diabetic neuropathy. Eur J Pain 2013;17:1347-56. doi: 10.1002/j.1532-2149.2013.00320.x.

Ceccanti M.1, Onesti E.1, Inghilleri M.1, Gori MC.1, Scambia G.2, Morciano A.2, Tartaglia G.1, Nasta
L.3, Gaetani E.2, Cervigni M.2
1Center for Rare Neuromuscular Diseases, Department of Neurology and Psychiatry, Sapienza
University Rome
2Multidisciplinary Referral Center of Interstitial Cystitis/Bladder Pain Syndrome, Catholic University,
3Interstitial Cystitis Association

Il prolasso complesso del pavimento pelvico rappresenta un’entità clinica che sempre più si
impone nel panorama della patologia benigna. La pelvi, infatti, viene oggigiorno considerata
un’entità anatomico-funzionale unica a contrasto della ormai obsoleta concezione di suddivisione
in compartimento anteriore, medio e posteriore del distretto pelvico.
L’isterocele, il prolasso di volta ed il cistocele rappresentano le principali manifestazioni cliniche.
Esse possono essere associate a sintomi specifici quali incontinenza urinaria, cistiti ricorrenti,
dispareunia, ingombro vaginale ma, anche, a quadri di defecazione ostruita ove, il prolasso
genitale rappresenta una causa extrarettale di distrurbi della funzione alvina. Da qui la necessità di
proporre, in casi selezionati ed accuratamente studiati, interventi chirurgici mirati alla risoluzione
del problema.
La Pelvic Organ Prolapse Suspension (POPs) è una tecnica chirurgica mininvasiva di sospensione
degli organi pelvici per mezzo di una protesi ancorata lateralemente ai muscoli della parete
addominale. Essa rappresenta un’ottima opzione terapeutica in caso di prolasso genitale con
possibilità di conservazione dell’utero. L’utero infatti è infatti il perno di supporto centrale della pelvi
e, di conseguenza, una sua rimozione potrebbe compromettere negativamente l’assetto degli
organi pelvici restanti. Il razionale della POPS con ancoraggio alla parete vaginale anteriore è
insito nel ripristino delle fisiologiche relazioni anatomo-funzionali tra la vescica, la vagina ed il retto
conservando, quindi, i normali volumi della pelvi nel suo complesso. Questa procedura utilizza una
protesi per ottenere il rinforzo dei legamenti sospensori pelvici.
Nella Nostra esperienza 20 sono state le paziente sottoposte a questo intervento nel periodo
dicembre 2013 maggio 2016. In tutti i casi l’ancoraggio della protesi era a livello della parete
anteriore del terzo superiore della vagina. Si sono utilizzate protesi in polipropilene, polipropilene
titanizzato e protesi biologiche cross-linkate. Non si sono verificate complicanze maggiori. Tra le
complicanze minori solamente 2 casi di dolore in sede di ancoraggio laterale alla parete
addominale. Il follow-up a breve termine ha dimostrato un ottimi risultati con 1 solo caso di
recidiva parziale. Le paziente hanno dimostrato un 100% di grado di soddisfazione dopo la
Nell’ottica della taylored therapy dei quadri di prolasso complesso del pavimento pelvico non si
può, quindi, prescindere dalla conoscenza di questa tecnica che appare sicura, efficace e
mininvasiva nel trattamento del prolasso uro-genitale.

F. Da Pozzo. A. Bressan, A. Stuto

Sacral nerve stimulation (SNS) is an established treatment for fecal incontinence
(FI) since 1994. Programming of the device is a critical part of this treatment process. However, to
date, there is a paucity of data to confirm this important finding. In addition, no guidelines currently
exist in regards to the accurate programming of this device.
Methods: an esaustive review of literature was performed. Data were collected in a database build
ad hoc and processed with PRISMA criteria.
Results: Only 2 papers had studied (in 14 and 15 patients groups respectively) the effects of
changing stimulation frequencies on patients outcome and both agree on a better results for
higher frequencies stimulation. Another study was performed (in 38 patients), with the aim to
establish if the ideal program recommended by the producer, for fecal incontinence, was the most
commonly used and the results showed it wasn’t .All the studies about the device programming
were done in small groups of patients and only 1 was a rct with the higher level of evidence. In the
most important papers about SNS for fecal incontinence there’s no mention about device
Programming of the device is one of the most crucial aspects of the SNS process,
but its role is often downplayed and frequently relegated to a non-surgical member of the team.
Device programming is an intricate process and often the hardest component of the procedure to
master. Very often it is believed to be a trial-and-error process, which can negatively impact patient
outcome. Unfortunately, no standardized algorithm of stimulation parameters in the follow up
exists in the literature.

M. Franceschin, A. Ramin*
Casa di Cura Rizzola San Donà Di Piave, *Complesso SS Casa ai Colli ULSS 16

Introduzione ed obiettivi
– L’incontinenza fecale è un disturbo frequente ed invalidante il cui
trattamento ottimale non è stato ancora individuato. Tra le varie tecniche le meno invasive sono
risultate le iniezioni intersfinteriche di agenti volumizzanti (PTQ™, Durasphere®, grasso autologo
etc). In questo studio riportiamo la nostra esperienza iniziale nel trattamento dell’incontinenza
sfinterica con THD Gatekeeper™, che è una protesi di materiale sintetico idrofilo utilizzato come
agente volumizzante.
Materiali e metodi
– Il kit THD Gatekeeper™, è costituito da protesi cilindriche di Hyexpan™
(polyacrylonitrile) che vengono impiantate sotto guida ecografica nello spazio intersfinterico in
numero variabile tra 4 e 6 e che si espandono nell’arco di 24 ore, e da una pistola per la iniezione
della protesi.
Nel nostro Dipartimento tra il 2013 e il 2016 abbiamo trattato con Gatekeeper™ 15 pazienti (14
femmine e 1 maschio) affetti da incontinenza fecale sono stati sottoposti a questo trattamento
mininvasivo effettuato in anestesia locale. I pazienti sono stati sottoposti a ecografia transanale pre
e post procedura a 2 mesi ed è stata eseguita la valutazione del Wexner incontinence score pre e
post intervento a un mese e a 1 anno.
– In una popolazione costituita al 93% da femmine, l’eta media al trattamento è di 66 anni
(d.s. 8.24) e il follow up medio di 21,9 mesi (d.s. 15.0).
Al controllo a 1 mese dall’intervento il punteggio Wexner è di 6.75 (d.s. 4.9) rispetto al
preoperatorio di 12.7 (d.s. 4.20) con un delta score di -6.67 con un significativo miglioramento nella
continenza e nella qualità di vita (p<0.001). Al controllo a 1 anno il punteggio Wexner è di 9.2 (d.s.
5.1) con un delta score di -3.47 (d.s. 6.52) con parziale recidiva dei sintomi (p=0.058).
Dopo un iniziale miglioramento dei sintomi, soprattutto sulla continenza alle feci solide e ai gas, si
rileva una parziale ricomparsa dei sintomi, soprattutto del soiling, ed in 3 casi (20%) al
peggioramento rispetto alla situazione basale.
Al controllo ecografico a 2 mesi le protesi risultano ben posizionate senza dislocazioni ma durante
il follow up sono state rimosse 3 protesi per dislocazione nel tessuto sottocutaneo. Abbiamo
registrato un unico episodio di iperpiressia post procedura risoltosi con antipiretici.
– Nel trattamento di un disturbo complesso come l’incontinenza fecale che tutt’ora
non presenta valide terapie mediche e chirurgiche, il posizionamento degli agenti volumizzanti
rappresenta un’ipotesi di trattamento sicura per il paziente per la sua natura mininvasiva ed
efficace per i risultati a breve e medio termine sulla continenza. Ci attendiamo ulteriori
miglioramenti dagli sviluppi della tecnica.

Roberta Di Vora, Giovanni Terrosu, Sergio Calandra, Filippo Caponnetto*, Edoardo Scarpa,
Massimo Vecchiato*, Cinzia Dri*, Marta Mozzon*, Andrea Risaliti
Clinica di Chirurgia Generale – ASUI Udine
*Chirurgia Generale – ASUI Udine