Challenges in the Surgical Treatment of Rectal Prolapse

The approach to a patient with overt rectal prolapse remains controversial since the choice of the most appropriate technical option may be a difficult task. The different approaches are based upon patients’ age, comorbidities, sex, size of prolapse, associated incontinence, constipation, and urinary and genital disturbances. However, analysis of the literature failed to detect a significant evidence favoring one among the large number of those different surgical techniques proposed for the treatment of rectal prolapse. In fact, many randomized prospective controlled trials, comparing perineal and abdominal operations, rectopexy alone, resection alone and/or resection plus rectopexy could not find significant differences in terms of morbidity, mortality, improvement of incontinence or constipation, quality of life and recurrence. Therefore, without a clear-cut support by the literature, a pragmatic approach is necessary, applying common sense, experience and considering the availability of resources as well. Nevertheless, we may expect that definitive answers to many open questions about surgery of rectal prolapse may come from larger studies and longer follow-up

Una policy per la governance collaborativa e la sussidiarietà orizzontale: il Regolamento per la cura dei beni comuni

Questa ricerca verte sulla comprensione dell’adozione del Regolamento per la cura dei beni comuni, un dispositivo legislativo per il governo locale recentemente diffuso in un consistente numero di comuni italiani. Di questo fenomeno è proposto un bilancio basato su alcuni dati riguardanti la diffusione e le logiche che ne hanno determinato l’adozione. Questo contributo tenta di fornire un tentativo di analisi della relazione tra le tre dimensioni della politica (politics, policy e polity) collegando alcuni strumenti analitici, qualitativi e quantitativi, con i modelli di riferimento che hanno elaborato direttamente le policy. Questi modelli sono stati a loro volta ricondotti ai paradigmi teorici di riferimento per stabilirne la genesi in un’ideale opera di decostruzione e ricostruzione del framework in cui i concetti di beni comuni, governance collaborativa o partecipativa, prendono significato e diventano operativi. La chiave per penetrare il rapporto tra amministrazione, teoria e politica è stata individuata in dei particolari strumenti di policy, i Regolamenti per l’amministrazione condivisa dei beni comuni, dei dispositivi normati adottati da un significativo numero di amministrazioni comunali italiane attraverso delle delibere di consiglio comunale, sulla base del “Regolamento sulla collaborazione tra cittadini e amministrazione per la cura e la rigenerazione dei beni comuni urbani” approvato dal Consiglio Comunale di Bologna nel maggio 2014. Nella ricerca sono indagati i Regolamenti dal punto di vista del loro portato teorico attraverso l’analisi dei due principali modelli che li hanno ispirati cioè l’amministrazione condivisa e la governance collaborativa. Sono quindi state analizzate le loro caratteristiche come policy locale, la loro diffusione e le motivazioni che hanno spinto i governi locali a deciderne l’adozione. Le domande a cui si è cercato di rispondere riguardano la congruenza tra la visione teorica e il reale funzionamento della policy. L’ipotesi che la ricerca ha tentato di verificare è, quindi, se il Regolamento rappresenti uno strumento di cambiamento sociale e politico in grado di rivitalizzare la democrazia a più livelli. Questa ipotesi avrebbe trovato suffragio nella constatazione della diffusione ed utilizzo del Regolamento in contesti storicamente caratterizzati da basso capitale sociale o indice di benessere e qualità della vita. La ricerca empirica ha invece evidenziato come il Regolamento sia maggiormente diffuso e utilizzato nelle città del Nord e di dimensioni medio-grandi (dove è mediamente più ricca l’offerta di servizi locali). Anche il riscontro elettorale non ha dimostrato una capacità significativa del Regolamento di generare consenso, come se la diffusione di uno strumento di partecipazione alla gestione locale non alimentasse la vicinanza dei cittadini alla vita politica. La realtà analizzata coincide quindi solo in parte con le prescrizioni delle teorie di riferimento che immaginano il governo locale come un sistema semplificato in cui agiscono attori coerenti, animati dalla medesima volontà e per cui i limiti delle teorie generali dell’amministrazione e delle politiche pubbliche potrebbero essere superati utilizzando le teorie sui beni comuni e la governance collaborativa

Proctologic Surgery Prioritization After the Lockdown: Development of a Scoring System

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has shown a very critical impact on surgical procedures all over the world. Italy faced the deepest impact from the beginning of March 2020. Elective operations, screening, and follow-up visits had been suspended giving priority to urgent and oncologic surgery. Patients: An observational study was carried out in the Surgical Coloproctology Unit of the Val Vibrata Hospital on 152 patients awaiting a proctological surgical treatment during the national lockdown. Methods: In order to monitor the health status of patients and reschedule postlockdown surgical activities, patients were interviewed by telephone submitting a questionnaire based upon the judgment of an expert senior clinician. Following the interview, we calculated a severity index for all the proctologic diseases (hemorrhoidal disease, anal fissure, anal sepsis, slow transit or obstructed defecation, incontinence), classifying the patients according to the score. Mean age of patients was 53 (±16) years, and there were 84 males (55.3%) and 68 females (44.7%). In total, 31% of our patients suffered from anal fissure, 28% suffered from hemorrhoidal disease, 14% suffered from anal sepsis, and the remaining patients suffered from benign anorectal diseases to a lesser extent. Results: A total of 137 patients were available and divided into three classes: priority surgery (PS) with 49 patients (36.2%), deferrable surgery (DS) with 25 patients (18.1%), and long-term surgery (L-TS) with 63 patients (45.6%). There was a significant correlation between the perceived health status reported during the interview and the priority class index (Spearman's rho = 0.97, p < 0.001). Differences related to age and sex were not significant (F-test = 0.43, p = 0.653; chi-squared test = 0.693, p = 0.707). 49 patients in class PS needed a prompt surgical treatment, while 24 patients allocated in class DS and 65 patients allocated in class L-TS could wait for a new ride plan for surgery. Conclusion: New tools, such as this simple score obtained during the telephone interview, can be useful for prioritization of patients on the waiting list for surgical coloproctology after the lockdown without further clinical examination and hospital access

Efficacy and Tolerability of a New Formulation in Rectal Ointment Based on Zn-L-Carnosine (Proctilor®) in the Treatment of Haemorrhoidal Disease

Haemorrhoidal disease (HD) shows high prevalence in western countries, reaching 4.4% per year in the US. Topical preparations are the first-line treatments, which are readily available as "over-the-counter" (OTC) products, often containing a nonstandardised mixture of "natural" remedies, or anaesthetics or cortisol;those latter are not free from undesirable effects. The Zinc-L-Carnosine is a cytoprotective compound, promoting mucosal repair in the gastrointestinal tract and also in mucosal repair, following radiation injuries to the rectum as well as in ulcerative colitis. Our aim was to study the efficacy of Zinc-L-Carnosine in relieving acute symptoms of HD, testing a preparation in the rectal ointment, Proctilor (R), in patients complaining of bleeding or thrombosed piles. In a multicentre open trial, 21 patients older than 18 years of age were enrolled. The symptoms of HD were graded according to the Haemorrhoidal Disease Symptoms Score (HDSS) in association with the Short Health Scale (SHS) to assess the influence of HD on quality of life. The pain was assessed with the VAS score, bowel habit by means of the Bristol scale. The patients were evaluated at enrolment (T0) and 2 (T1) and 4 (T2) weeks of treatment with Proctilor (R) rectal ointment. There were 10 men and 11 women; mean age, 49 years. Pain, bleeding, and thrombosis were all significantly reduced after treatment; the mean VAS score decreased from 4.71 +/- 3.05 at T0 to.52 +/- 0.87 and.05 +/- 0.22 at T1 and T2, respectively; (mean +/- SD; p < 0.001 in both cases). Similarly, the HDSS score showed to be significantly reduced between T0, T1 (8.05 +/- 4.55 vs. 1.14 +/- 1.01), and T2 (8.05 +/- 4.55 vs. 24 +/- 0.44) (mean +/- SD; p < 0.001 in both cases). Quality of life showed to be improved as the SHS score decreased significantly with treatment (7.90 +/- 4.17 at T0 vs. 4.24 +/- 0.44 at T1 vs. 4.05 +/- 0.22 at T2; mean +/- SD; p < 0.001 in both cases). The Bristol score of defecation remained substantially unchanged. No side effects or discontinuation of treatment were reported. Results of our investigation suggest a role of Proctilor (R) rectal ointment in treating symptomatic HD with good results and an excellent safety profile. However, our preliminary results encourage further studies on a larger number of patients to confirm the role of Zinc-L-Carnosine in the rectal ointment for the topical treatment of HD

The impact of experience on recurrence rates after biopsy punch excision for pilonidal disease

Aim We present the outcomes and the recurrences of 848 patients with pilonidal disease (PD) treated by biopsy punch excision (BPE) and we weigh our results against progressively obtained operative experience. BPE is a modified 'merged' version of both the Bascom 'pit picking' procedure and the Gips procedure. It employs biopsy punches of different calibre, depending on whether treatment is in the natal cleft (calibre as small as possible) or lateral (larger calibre punches or even small incision). Sometimes this procedure is referred to as the Bascom-Gips procedure. Methods In all, 848 consecutive patients with PD were treated from January 2011 until December 2016 (sex 622 [73.4%] men and 226 [26.6%] women; median age 26.2 years, mean age 24.6 +/- 28.99 [range 14-55] years, men 25.1 years, women 24.8 years). Of these 848 patients, 287 were operated in 2011-2012, 301 in 2013-2014 and 260 in 2015-2016. The recurrence rates were recorded 12, 24 and 60 months after surgery both cumulatively and by examining the outcomes of the three biennia individually (years of treatment 2011-2012 or group A, 2013-2014 or group B, 2015-2016 or group C). Results The mean operating time was 34 +/- 24.45 min. Postoperative complications included early (n = 22 or 2.6%) and delayed (>24 h; n = 26 or 3.1%) postoperative bleeding. Postoperative fluid collections (<2 weeks) occurred in 83/848 patients (9.8%) and included haematoma (n = 25) and seroma (n = 58). Full recovery was obtained after a mean of 21 +/- 12.72 days and work/school/university activities were resumed after a mean of 4 +/- 12.02 days. Twelve-, 24- and 60-month follow-ups were possible in 725 (85.5%), 682 (80.4%) and 595 (70.2%) patients out of 848. An overall significant (chi(2) = 16.87, P = 0.0002) difference was found in the recurrence rates: 59 recurrences/725 patients (or 8.1%) after 1 year, 89 recurrences/682 patients (or 13.0%) after 2 years and 98 recurrences/595 (or 16.4%) after 5 years. However, when subgrouping patients in three 24-month subsets, the recurrence rates showed a steady and progressive decrease in the three biennia 2011-2012 (group A), 2013-2014 (group B) and 2015-2016 (group C) at 12-, 48- and 60-month follow-ups. Recurrences after 12 months were 29/225 (12.9%), 19/285 (6.7%) and 11/215 (5.1%) (chi(2) = 8.53, P = 0.014) in groups A, B and C respectively; after 24 months, 36/226 (15.9%), 31/242 (12.8%) and 22/214 (10.2%) (chi(2) = 2.38, P = 0.30 N.S.) in groups A, B and C respectively; after 60 months, 38/194 (19.5%), 36/215 (16.7%) and 24/186 (12.9%) (chi(2) = 2.23, P = 0.32) in groups A, B and C respectively. Conclusions BPE is an effective, disease-targeted, minimally invasive and inexpensive way to treat PD. Its results are influenced by the experience of the team involved, especially regarding early recurrences/failure of surgery. At least 5-year follow-ups are needed to ascertain the outcome of surgery for PD

Appendiceal Neuroendocrine Tumors and Anorectal Melanoma

Tumor growth and spread are a complicated matter and are the result of many interconnected factors. The analysis of patterns emerging from highly numerous populations might help shed some light on such an intricate mechanism. In this respect, our studies are mostly based on the SEER database, a nation representative dataset collecting data regarding the US population, over a very long time span. This approach is revealed to be particularly useful for rare tumors, as prospective studies are not feasible. Here, we present the results and the clinical implications of our inquires: we show the impact on overall survival of several morphological and demographic characteristics of various malignancies including anorectal melanoma and neuroendocrine tumors of the appendix. The impact of surgical treatment is discussed as well. Finally, we endorse the need to find more reliable markers of tumor biology, such as genetic patterns, to tailor an effective multidisciplinary treatment

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM)

Background: The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. Methods: A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. Results: There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125). Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred. Conclusions: Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM)

Background The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. Methods A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. Results There were 183 patients [111 males; 60.7%, mean age 51.3 +/- 13.5 (18-75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125). Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred. Conclusions Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids. © 2022, The Author(s)