F. La Torre

A prospective multicentre study to investigate percutaneous tibial nerve stimulation for the treatment of faecal incontinence

Aim  Percutaneous tibial nerve stimulation (PTNS) is a minimal invasive treatment that can be performed in the outpatient clinic. This is a pilot study to investigate PTNS in the treatment of faecal incontinence.

Disappointing long-term results of the artificial anal sphincter for faecal incontinence†

1Department of General Surgery and Liver Transplantation, University of Bari, Bari, 2Coloproctological Unit, Galliera Hospital, Genoa, 3Section of Surgical Clinic II, Department of Surgical and Oncologic Sciences, University of Padua, Padua, 4Department of Surgical Sciences, University of Rome ‘La Sapienza’, Rome and 5Department of Emergency Surgery, ‘S. Moscati’ Hospital, Avellino, Italy Correspondence to: Dr D. F. Altomare, Department of Emergency and Organ Transplantation, Section of General Surgery and Liver Transplantation, University of Bari, Policlinico, piazza G. Cesare 11, 70124 Bari, Italy (e-mail: altomare@clichiru.uniba.it)

Seton or glue for trans-sphincteric anal fistulae: a prospective randomized crossover clinical trial

Objective  Fibrin glue treatment of anal fistulae has been proposed to minimize the risk of faecal incontinence but its acceptance by coloproctologists is still poor because the published data is controversial. Therefore, we carried out a prospective randomized crossover trial comparing treatment with a commercial fibrin glue to classical seton treatment, with healing rate, hospital stay, healing time, faecal incontinence and postoperative pain as study outcomes.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

Background The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR)Methods Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravityResults There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age ( p <0.05), lower (<20 per year) centre case volume ( p <0.05), obesity ( p <0.05), malnutrition ( p <0.01) and intraoperative contamination ( p <0.05), and was lower in patients with a colonic J-pouch reservoir ( p <0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits ( p <0.05) while the absence of a diverting stoma was borderline significant ( p <0.07)Conclusion Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies

Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence

AIM Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment. METHOD This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected. RESULTS Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection. CONCLUSION NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long‐term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long‐term efficacy and safety of NASHA/Dx, assessed 24 months after treatment.

Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly

Aim  Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients.

Total anorectal reconstruction with an artificial bowel sphincter: Report of five cases with a minimum follow‐up of 6 months

Background The artificial bowel sphincter (Acticon ABS – American Medical Systems, Minneapolis, MN, USA) has been proposed as a treatment for patients with faecal incontinence. The good results achieved with this procedure encouraged us to utilize this device for reconstruction of patients who previously underwent an abdominoperineal resection (APR).

Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence

The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT.

T1 colon cancer in the era of screening: risk factors and treatment.

BackgroundThe aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit.MethodsThe sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases.ResultsOut of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN.ConclusionsSome factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.

Psyllium fiber food supplement in the management of stoma patients: results of a comparative prospective study

High ileostomy output may require dietary and pharmacologic manipulation. Psyllium fiber has been used in ileostomy patients because of its role in lipid and glucose absorption [1]. Psyllium fiber is also considered to have antidiarrheal effects, which is why it is sometimes recommended to decrease stoma output. The aim of this comparative non-randomized prospective study was to determine whether treatment with psyllium fiber decreased stoma output. The primary endpoint of this study was to evaluate whether the use of psyllium fiber had any effect on the number of disposable, single use stoma bags used by each patient. The number of bags used was considered a surrogate of stoma output. The secondary endpoint of this study was to assess the effect of psyllium intake on peristomal dermatitis. The psyllium fiber used was the seed husk of Plantago ovata Forssk., seminis tegumentum (Psyllogel Fibra— Nathura Srl, Montecchio Emilia (RE), Italy). Thirty-eight consecutive ileostomy patients (20 males and 18 females; mean age ± SD 66.3 years ± 10.8 years) referred to the outpatient Ostomates Rehabilitation Center (O.R.C.) at the ‘‘Sapienza,’’ University of Rome, between 2002 and 2007 were enrolled in the study. At the first visit (T0), all patients were instructed about a diet poor in fiber. The recommended diet included bread, pasta and rice, meat and fish, eggs, and aged cheese as well as some fruits like apples, pears, bananas, peaches, and apricots. Tea, barley, jam, honey, and biscuits were also allowed. It was strongly recommended not to eat: raw vegetables like lettuce, cucumber, fennel and celery, any kind of legumes, meat and vegetable soups, fruits such as kiwi, plums, grapes, and figs. The first 20 patients were also prescribed one bag of psyllium fiber (=7 g) between the two main meals and given recommendations about proper hydration, that is, intake of at least 2 l of water daily. These 20 patients were the treatment group, while the following 18 consecutive patients were the control group. The demographic data of the patients included in the study were collected, and the presence of peristomal dermatitis was evaluated and recorded. At T0, an approximate quantification of the daily ileostomy output was made based on the patient’s history taken by a skilled stoma nurse. Patients were instructed to use disposable stoma bags (one piece single use bags with a 340 ml capacity) and to record the number of bags used in a diary. The ileostomy output was evaluated as the number of 340-ml ileostomy bags used per day. The results in number of bags/day were converted into ml. Since the bag is replaced once, it is two-thirds of full each bag recorded was considered as 267 ml. Patients were instructed not to record bags changed because of accidents or social reasons. Patients were invited to come back for a follow-up visit every 2 weeks for 3 months: A final visit was scheduled at 90 days (T1) after study entry. The average ml/patient/day was significantly lower and the decrease in the output between TO and T1 was greater in the treatment group (Table 1). Peristomal dermatitis improved in both groups (Table 2). The latter finding is probably due to better management of the stoma by trained staff during the follow-up period. D. Crocetti F. Velluti (&) V. La Torre E. Orsi L. De Anna F. La Torre Surgery of Rectum and Pelvic Floor Unit, Emergency Department, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy e-mail: francescovelluti@hotmail.it