Federico Perrone

Ligation of the Intersphincteric Fistula Tract (LIFT): A Minimally Invasive Procedure for Complex Anal Fistula: Two-Year Results of a Prospective Multicentric Study

Introduction. The surgical management of anal fistulas is still a matter of discussion and no clear recommendations exist. The present study analyses the results of the ligation of the intersphincteric fistula tract (LIFT) technique in treating complex anal fistulas, in particular healing, fecal continence, and recurrence. Methods. Between October 2010 and February 2012, a total of 26 consecutive patients underwent LIFT. All patients had a primary complex anal fistula and preoperatively all underwent clinical examination, proctoscopy, transanal ultrasonography/magnetic resonance imaging, and were treated with the LIFT procedure. For the purpose of this study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula, or preexisting incontinence. Patient’s postoperative complications, healing time, recurrence rate, and postoperative continence were recorded during follow-up. Results. The minimum follow-up was 16 months. Five patients required delayed LIFT after previous seton. There were no surgical complications. Primary healing was achieved in 19 patients (73%). Seven patients (27%) had recurrence presenting between 4 and 8 weeks postoperatively and required further surgical treatment. Two of them (29%) had previous insertion of a seton. No patients reported any incontinence postoperatively and we did not observe postoperative continence worsening. Conclusion. In our experience, LIFT appears easy to perform, is safe with no surgical complication, has no risk of incontinence, and has a low recurrence rate. These results suggest that LIFT as a minimally invasive technique should be routinely considered for patients affected by complex anal fistula.

Reinterventions for specific technique-related complications of stapled haemorrhoidopexy (SH): a critical appraisal.

IntroductionStapled haemorrhoidopexy (SH) is an attractive alternative to conventional haemorrhoidectomy (CH) because of reduced pain and earlier return to normal activities. However, complication rates are as high as 31%. Although some complications are similar to CH, most are specifically technique-related. In this prospective audit, we report our experience with the management of some of these complications.MethodsData on patients undergoing SH at our unit or referred to us are prospectively entered in a database. The onset or duration of specific SH-related complications as well as reinterventions for failed or complicated SH was recorded.ResultsFrom 1/03 to 10/07, 110 patients underwent SH, while 17 patients were referred after complicated/failed SH. Overall early and late complication rates after SH were 12.7% and 27.2%, respectively. Overall reintervention rate was 9.1%. Among the referred SH-group, one patient underwent Hartmann’s procedure because of rectal perforation. The remaining 16 patients experienced at least one of the following: recurrence, urgency, frequency, severe persistent anal pain, colicky abdominal pain, anal fissure and stenosis. Four patients underwent CH with regular postoperative recovery. Two patients underwent exploration under anaesthesia because of persisting pain. One patient underwent anoplasty.ConclusionsSH presents unusual and challenging complications. Abuses should be minimized and longer-term studies are needed to further clarify its role.

Collagen matrix injection combined with flap repair for complex anal fistula

Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non‐cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two‐staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two‐stage approach seems to be safe and effective.

Laparoscopic Sleeve Gastrectomy versus Laparoscopic Banded Sleeve Gastrectomy: First Prospective Pilot Randomized Study

Introduction. The placement of ring or band around the gastric tube might prevent the dilation after Laparoscopic Sleeve Gastrectomy (LSG). We describe the first randomized study comparing LSG and Laparoscopic Banded Sleeve Gastrectomy (LBSG). Material and Method. Fifty obese patients were enrolled in the study between January 2014 and January 2015. We analysed differences in operative time, complication rate, mortality, and BMI between the two groups over a period of 12 months. Results. Twenty-five patients received LSG (group A) and 25 LBSG (group B). The mean preoperative BMI was 47.3 ± 6.58 kg/m2 and 44.95 ± 5.85 kg/m2, respectively, in the two groups. There was no statistical relevant difference in operative time. No intraoperative complications occurred. Mean BMI registered after 3, 6, and 12 months in groups A and B, respectively, were 37.86 ± 5.72 kg/m2 and 37.58 ± 6.21 kg/m2 (p = 0.869), 33.64 ± 6.08 kg/m2 and 32.03 ± 5.24 kg/m2 (p = 0.325), and 29.72 ± 4.40 kg/m2 and 27.42 ± 4.47 kg/m2 (p = 0.186); no statistical relevant difference was registered between the two groups. Conclusion. LBSG is a safe and feasible procedure. The time required for the device positioning did not influence significantly the surgical time. The results of bodyweight loss did not document any statistically significant differences among the two groups, even though LBSG group showed a mean BMI slightly lower than that of the control group.

Outcome of Colorectal Surgery in Elderly Populations

Purpose The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates. Methods The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed. Results A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance. Conclusion Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.

Epidemiology and Prevalence of Pelvic Floor Disorders

Pelvic floor disorders (PFDs) manifest with a variable spectrum of symptoms and can involve anterior, middle and posterior compartments. PFDs represent an important aspect of global healthcare, with about 28 million women affected by these diseases worldwide. This number is expected to reach 44 million in the next 40 years. In the literature, the incidence and prevalence of PFDs are often reported inconsistently, depending on the definitions used, the measures considered to assess the stages, the gender and age of the patient, and the severity of the pathology. The etiology of these disorders is multifactorial and it is important to identify the risk factors, because avoiding them or reducing exposure to them can change the natural history of PFDs, allowing physicians to make an earlier diagnosis and use more effective therapy.

Corrigendum: Correction of the First Author's Affiliation. Outcome of Colorectal Surgery in Elderly Populations

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

Enhanced Recovery Following Bariatric Surgery: Is Feasible?

Background: There has been a relative lack of research on the effect of applying enhanced recovery principles in the context of morbid obesity surgery and monitoring outcome. Objectives: To determine the feasibility of applying enhanced recovery after surgery (ERAS) principles application on a bariatric population and review the effect on outcome in this population. Methods: We analyzed data prospectively collected on a cohort of 111 patients undergoing laparoscopic bariatric surgery between March 2013 and December 2014. All patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge. We focused our attention on earlycomplications (within 30 days) and any late complications. Results: All 111 patients who underwent bariatric surgery were suitable for early discharge between 24-72 hours. Short term complications (within 30 days postoperatively) were acceptable. Mortality rate was 0%, reoperation rate was 0% and hospital readmission rate was 2%. Concerning the short term complications in the 63 patients who underwent LAGB the commonest was the raised temperature. Hospital readmission rate, reoperation rate and mortality were all 0%. Conclusion: Application of ERAS protocol on bariatric surgery is feasible with an acceptable number of minor complications. Further studies are required to improve outcome further.

Short Term Outcomes After Colorectal Surgery in Octogenarians

PURPOSE: Sphincter-sparing chemoradiotherapy (CRT) is the standard of care for patients with anal canal cancer. Despite good response rates, some patients require radical surgery (abdominoperineal resection or exenteration)for persistent or recurrent disease. The purpose of this study was to evaluate the outcomes of patients following radical resection for persistent or recurrent disease. METHODS: All patients treated with CRT or RT for anal cancer between 1990 and 2008 were identified using the regional cancer registry. Inclusion criteria: pathologically confirmed squamous cell carcinoma of the anal canal, localized disease, receiving ≥ 45Gy of RT. Statistical analysis was conducted to calculate survival rates and identify risk factors for poor outcomes. RESULTS: 105 patients (25 male) were identified. Median age was 57 years (range 33-87 yr). Median follow up was 40 months (range 3185). Median T stage and size at presentation were 2 and 35 mm (range 6-260mm) respectively. Median dose to the primary tumor was 54 Gy (45-76 Gy) at a median 28 fractions (range 20-37). 92 patients(88.5%) received concurrent chemotherapy. At 3 month followup 85 (83.3%) patients had complete clinical response, one patient had insufficient followup. 19 (18.1%) patients had persistent disease, of whom 12 underwent radical resection for cure; 5 (41.7%) are alive at a median of 106 months from diagnosis, while the remaining 7 died at a median 15 months from diagnosis. Recurrence occurred in 17 (20.0 %) patients at a median time of 9 months (4-53m). 8 patients underwent radical resection for recurrence; 2 (25.0%) patients are alive at 127 and 21 months, the remaining 6 died at a median time from recurrence of 24.5 months. Overall, disease specific and disease free survival, were 66%, 71% and 67% respectively for all anal canal carcinoma patients at 5 years. Multivariate analysis showed tumor size to be a significant risk factor for disease free (aOR 1.02, 95% CI: 1.01-1.04) and overall survival (aOR 1.03, 95% CI: 1.01-1.04) for all patients. CONCLUSION: Despite good response rates to sphincter-sparing therapy, 20% still required radical resection for persistent or recurrent disease. Survival rates following radical resection are poor.