A think tank of the Italian society of colorectal surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: Crohn's disease.

The management of Crohn's disease (CD) requires extensive expertise. Many treatment options are available, and surgery still plays a crucial role. In recent years, many medical societies have provided surgeons and gastroenterologists dealing with CD with authoritative guidelines. However, a certain degree of variation can be observed in these papers, and application of guidelines in clinical practice should be improved. The Italian society of colorectal surgery (SICCR) promoted the project reported here, which consists of a think tank of Italian colorectal surgeons to address the surgical aspects of CD management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of CD. The management of CD is, by necessity, patient-tailored, and it is based on clinical data and surgeon's preference, but the committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

A think tank of the Italian Society of Colorectal Surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: ulcerative colitis.

The majority of patients suffering from ulcerative colitis (UC) are managed successfully with medical treatment, but a relevant number of them will still need surgery at some point in their life. Medical treatments and surgical techniques have changed dramatically in recent years, and available guidelines from relevant societies are rapidly evolving, providing UC experts with updated and valid practical recommendations. However, some aspects of the management of UC patients are still debated, and the application of guidelines in clinical practice may be suboptimal. The Italian Society of Colorectal Surgery (SICCR) sponsored the think tank in order to identify critical aspects of the surgical management of UC in Italy. The present paper reports the results of a think tank of Italian colorectal surgeons concerning surgery for UC and was not developed as an alternative to authoritative guidelines currently available. Members of the SICCR voted on several items proposed by the writing committee, based on evidence from the literature. The results are presented, focusing on points to be implemented. UC management relies on evaluations that need to be individualized, but points of major disagreement reported in this paper should be considered in order to develop strategies to improve the quality of the evidence and the application of guidelines in a clinical setting.

Is an ileal pouch an alternative for patients requiring surgery for Crohn's proctocolitis?

BACKGROUND: Most surgeons consider Crohn's colitis to be an absolute contraindication for a continent ileostomy, due to high complication and failure rates. This opinion may, however, be erroneous. The results may appear poor when compared with those after pouch surgery in patients with ulcerative colitis (UC), but the matter may well appear in a different light if the pouch patients are compared with Crohn's colitis patients who have had a proctocolectomy and a conventional ileostomy. METHODS: We assessed the long-term outcomes in a series of patients with Crohn's colitis who had a proctocolectomy and a continent ileostomy (59 patients) or a conventional ileostomy (57 patients). The median follow-up time was 24 years for the first group and 27 years for the second group. RESULTS: The outcomes in the two groups of patients were largely similar regarding both mortality and morbidity; the rates of recurrent disease and reoperation with loss of small bowel were also similar between groups. CONCLUSIONS: The possibility of having a continent ileostomy, thereby avoiding a conventional ileostomy-even if only for a limited number of years--may be an attractive option for young, highly motivated patients.

The ileoanal pouch procedure in the long-term perspective: a critical review.

An ileo-pouch anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis. Clinical results on the pelvic pouch procedure have often been encouraging; when confronted with the different surgical options, the majority of patients select IPAA as the best operation. However, even if IPAA is a great innovation, it is by no means the first choice for all patients. For patients old enough to join in a responsible discussion, the pros and cons of the various operations must be carefully described; the choice of surgical procedure must meet the patient's wishes and appear soundly based to the surgeon. The young age of most patients has to be considered and a long follow-up time is required to establish whether and, if so, to what extent the operation may adversely impact the patient's continence, sex life, fertility, and quality of life. The risk of cancer transformation in the residual rectal mucosa in the muscular or columnar cuff is another important factor that may influence the eventual decision. This article critically reviews our experience and the literature.

Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome.

PURPOSE: Patients with acquired immunodeficiency syndrome are often in poor general physical condition. Diarrhea and bleeding hemorrhoids frequently contribute to the morbidity, and patients with such problems cause an increasing load on many outpatient clinics. METHODS: Twenty-two patients (17 males) with acquired immunodeficiency syndrome had injection treatment for bleeding second-degree to fourth-degree hemorrhoids according to standard outpatient clinic routines. Mean follow-up was 24 months. RESULTS: No complications were recorded. The treatment was successful in all patients, and no hemorrhoidectomy was necessary. Nineteen patients improved after their first injection, whereas 3 patients required two to six weeks repeated treatments to improve. Four subjects with the longer follow-up (4 years) showed an improvement lasting 12 to 18 months and then required one to two treatments per year to stop recurrent bleeding. CONCLUSIONS: Because of their poor general condition and poor wound healing, a conservative approach is preferable to avoid a formal hemorrhoidectomy in patients with acquired immunodeficiency syndrome. Sclerotherapy seems to be an attractive alternative.

[Hemorrhoidal thrombosis and perianal hematoma: diagnosis and treatment]. / Trombosi emorroidaria ed ematoma perianale: diagnosi e trattamento.

Thrombosed haemorrhoids and anal haematomas are very usual in patients with haemorrhoids. Conservative treatment and surgery are effective by the features and time of presentation. Authors refer about pathological and clinical findings and discuss the treatment.

[The functional and manometric results of 2 surgical methods of posterior abdominal rectopexy]. / Risultati funzionali e manometrici di due metodi chirurgici di rettopessi addominale posteriore.

Functional changes after posterior abdominal rectopexy for the treatment of rectal prolapse are not fully understood. We studied the effects of Wells' or Ripstein's rectopexy on functional characteristics as related to anal sphincter function, rectal volume and sensory function in 31 patients with complete or internal rectal prolapse. We have observed an improvement of continence over 70% in both groups. However, an absent or a decreased call to stool, constipation and evacuation difficulties are the aftermath of Wells' rectopexy, while these complaints appear basically unaffected by Ripstein's technique. Maximal squeeze pressure was slightly increased after Ripstein's rectopexy, whereas no significant effects were found on anal pressures. Postoperatively the rectal capacity was reduced by Well's procedure (p < 0.05), while no significant changes were observed with Ripstein's operation. After the Wells procedure patients developed at the threshold for the relaxation of the internal sphincter progressively lower rectal volumes, reaching one year after rectopexy the statistical significance. Sensory thresholds for sense of filling and urge were significantly raised after Wells' rectopexy even one year after operation, whereas after Ripstein's operation sense of filling was not significantly affected and while sense of urge was increased early postoperatively, it was not significantly changed at one hear postoperative control. In conclusion, when fecal incontinence appears associated to a rectal prolapse has good chances to improve postoperatively. Preoperative evacuation difficulties seem to be unaffected by a posterior abdominal rectopexy, Wells or Ripstein, but an extensive dissection of the rectum with the division of the lateral stalks, as it is performed in Wells' operation, seems to be a procedure that can create a further burden of problems the the patient and it seems coupled to a manovolumetric elevation of rectal sensory thresholds.

[Abdominal rectopexy in the treatment of rectal prolapse: how to foresee the functional result]. / Rettopessia addominale per il trattamento del prolasso del retto: come prevedere il risultato funzionale.

21 patients (19 women) who underwent rectal prolapse repair were prospectively studied. At the one year follow-up, 6 of the eleven incontinent patients (54 per cent) regained full continence and while three of the remaining 5 patients improved they still referred occasional imperfection of continence. Resting anal pressure and maximal squeeze pressure were both significantly lower in the five patients who remained incontinent, 23 (17-31) mm Hg vs 50 (31-52) mm Hg (p < = 0.02) and 52 (17-75) mm Hg vs 108 (89-110) mm Hg (p < = 0.02), respectively. Moreover the manometric results showed evidence that in patients who remained incontinent, the anal pressure in response to rectal distention, was significantly lower than patients who regained continence (p < = 0.05) both before and after operation. We conclude that incontinent patients with rectal prolapse who exhibit a markedly low minimal residual anal pressure on recto-anal reflex inhibition are less likely to improve after rectopexy and that this preoperative test may be a useful predictor.

[Repeated liver resections for metastases from colorectal carcinoma: the experience of 23 cases]. / Resezioni epatiche reiterate per metastasi da carcinoma colo-rettale: esperienza su 23 casi.

One hundred and thirteen patients with metastases from colorectal carcinoma underwent liver resection. The authors report their experience with respect to 23 repeated hepatic resections (or metastases from colorectal carcinoma). The calculated actuarial survival from the first operations is 100% at 12 months, 67% at 24 months, 48% at 36 months and 26% at 60 months. In 90 patients who underwent a single liver resection during the same period, 76% were alive at 12 months, 40% at 24 months, 27% at 36 months and 14% at 60 months (p = 0.03). Survivals calculated from the second operation were 67% at 12 months, 41% at 24 months and 11% at 35 months. There was no operative mortality with morbidity added to that of the first operation. None patients had extrahepatic disease at the second operation: this was resected. Seven patients were treated with neo adjuvant chemotherapy; six with systemic adjuvant chemotherapy; in one this was associated with loco-regional chemotherapy. The number of lesions (single versus multiple), the presence or absence of extrahepatic disease, neo-adjuvant chemotherapy and adjuvant chemotherapy did not seem to influence the prognosis. Average survival calculated from the appearance of the first metastasis in the liver is better in patients with a synchronous lesion compared to the patients with a metachronous lesion (48.1 months versus 29.3). The authors claim that surgery is indicated, when technically possible, in the hepatic recurrence of disease. The results are not as good as those obtained following the first liver resection, with a probability of earlier recurrence of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Occult rectal prolapse: functional results after rectopexy]. / Prolasso occulto del retto: risultati funzionali dopo rettopessia.

In the present work the Authors have studied 19 patients with occult rectal prolapse evaluating symptoms and functional results after posterior abdominal rectopexy. Symptoms of internal rectal procidentia appear as a definite syndrome. In our patients pain upon defecation, this being often localized to the perineal and sacral region, was observed in 14 on 19 cases, while fecal incontinence was present in 5 cases (29%) and rectal bleeding in 8 (44%). These compliances are relieved by the anatomical correction of the rectal intussusception, but the preexisting functional disorders in the mechanism of defecation appear to be unaffected by rectopexy. (Sensation of obstruction 11 cases (58%) preop. e 9 cases (53%) postop.).

[Variations in rectal capacity and compliance after abdominal rectopexy]. / Variazione della capacità e della compliance rettale dopo rettopessia addominale.

The aim of this study was to attempt to gain insight in to the pathophysiologic characteristics of rectal prolapse by evaluating rectal compliance in patients with complete or incomplete rectal prolapse, before and after rectopexy. 21 subjects with complete rectal prolapse and 10 subjects with internal procidentia of rectum were treated with one of two abdominal rectopexies, according to Wells or according to a modified Ripstein's technique. For comparison, measurements were also carried out in 17 age and sex control subjects who had no bowel disturbances or anal symptoms. On distension with 40 cm H2O rectal volume amounted to 218 (175-255) ml for controls, 225 (178-256) ml for complete prolapses and 200 (125-225) ml for invaginations. Compliance amounted respectively to 9.5 (5-11,4), 8.5 (5-12,6), 7.5 (4-10,6) ml/cm H2O in the pressure interval 0-10 cm H2O with a decrease in compliance at higher pressure intervals. There was no correlation between rectal volume and compliance and gas or faecal incontinence, evacuation difficulties, feeling of blockade upon defecation and constipation. The effect of rectopexy has been separately evaluated according to the diagnosis. In complete prolapse significant changes of rectal capacity were observed for lower distending pressures (from 10 to 30), but not for higher (40-50). The compliance was significantly different for even lower distending pressures (0-10 cm H2O). In internal rectal procidentia rectopexy did not significantly changed capacity compliance. This work confirms the observations that the rectal compliance in rectal prolapse, complete and incomplete, do not differ from healthy controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the sphincter function and rectal sensitivity in rectal prolapse associated with fecal incontinence]. / Valutazione della funzione sfinterica e della sensibilità rettale nel prolasso del retto associato ad incontinenza fecale.

It has been suggested that incontinent patients with rectal prolapse develop a relaxation of the internal sphincter at a lower filling volume than those with the same disorder who were continent. A constant relaxation of the internal sphincter during filling before the individual experiences a need to defecate could be a contributory cause of the incontinence in these patients. Aiming to evaluate the former observations we have investigated continent and incontinent patients, with complete and internal rectal prolapse, by mean of the recto-anal manovolumetry. 31 patients were studied, 21 had a complete rectal prolapse and 10 had internal rectal prolapse and 28 sex and age matched controls were selected among volunteers. No difference has been found between the continent and incontinent patients with rectal prolapse, in term of sensory function studied by graded isobaric distention. Moreover, no difference has been found between the rectal volume at which perception of filling and relaxation of the internal sphincter during filling occurs. Therefore, in this respect, the present data are not in agreement with the theory proposed.

[Defecography in internal invagination of the rectum]. / La defecografia nell'invaginazione interna del retto.

Rectal invagination has been considered an important cause of defecation difficulties and blockade (obstructed defecation). In the present study defecographies performed on 15 patients, with previous diagnosis of rectal invagination have been reviewed. Six patients had an intra-rectal (IR) invagination, three had an intra-anal (IA) invagination, while two patients did not show a typical rectal invagination. In the present series there is a suspected radiologic recurrence of the invagination. Three patients show a tendency to rectal stenosis. Anorectal angles at rest and under straining appears higher than the ones in normal subjects, after rectopexy, anorectal angles do not appear to be significantly changed and the pelvic floor is not significantly raising post-operatively. 7 out of 10 women had a rectocele preoperatively and 4 out 9 postoperatively. In 8 patients it was possible to compare a pre to a post-operative defecography. All patients but one displayed a reduction in the ability in emptying the rectum. The fact that rectal emptying is impaired may suggest that some autonomic denervation might occur following rectal mobilization.

[Medical therapy of chronic idiopathic constipation]. / Terapia medica della stipsi cronica idiopatica.

The medical care of the idiopathic constipation requires the correct patient identification based on precise classification items and on physiopathological considerations. The laxative abuse is often the most difficult problem to be solved and it has to be dealt with the consideration of different clinical aspects (wrong diet, psychological profile, concomitant diseases, drug therapy, etc.). The first step exactly consists in the identification and correction of the wrong convictions, of the behavioural attitudes and of the unbalanced dietary habits. Adding bran is the second widely accepted therapeutic step based on both physiopathological and epidemiological considerations. Even if the mechanism of action is still not completely understood, the fibre addition per se leads to an improvement of the constipation in quite a relevant percentage of patients, although it is often poorly tolerated. Nevertheless there are peculiar conditions not responsive to the bran addition such as the so-called "anismus". For these situations different therapeutic approaches have been proposed with variable results. Among these we can mention the re-educational programmes of the modalities of the defecation using biofeedback techniques. The chronic idiopathic constipation not respondent to the conventional medical therapy appears anyway a problematic and very difficult condition both from the investigational viewpoint and the therapeutic options. Finally it can be stated that the laxatives have a certain role in those clinical conditions most probably leading to the constipation. For each therapeutic drug class it is, of course, of great importance to know its mode of action as well as its adverse event profile.

[Diagnostic imaging in constipation]. / Il contributo dell'imaging nella stipsi.

Diagnostic imaging modalities play a key role in the definition of the possible causes of constipation. Barium Enema (BE), Defecography (DG), Intestinal Transit Time (ITT), Computed Axial Tomography (CT) and Magnetic Resonance (MR) are necessary diagnostic tools for the identification either of the possible organic causes of the disease or of the functional disorders. The ITT evaluation is the main investigation to look for functional colic constipation; this method is in fact able to distinguish between the hypertonic type (in which the fecal progression is slowed down to such an extent that radiopaque markers accumulate in the most proximal part of the colon) and the atonic one (characterized by a global slowing down with the markers distributed along the whole colon). DG gives very accurate dynamic documentation of the pathologic alteration of the rectum-anal conduit, as well as of the disease of the supporting and anchoring system and of the levator complex; this type of investigation allows the definition (characterisation) of the different types of the functional rectum-anal constipation. Even in this case TAC and RM can greatly contribute to the definition of the whole picture of the constipation.

[Rectal prolapse and fecal incontinence. A prospective manometric study]. / Prolasso rettale ed incontinenza fecale: studio prospettico manometrico.

In the present work we have studied two consecutive series of patients who underwent a posterior abdominal rectopexy according to Wells or Ripstein. During the year of follow up no recurrences were observed. Functional results, evaluated according to a protocol, by history of the patient and manovolumetry, shoved an improvement of fecal continence in more than half of the incontinents in both series. However, constipation increased after Wells' rectopexy, while no major changes were observed after Ripstein's rectopexy. We conclude that the first surgical technique may offers worse functional results.

[The long-term complications from ileostomy in patients with Crohn's disease and ulcerative colitis]. / Le complicanze a lungo termine dell'ileostomia in pazienti affetti da morbo di Crohn e colite ulcerativa.

In the period between 1959 and 1984 at the Surgery Department of the University of Goteborg, ileostomy (after colectomy) was mad in 203 patients affected by chronic inflammatory bowel disease. Patients were followed up prospectively to evaluate the frequency and severity of the complications. The cumulative rate of surgical reoperation was significantly higher in the group of patients with Crohn disease in comparison with those affected by ulcerative colitis. After 8 years it reached 75% in the first group and only 44% in the second. The most frequent indication for surgery reoperation were stenosis and retraction. 83% of the operations were only local not requiring laparotomy. No statistically significant correlation was found for the reoperation rate, the surgical technique, the length of the ileal resection and the post-operative weight gain. Only a systematic and accurate follow-up done by the surgeon and the enterostomist can detect an optimal functioning of the ileostomy. In case of complications which could be surgically corrected an early operation is needed. In most cases this can be simply made by local anesthesia.

[The functional and manometric-volumetric results following abdominal rectopexy for total rectal prolapse]. / Risultato funzionale e manovolumetrico dopo rettopessia addominale posteriore per prolasso totale di retto.

Functional changes after the posterior abdominal rectopexy for the treatment of rectal prolapse are not fully understood. We studied the effects of Wells' or Ripstein's rectopexy on functional characteristics as related to anal sphincter function, rectal volume and sensory function in 21 patients with complete rectal prolapse. We have observed an improvement of continence over 70 per cent in both groups. However, an absent or a decreased call to stool, constipation and evacuation difficulties are the aftermath of Wells' rectopexy, while these complaints appear basically unaffected by Ripstein's technique. Sensory thresholds for sense of filling and urge were significantly raised after Wells' rectopexy even one year after operation, whereas after Ripstein's operation sense of filling was not significantly affected and while sense of urge was increased early postoperatively, it was not significantly changed at one year postoperative control. In conclusion, when fecal incontinence appears associated to a complete rectal prolapse has good chances to improve postoperatively. Preoperative evacuation difficulties seems to be unaffected by a posterior abdominal rectopexy, Wells or Ripstein, but an extensive dissection of the rectum with the division of the lateral stalks, as it is performed in Wells' operation, seems to be a procedure that can create a further burden of problems to the patient and it seems coupled to a manovolumetric elevation of rectal sensory thresholds.