Robotic right hemicolectomy with complete mesocolic excision

and central vascular ligation vs laparoscopic right hemicolectomy:

our experience and short-term outcomes.

Crestale S. 1, Ziccarelli A.1 , Calandra S.2 , Terrosu G.2 , Petri R.1

1General Surgery Unit, Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy. 2 Clinical Surgery Unit, Department of Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy.

Background: Precision of oncological resections has an im- pact on cancer recurrence and survival. The key quality fac- tor for colon resections is the necessity to respect embryonic planes to guarantee en-bloc clearance of the tumor’s lym- phatic drainage. Building on the concept of total mesorectal excision (TME) Hohenemberg coined the term “Complete

Mesocolic Excision” (CME). CME with central vascular ligation (CVL) consists in dissection along the mesocolic plane between the visceral and parietal fascia layers with true central ligation of the main arteries and veins at their roots with regional lymph nodes. It results in a higher num- ber of resected lymph nodes with a corresponding reduction

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of recurrence rates and increase 5-year survival. Methods: Retrospectively obtained data from consecutive patients un- dergoing robotic right hemicolectomy with CME or laparo- scopic hemicolectomy between October 2020 and April 2022 were analyzed. The standard procedure was done in 32 cases and hemicolectomy with CME was done in 16 cases. Results: In our experience, robotic right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (p=0.32), overall postoperative compli- cations (p=0.75) and conversion to open approach (p=0.61). Traditional surgery is associated with a shorter operating time (192 min vs 253 min; p<0.001). As objective signs of the quality of CME related to oncological outcomes, histo-

pathologic data were evaluated, including specimen length and the number of lymph nodes harvested. Right hemicol- ectomy with CME leads to a higher lymph node yield (25.9 vs 18.3; p=0.002) and larger surgical specimens than tradi- tional surgery (28.9 cm vs 16.9 cm; p<0.001). Conclusions: We could demonstrate that this technique is safe and feasible for oncological right hemicolectomy with improvement in lymph nodes sampling and length of surgical specimens and without increase of surgical intraoperative or postoperative complications. However, follow-up is ongoing and data on overall survival and 5-year disease free survival are not yet available.

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Impact of SARS-CoV2 pandemic on colorectal cancer screening activity

in a single institution.

Vitturi A., Sinatti E., Mammano E., Rosa-Rizzotto E., Sarzo G., Passuello N.

Azienda Ospedale – Università Padova, Chirurgia Generale OSA – Gastroenterologia OSA

Introduction :Aim of this work is to analyze the outcomes of colo-rectal cancer (CRC) patients coming from screening activity (Faecal Immunochemical Test, FIT+) of Universi- ty of Padua, treated both endoscopically and surgically, in pre-pandemic and pandemic period.

Materials and methods:We retrospectively assessed compli- ance to the CRC screening campaign and data of patients who were diagnosed with CRC coming from the Screening Ser- vice from July 2018 to December 2021. Patients were divid- ed into two groups, depending on whether they were treated in the pre-pandemic two-years period (2018-2019) or in the pandemic two-years period. A further subdivision between surgical and endoscopic treatments was also performed in both groups. 30-days outcomes were analyzed. Results:Screening activity of CRC was halted from 15.03.2020 to 04.05.2020. Compliance was the same in all years. Patients were 116: 57 (group A) in 2018-2019 (36 op- erated, A1; 21 treated endoscopically, A2), 59 (group B) in 2020-2021 (44 operated, B1; 15 treated endoscopically, B2)

(p = n.s.). Main 30-days outcomes had no statistical dif- ference in the two groups. Time from FIT+ to colonoscopy was 1 month (IQR 1-2) in group A vs 2 months (IQR 2-2.5) in group B (p <0.05). The surgical specimen examination showed 22/44 T3-T4 stages in group B1 vs 10/36 in group A1 (p = 0.06).

Conclusion:As in literature, our study has found an initial upstage of the colorectal neoplasms of patients undergoing surgical resection, as a consequence of the suspension of the CRC screening activity during the pandemic period. This re- sult is supported by stability of the global adhesion of the population to screening programs over the years, despite the pandemic. We found an increase in the average time for per- forming colonoscopy in FIT+ patients, probably due to the slowdown of activities during lockdown periods or to the fear of contagion of the population. To date, it is still impossible to assess whether this initial upstage can be confirmed, or even transformed into an increase in mortality: in fact, only predictive models of such events are available.

Colorectal cancer surgery in the elderly patient: case series and effect

of the COVID19 pandemic.

Sinatti E., Vitturi A., Faccio L., Vittadello F., Frasson A., Sarzo G., Passuello N.

Azienda Ospedale – Università Padova, Chirurgia Generale OSA

Introduction: Aim of this work is to evaluate the 30-day out- comes of elderly patients (> = 80 years) undergoing surgery for colorectal cancer (CRC) at our Unit, and how the advent of the COVID19 pandemic has influenced the treatment of this pathology in this type of patients.

Materials and methods:We retrospectively analyzed data of patients who underwent surgery for CRC from July 2018 to December 2021. These patients were divided into two groups according to the age: >= 80 years old and < 80 years old. We evaluated short term outcomes like setting of surgery, laparoscopy rate, conversion rate, length of stay, major com- plications (Clavien-Dindo 3b), deaths, number of retrieved lymph nodes, stage. Same outcomes were then analyzed only in the group of elderly patients, comparing the pre-pandemic (2018-2019) and the pandemic (2020-2021) period. Results:281 total patients, 88 (group A) aged 80 years or old- er, 193 (group B) younger than 80 years. Patients who came from ER/other Units were 33/88 in group A and 16/193 in group B (p <0.0001). We performed laparoscopic surgery in 74/88 cases (84%) in group A and in 180/193 cases (93%) in group B, while there is no statistical difference considering

only the elective cases (74/82 vs 180/191, p = 0.2); open con- version: group A 12/74 (15%), group B 11/180 (6%) (p <0.02). Median hospital stay of 9 days (IQR 6-14) in group A and 6 days (IQR 5-8) in group B (p <0.00001). No significant dif- ferences for Clavien-Dindo 3b complications. Deaths: 6/88 in group A, 2/193 in group B (p <0.01). Oncological radicality is comparable: retrieved lymph nodes in group A (IQR 14-27), group B 20 (13-26). No differences in stages. In group A we have pre-pandemic cases (35, group A1) and pandemic ones (53, group A2). In these last groups no outcome had signifi- cative differences.

Conclusion: Analysis of our experience highlights a con- vinced propensity for the use of minimally invasive tech- niques even in the elderly patient, although this fact do not always turn into a real shortening of hospital days in these patients, often because of many comorbidities which afflict them. In our experience, however, advanced age didn’t affect complications and oncological radicality. Elderly patients with CRC in our Unit, during COVID19 pandemic, had same outcomes as in the pre-pandemic period.

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Low cost procto-trainer: a new tool for training in surgical proctology Passannanti D.1, Telesco D.1, Gaj F.1

1 – Azienda Ospedaliera-Universitaria Policlinico “Umberto I” – Dipartimento di Chirurgia Generale e Specialistica “Paride Stefanini” – UOC Chirurgia della parete addominale – Roma

Objectives: It is not always possible to take advantage of state- of-the-art technologies, such as simulators, to be dedicated to the training of young surgeons. Moreover, as far as we know, there are no simulators dedicated to proctological surgical tech- niques. We have therefore designed an organic simulator to make up for this deficiency.

Patients and Methods: The device consists of low-cost com- ponents, assembled to reproduce the conformation of the anal canal. An organic material (pig rectum) is placed inside to in- crease the fidelity of the simulation. We tested this device by simulating a mucoprolassectomy performed according to Lon- go’s technique. We then consulted the opinion of numerous ex- perts in the proctological field and young surgeon colleagues

not usually involved in proctological interventions. Thanks to their feedback, we arrived at this updated version of the device. Results: We evaluated the young surgeons’ skills, in terms of manual dexterity, knowledge of the operating times and tim- ing. After 3 hours of training, these skills are visibly increased, demonstrating the effective usefulness of this device. Conclusions: In our experience, this device is therefore a valid low-cost option to allow young surgeons to have direct experi- ence with proctological surgical techniques. The device allows to acquire the necessary skills without consequences for the patients and therefore with a greater margin of error. The next step will be to evaluate the simulation with different surgical techniques.

Prevalence of HPV subtypes and anal dysplasia among a group of HIV positive people with anal complaints

Marchese V., Dal Conte I.1, Lucchini A.1, Ghisetti V.2, Cassoni P.3, Morino M., Mistrangelo M.

Surgical Science Department, University of Turin, Italy, Dir. Prof. M. Morino
1)Infectious Diseases Department, CEMUSS, University of Turin, Italy.
2)Microbiology and Virology Laboratory, Amedeo di Savoia Hospital, ASL TO2, Turin, Italy. 3)Department of Biomedical Sciences and Human Oncology, University of Turin, Molinette Hospital.

Objectives: The aims of the study were: evaluate the prevalence of HPV infection in HIV positive people; evaluate the distribution of different HPV strains in the study population; correlate the prev- alence of high-risk strains with the presence of cell degeneration. Materials and methods: From January 2021 to March 2021, a group of consecutive patients underwent anoscopy and anal swabs. The samples were analyzed using INNO-LiPA HPV Genotyping Extra which covers 32 different HPV genotypes, including all high-risk HPV genotypes, a number of low-risk HPV genotypes and some additional types (i.e. HPV62, HPV67, HPV83 and HPV89).

Results: We collected 31 cases. All women and 25% of men were heterosexual. The average number of lifetime partners was over 50. Nine patients were asymptomatic; while the most common symptom was bleeding (37% of cases). In 25 cases a good cy- tological sample was obtained: 76% (19/25) were normal, 8% (2/25) had an inflammatory picture, 8% (2/25) were diagnosed

with AIN III, 8% (2/25) were classified as ASCUS. HPV genome was detected in 25/25 cases. The typing was unable to identify a particular HPV genotype in two cases, while in 6/25 the strain was a low risk, in 2/25 the strain was a high risk and in 15/25 there was a mixed infection with high and low risk strains.

HPV-16 was the most prevalent strain (63%), followed by HPV-18 (32%); the least represented was HPV-19. The most significant finding was the prevalence of anal carcinoma: 3 cases out of 31 patients (10%). These individuals were all symptomatic, but only one presented a positive cytology (AIN III).

Conclusion: Molecular tests for HPV aren’t helpful in HIV-infect- ed patients with a history of anal sexual exposure since the virus is found in 100% of cases. Moreover, the result of anal cytology poorly correlates with the most appropriate treatment and should be followed by high resolution anoscopy (HRA), which is now considered the gold standard in the detection of suspicious pre- cancerous lesions, guiding biopsy and treatment.

A new paradigm in the management of anorectal melanoma:
trans-anal excision with sphincter preservation and sentinel node biopsy

Marchese V., Picciotto F.1, Quaglino P.2, Lesca A.3, Canavese G.4, Deandreis D.3, Morino M., Mistrangelo M.

Surgical Science Department, Centre of Minimal Invasive Surgery, University of Turin, Città della Salute e della Scienza Hospital, Italy. 1 Dermatologic Surgery Department, Surgery Department, University Hospital, Turin, Italy.
2 Department of Medical Sciences, Dermatology Clinic, University of Turin, Turin, Italy.
3 Nuclear Medicine Department, University of Turin, Città della Salute e della Scienza, Turin, Italy.

4 Department of Biomedical Sciences and Human Oncology, University of Turin, Molinette Hospital.

Background: Anorectal melanoma (ARM) is a rare and highly le- thal neoplasm with an overall 5-year survival of 0-45% (2). Com- pared with cutaneous melanomas, it has a poorer prognosis and 2/3 of patients are diagnosed in advanced stages. Historically, ARM has been treated with abdominoperineal resection (APR) and de- layed groin dissection for nodal relapse. As an alternative, current guidelines suggest trans-anal excision with sphincter preservation and sentinel lymph node biopsy (SLNB).

Materials and Methods: We collected cases of ARM treated in our Department since 2017. According to Local and International guidelines, all patients were firstly treated with trans-anal excision with sphincter preservation and, if indicated, with SLNB.

Results: Four women were treated in our Department. Mean age was 58 (range 30-80y). SLNB was performed in three cases; the re- maining case did not undergo SLNB due to multiple lymph-node,

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lung and brain metastases seen on CT scan. One patient developed a recto-vaginal fistula postoperatively and was treated conserva- tively. Excision margins were widened in two cases. All patients were started on immunotherapy with Nivolumab. Mean follow up was 23 months (range 9-55mo). One patient died 13 months after surgery for disease progression. The patient with multiple metasta- ses had a local bleeding and bulking recurrence treated with APR. Conclusions: In the past few years trans-anal excision of ARM is starting to catch on. When compared with APR, it has not shown an adverse affect on survival. Trans-anal excision associated to SLNB is preferred when negative margins can be obtained in order to better stage and treat patients negative for lymph nodes at preop- erative exams. APR and radical inguinal lymphadenectomy should be reserved for locally advanced tumors not eligible for trans-anal excision.

Pelviperineologia 2022; 41: 46-52 http://www.pelviperineologia.it

Trimodal Colorectal Anastomosis Testing Sammartino F., Falbo F., Peluso I., Krizzuk D.

General Surgery Department, Aurelia Hospital, Rome, Italy

Aim: Colorectal Anastomotic Leak (CAL) is a severe compli- cation with an incidence up to 20% . Several variables have been associated with increased risk of CAL, but its predic- tion remains challenging. In addition to aseptic technique, careful dissection and tension-free anastomosis construc- tion, ICG angiography (IA), air leak test (AL), and Methy- lene Blue enema (MB) is used to assess vascularization and adequate tissue approximation . This study aims to assess the feasibility and impact on anastomotic leakage of the trimodal anastomosis test (TAT) as previously suggested .

Methods: This is a retrospective analysis including all pa- tients undergoing elective surgery with the construction of a Colorectal Anastomosis (CA) between Jan 2020 and April 2021 in our institution. A total of 47 patients had a CA con- structed. Procedures included are Laparoscopic and open left hemicolectomy for colon cancer and diverticular disease and laparoscopic and open Hartman Reversal procedure. Demo- graphic and perioperative data were collected and analyzed

using IBM SPSS software. Pearson correlation test, Chi2, and T-Test were used.
Results: CA was tested with TAT in 22 patients, while in 25 patients, one of the three tests was missing. In 4 patients, a test positivity occurred, leading to stoma creation in 2 cases and suture repair in the remaining patients. None of these patients developed a postoperative leak. Two patients, who didn’t undergo IA, had a significant leak (4.3%). Both pa- tients had negative AL and MB tests. The use of TAT didn’t have a statistically significant impact on operative time (.66), intraoperative complications (.43), postoperative complica- tion rates (.18), leak (.26), and length of stay (.28). Conclusions: In conclusion, TAT of CA does not impact post- operative leak rates and overall complication rates. Also, it had no statistically significant impact on operative time and length of stay. This is a safe and feasible method of anasto- mosis testing and further investigation is needed to assess its significance in clinical practice.

Introduction: Anal Intraepithelial Neoplasias (AINs) are pre- cursors of anal squamous cell cancer (SCC) and mostly HPV infection-related. Gold standard for the diagnosis is histolo- gy. Tissue biomarkers are progressively taking on a role in improving diagnostic accuracy of AIN and in reducing intra and inter-observer variability. Among these, p16 and ki67 are the most widely used. We reviewed the literature to evaluate the clinical impact of tissue biomarkers in the management of Anal Intraepithelial Neoplasia (AIN).

Materials and methods: After a review of the literature, we selected the studies in which the analysed biomarker was involved in one or more phases of the diagnostic-therapeu- tic process and therefore useful in clinical practice, such as diagnosis, classification and grading, treatment monitoring, prognosis phases.

Results : The analysis of the studies showed that to date p16

represents the only useful biomarker in clinical practice. According to LAST the indications for p16 immunostaining are: 1) differential diagnosis -IN2 -IN3; 2) -IN1 lesions in high-risk patients; 3) grading of lesions -IN2; 4) disagree- ment in the interpretation of precancerous lesions. Ki67 is currently not recommended unless p16 is conclusive. CD17, Stathmin-1, DNA methylation, HPV L1 capsid protein, p53, minichromosome maintenance proteins are other promising markers but used only in clinical trials, however none of these recommended in everyday practice.

Conclusion : p16 and ki67 are currently the most used bio- markers in the management of AIN. To date, no study has identified biomarkers with prognostic value in precancerous anal lesions, so this could represent an interesting challenge for the future.

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Clinical impact of tissue biomarkers in the management of anal intraepithelial neoplasia (ain)

Nicotera A.1, Canavese G.2, Bonomo L.D.1, Senetta R.2, Morino M.1, Mistrangelo M.1

1) Department of Surgical Science, University of Turin
2) Pathology Department, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin

The role of High-Resolution Anoscopy in squamous intraepithelial lesions: are we overscreened
and overtreated the patients?
Folliero C., Scarpa E., Gattesco D., Vecchiato M., Ziccarelli A., Uzzau A., Terrosu G., Petri R., Mozzon M.

Background: High-Resolution Anoscopy (HRA) is a poten- tial screening method for detection of anal cancer precursors. Even if there are no widely adopted screening guidelines HRA is identified as the most cost effective screening strate- gy for detection of HSIL.

Methods We employed a retrospective, observational cohort study and evaluated our serie of consecutive 213 patients at risk of developing anal cancer.These patients were screened and treated by HRA between 2018-2021. We analysed the re- sults in term of cancer prevention, standardization of proce- dures and learning curve .

Results: In our series we found 1 in situ anal cancer and 40,2% anal dysplasia ( of which 8,6% AIN 3, treated in the

OR). The majority of patients were HIV, but there was scarce partecipation to the screening of women with previous CIN and genital dysplasia. Our practice was influenced by the learning curve . There may be a role of PAP test and HPV screening as a I level screening of these patients. Conclusions: The scarce incidence of anal cancer detection in our series pose us the doubt if we are overscreening our patients and if we have to fix other criteria of enlistment for the screening (older age and sex), expecially considering that anal cancer is more frequent in women and possibility of re- currence of HSIL Furthermore it’s mandatory to standardize the procedure.

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Post-haemorrhoidectomy wound healing after local treatment with bergamot flavonoid-based gel and hyaluronic acid.

Cafaro D.1-2, Sturiale A.1, Sinicropi M.S.3, Onofrio L.4, Naldini G.1

1) Centro Clinico Chirurgia Proctologica e Pavimento Pelvico, Azienda Ospedaliera-Universitaria di Pisa 2) Dipartimento di Chirurgia Generale, Servizio di Chirurgia Proctologica Ospedale Tropea(VV)
3) Dipartimento di Farmacia e Scienze della Salute e delle Nutrizione, Università della Calabria (CS)
4) Dipartimento di Chirurgia Generale, Ospedale Piedimonte Matese (SA)

Background: Haemorrhoidal Disease (HD) is a very diffuse anorectal condition that involves a large part of the popula- tion, both male and female of every age. Among the several procedures proposed to treat HD, conventional excisional sur- gery remains one of the most performed, it is characterized by important post-operative pain whose historical knowledge often scare the patients. The pain is mainly related to the anal wounds and the healing speed surely influence the post-oper- ative course. The aim of this study was to evaluate the effect of using Benebeo Gel® on post-operative wound healing after open haemorrhoidectomy. Methods and Results: This was an observational prospective study conducted in the Proctologi- cal and Pelvic Floor Clinical Centre (PPFCC) of the Universi- ty Hospital of Pisa. From April 2019 to January 2020 all the patients aged between 18 and 75 undergone to open hemor- rhoidectomy were enrolled. The post-operative follow-up was scheduled as follows: 7 day, 15 day, 22 days and 30 days after surgery. The primary end point was: time taken to get com-

plete wound healing with a re-epithelized tissue. Secondary endpoints were: evaluate post-operative pain using VAS scale, bleeding, discharge and overall patients satisfaction about the procedure and the topical gel. All the patients were instructed to take topical gel by using the cannula provided with the prod- uct put it into the finger phalanx and then upon injured area twice a day (once in the morning after defecation and once before sleeping) for 25 days after. The administration of the product begins in 4th post-operative day. The mean post-op- erative pain at 7 days was 6±2, at 15 days 4±1 and at 30 days was 2±1. The mean time to get complete wound healing was 23±4 days. Conclusions: he present study aimed to evaluate the efficacy of a new topical gel mainly composed by berga- mot-derived flavonoids and hyaluronic acid in patients treated with excisional hemorrhoidectomy. The results after 2 weeks of treatment seems to be promising with a very good clinical outcome and patient satisfaction within 1 month.

Topical treatment with adelmidrol and trans-traumatic acid in chronic anal fissure

Ramin A.3, Segre D.2, Tricomi N.1, Dodi G.4

U.C.P. Palermo, Casa di Cura Candela1; Ambulatorio Specialistico di Proctologia, Cuneo2; Chirurgia Generale- Ospedale Piove di Sacco (PD)3; Centro Pelvi, Padova4

Introduction a therapeutic approach to control the hyper-reac- tivity of the mast cells located in the anoderm, and to improve the neuro-vascular trophism in the injured area, could be ob- tained by the topical supply of the association adelmidrol and traumatic acid (am-ta ). aim of the present clinical investiga- tion is the assessment of effectiveness and tolerability of the am-ta topical application in the chronic anal fissure. Materials and methods a clinical investigation on 81 outpa- tients with chronic anal fissure, evaluates the effectiveness of the application of am-ta at a dosage of 3ml a day. the assess- ment of intensity of the symptoms pain, spasm and itching is carried out by means of the numeric rating scale at baseline, at 15th, 30th and 60th day of treatment and after 2 months fol- lowing discontinuation; bleeding and size of the fissure varia- tions are assessed as well.

Results the analysis performed applying the glmm model (generalized linear mixed model) shows that at the end of the treatment the intensity of pain, spasm and itching decreases in a statistically significant (p< 0.0001) way. in particular, the pain mean score switches from a value of 7,7 to a value of 0,8. bleeding, initially present in 71.1% of patients, at the end of the treatment is reported only by 10% of the patients; at the end of the treatment the fissure is completely healed in 80% of the patients, the effects persisting also in the post-treatment follow-up. the product appeared overall well tolerated. Conclusions the outcomes of this clinical investigation demonstrate that the topical supply of am-ta represents a ther- apy comparable to the best non-surgical clinical practice in the treatment of chronic anal fissure.

Sarcopenic obesity: another side of malnutrition impacting on colorectal surgery

La Mendola R., Parini D., De Luca M.

General Surgery Unit, Rovigo Hospital – Viale Tre Martiri, 140, 45100 Rovigo, Italy; roberta.lamendola@gmail.com

Background – A poor nutritional status impacts on cancer pa- tients, leading to increase complications and low compliance to treatments. According to the common definitions, mal- nutrition is related to weight loss. Nevertheless, Body Mass Index (BMI) does not reflect body composition: also people with normal or high BMI can be malnourished. Over-nutrition and malnutrition coexist in “Sarcopenic Obesity” (SO). Obe- sity and sarcopenia represent risk factors for complications after colorectal (CR) surgery so their preoperative definition helpsto obtain a risk stratification and potentially to carry out effective prevention and treatments. Methods – Guidelines do not provide a widely accepted definition of SO but a strong consensus was reached by scientific societies. Screening for SO is based on the concomitant presence of a high BMI and symptoms suggestive of sarcopenia, identified by validated questionnaires (e.g., SARC-F). A positive screening should be followed by the assessment of muscle strength by specific tests

(e.g., 30-s chair stand test) and the analysis of body composi- tion that in cancer patients is performed by CT scan, useful to identify sarcopenia and myosteatosis in addition to visceral obesity (VO). If both functional and imaging parameters are detected, a diagnosis of SO can be established. Results and discussion – VO is associated with increased operative time, postoperative complications, open conversion rate and hospi- tal stay after CR surgery. On the other hand, sarcopenia and myosteatosis represent risk factors for anastomotic leak and reduced survival in patients with CR cancer. Literature shows how these factors enhance each other and predict surgical and oncologic outcomes better than BMI, so their assessment is crucial. Preoperative interventions on obesity and sarcopenia are currently not adopted. Pre-habilitation includes physical and nutritional measures prior to surgery and demonstrated beneficial effects, but the time needed to optimize nutritional status is not acceptable in cancer setting. In case of neoad-

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juvant treatment, that interval should be used to achieve the nutritional goal in order to improve patients’ outcomes. Con- clusions – CR cancer patients should be screened for sarco- penia independently of their BMI. SO represents a risk factor for postoperative complications and poor survival and should

be identified at the time of cancer diagnosis. Future studies on outcomes among patients with SO should considerate the impact of pre-habilitation programs and the proper timing to implement them.

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Short stump and High anastomosis Pull-through – SHiP – procedure for low

rectal cancer

Pollesel S., Lauretta A., Belluco C.

Istituto di appartenenza: IRCCS CRO Aviano (PN)

Introduction: The ideal ultra-low coloanal anastomosis proce- dure remains matter of debate. The Turnball-Cutait delayed colo-anal anastomosis, also referred as pull-through proce- dure was introduced in 1961 but was progressively abandoned in the 1980s following the introduction of mechanical staplers. Recently, this technique regained popularity as first choice op- tion in case of low rectal cancer. In fact a modified technique (Short stump and High anastomosis Pull-through’ – SHiP- pro- cedure) was introduced in order to overcome the drawbacks of the old technique. This is a retrospective single-centre study that investigates the effectiveness SHiP procedure for delayed coloanal anastomosis without a stoma.

Materials and methods: Data of Patients affected by low rec- tal cancer treated using SHiP procedure in our institution be- tween 2019 and 2021 were collected. SHiP technique was ap- plied in case of rectal cancer located within 5 cm from the anal margin. Functional outcomes, morbidity, mortality rates and local recurrence were retrospectively analyzed. The surgical technique carried out is a conventional low anterior resection, including high vascular ligation, complete left colon, splenic flexure and half transverse colon mobilization (up to middle colic vessels) and total mesorectal excision. Anal mucosecto- my and transanal rectal section are then performed and the left colonic stump is pulled through the anus. Four referral stitch- es are placed between the colic serosa and the upper verge of the anal canal. In the second stage of the procedure the adhe- sions between the colonic stump and the anal canal are bluntly dissected until the marker stitches. The colonic stump is then

sectioned at this level, leaving the anal canal free from the residual colon, and a “high” anastomosis completed with four additional stitches
Results: A total of 7 patients (mean Age 63 ± 6) underwent SHiP procedure, out of the 78 patients affected by rectal can- cer treated in our institution between 2019 and 2021. All pa- tients had preoperative neoadjuvant treatment (standard loung course chemo-radiotherapy; total neoadjuvant chemo-radio- therapy). The total lenght of hospital stay was 20 ± 5 days and the mean surgical time was 344 ± 96 minutes. The second surgical step (resection of the transanal colonic stump) was performed an average of 12± 3 days later. No mortality was recorded. No major leak of the colonic stump occurred. One case deveoped ischemia and retraction of the colonic stump, without affecting integrity or functionality of the anastomosis. No local recurrence was recorded. One patient experienced peritoneal and liver metastasis at 6 months after surgery and another one developed hepatic metatasis; 2 patients (33%) had early complications: acute urine retention and paretic ileus. The lenght of follow up was 21 ± 10 months. The mean Wexner scores at 12 months was 7 points. The mean LARS score at 12 months was 23 points. 3 patients (42.8% ) had major LARS, 4 (57.2%) had minor LARS.

Conclusion: The SHiP technique combines the advantage of a minimally invasive approach to those of a delayed “high” colo-anal anastomoses. It is a viable option for the surgical treatment of low rectal cancer.

Multicompartimental surgery for pelvic floor disorders: Preliminary Results Salmaso B.*, Giunta G.*, Legnaro A.*, Minardi V.§, Breda E. §, Pietrangeli F.*, Longo M.*, Losacco L.*

*Centro Pelvico III Livello Rovigo – Regione Veneto – ULSS 5 Polesana § U.O.C. Ginecologia e Ostetricia, Ospedale di Rovigo

Introduction: The pelvic diaphragm is an anatomical-pelvic unit, divided by convention and classification convenience into anterior, middle and posterior compartment. Multior- gan pelvic prolapse has a higher incidence in women and it is estimated that more than half of women in their life can develop this pathology. Risk factors are represented by: pre- vious hysterectomy, birth trauma, multiple parity, age, family history, connective tissue deficiency, body mass index equal to or greater than 25, abdominal circumference equal to or greater than 88 cm and constant weight lifting. While phys- ical activity, in particular involving the pelvic floor, appears to be a protective factor. For decades, disorders attributable to prolapse of the organs of the anterior-middle compartment have been the prerogative of urogynecology, while disorders of the posterior compartment were treated by the general sur- geon coloproctologist. It is widely demonstrated that treating pelvic floor problems separately, which must instead be con- sidered a single anatomical-functional structure, has often led to the correction of some symptoms, but to the worsening of others. This has an impact on the quality of life of patients, also exposing them to the possibility of having to undergo sev- eral chronologically separate surgeries. It is, therefore, a com- mon opinion that the establishment of Pelvic Units allows the

global assessment of multiorgan pelvic prolapse, allowing a multidisciplinary approach with interaction and collaboration of the various specialists involved: urologist, gynecologist, coloproctologist surgeon. This represents the gold standard for the diagnosis of pelvic prolapse and for its treatment, with particular attention to the correct indications for the surgical approach. The latter will be carried out by a multidisciplinary team in a single surgery. For more than ten years, in our hospi- tal reality, we have been carrying on this concept of multidis- ciplinarity of pelvic floor experts.

Materials and methods: From 2008 to today we have evaluat- ed about 1000 patients, all female, at the “Santa Maria della Misericordia” Hospital in Rovigo and “San Luca” Hospital in Trecenta (RO) in the context of multidisciplinary pelvic floor surgery. The selection of these patients takes place prelimi- narily during the proctological, gynecological or urological outpatient assessments to which the patients undergo in search of a solution to their disorders. Thanks to the careful medical history and physical examination, but also to the unitary vi- sion of pelvic floor disorders, these patients are introduced to the multidisciplinary path for a global assessment of the prob- lem. We currently have complete data on 672 women, of which 533 treated conservatively with medical therapy, physiokine-

Pelviperineologia 2022; 41: 46-52 http://www.pelviperineologia.it

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sitherapy and/or biofeedback, excluding pessary carriers. 115 patients underwent surgery and, depending on the different indications, 57 underwent unicompartmental surgery main- ly in the posterior compartment and the other 58 underwent multi-compartment gynecoproctological surgery. The scien- tific literature tells us that patients with pelvic floor prolapse have an estimated 10 to 20% risk of undergoing surgery by the age of 80. In our series, 17.11% of the patients underwent surgery, in line with literature data. In particular, patients un- dergoing multicompartmental surgery represent 8.63% of the total number of cases. It was decided to undertake a study on the quality of life of these patients, selecting the “Pelvic Floor Distress Inventory-short form 20” questionnaire from various available questionnaires on the quality of life, to which we made changes by adding two questions relating to disorders urinary and defecators. The choice to use this simple but at the same time targeted questionnaire was influenced by the fact that most of the questionnaires would be administered by telephone.

Results: We reached out by telephone to the paents who had undergone mulcompartmental surgery, an intervenon in which we strongly believe for the synergisc properes of muldiscipli- narity and implemented by a few centers in Italy, including ours. During the phone calls to our paents, the quality of life quesonnaire was administered, asking them to provide a score on the symptoms complained of before surgery and on the current clinical status. All paents operated on with mul- compartmental intervenon achieved a significant benefit from the surgery, as demonstrated by the total pre-intervenon and post-intervenon scores, where the negave increase given by the difference of the two demonstrates a clinical improvement, even at a greater distance 5 years old. Data collecon is also underway for paents undergoing single-compartment surgery and comparing the data currently available for your types of intervenon, the average improvement perceived by the paents

interviewed undergoing mul-compartmental intervenon is greater than the average perceived improvement of those un- dergoing single-compartment intervenon, even longer than 5 years aer the intervenon.

Conclusion: Pelvic Units represent the gold standard for the diagnosis and therapy of mulorgan pelvic floor disorders. Our many years of experience also demonstrates the importance of muldisciplinarity in the evaluaon of this pathology. Despite the current limitaons linked to the small number of paents in the sample analyzed and the evaluaon method related to telephone data collecon, we will connue the study on the quality of life trying to reach all the paents operated on since 2008, thanks to the preliminary encouraging results obtained unl now. Bibliography Renzi A, Lenisa L, Boccasanta P, Crafa F; “Chirurgia colonproctologica e pelviperineale”; SIUCP So- cietà Italiana Unitaria di Colonproctologia; Piccin Editore – Boccasanta P, Venturi M, Spennacchio M, Bonaguidi A, Ai- roldi A, Roviaro G; “Prospecve clinical and funconal results of combined rectal and urogynecologic surgery in complex pelvic floor disorders”; Am J Surg 2010 Feb; 199(2):144-153 – Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, Kuzu MA; “Prevalence of pelvic floor disorders in the female populaon and the impact of age, mode of delivery, and parity”; Dis Colon Rectum 2011 Jan; 54(1):85-94 – Miedel A, Tegerstedt G, Morhle-Schmidt M, Nyren O; “Non obstet- ric risk factorsfor symptomac organ prolaps”; Obstet Gynecol 2009 May; 113(5):1089-1097 – Barber MD, Walters MD, Bump RC; “Short forms of two condion-specific quality-of-life que- sonnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7)”; Am J Obstet Gynecol 2005 Jul;193(1):103-113 – Olsen AL, Smith VJ, Berstrom JO, Colling JC, Clark AL; “Epidemiology of surgically managed pelvic organ prolapse and urinary inconnence”; Obstet Gynecol 1997; 89:501-506 – www.pelvicorganprolapsesupport.org

Chronic Pilonidal disease: a comparison of four surgical techniques Pepe F., Sbuelz F., M. Giaccone, Falletto E., Comba A., Sandrucci S., Mistrangelo M.

Department of Surgical Science, University of Turin

Background: Pilonidal Disease is a common condition that mainly affects young adults, with an etiology that remains unclear. The clinical presentation is highly variable, ranging from asymptomatic conditions to acute infection or chronic inflammation. The aim of optimal surgical treatment is the achievement of a short healing time with a low recurrence rate. The best surgical choice is still uncertain.

Methods: We retrospectively analyzed the data of every pa- tient who underwent surgical treatment for chronic pilonidal disease in our institution between 1/1/2010 and 31/12/2021 to evaluate if there are any differences in clinical outcomes be- tween four surgical treatments. The analyzed techniques were: “Wide excision and open healing” (Group I), “Wide excision and primary midline closure” (Group II), minimally invasive “Bascom-Gips” (Group III), and “Wide excision and rhom- boid flap repair” (Group IV). Main outcomes of the study were recurrence rate and time of resumption of everyday activity. Secondary outcomes were the length of hospital stay, compli- cations rate, and healing time.

Results: A total of 253 patients were included in the trial: 64 in Group I, 128 in Group II, 43 in Group III, and 18 in Group

IV. The median follow-up time was at least 27 months in each group. The recurrence rate was 16.7% in Group I, 25 % in Group II, 9.8% in Group III, and 14.3% in Group IV with a dif- ference only when comparing Group II vs III (P-value <0.05). “Bascom-Gips” proved to have the shortest resumption of everyday activity, the “Rhomboid flap” the longest (P-value <0.05). Healing time was longer in the “open healing” Group with a median length of 62 days when compared with all other groups (P-Value <0.05). Median healing time was 24 days in Group II, 30 in Group III, and 39 in Group IV without signif- icant differences.

Conclusion: High recurrence rate remains the main problem in the surgical treatment of pilonidal disease and no operative strategy shows to be better than the other. The “Bascom Gips” technique, characterized by a quicker resumption of everyday activities and a low complication rate, seems to be a secure, feasible, and low-cost technique. The rhomboid flap technique is the more time-consuming technique, with the highest com- plication rate, and time of resumption of everyday activities. Because it fails to show a reduction in recurrence rate, it may be a choice only in selected scenarios.