GIOVEDI’ 9 MAGGIO 2024

SESSIONE COMUNICAZIONI ORALI UNDER 40

Presidente: M. Mistrangelo
Moderatori: C. Bottini, A. Lauretta
Provoker: S. Ascanelli, F. Cantarella, U. Grossi, D. Parini

Tutor: D. Parini
1. Quality of Life (QoL) after sigmoid resection for diverticular disease

2. Urgent clinical presentation of colorectal cancer: risk factors for worse outcomes after surgery

3. Benefits of minimally invasive surgery for T4 colorectal cancer: still any doubts?

4. GUT MICROBIOTA AND CHRONIC PAIN: Overview of their relationship and possible future new therapeutic approaches

Tutor: S. Ascanelli
5. Tailored Pelvic Floor Repair and Overlapping Sphincteroplasty for Postoperative

Anal Incontinence: A Case Report

6. Laparoscopic ventral mesh rectopexy (LVMR) plus transverse perineal support (TPS) compared to LVMR alone in rectal prolapse and perineal descent treatment

7. Stapled Prolassectomy: Postoperative Pain Control with Intraoperative Intravenous Methadone. Our Experience

8. Analysis of Factors associated with persistent severe fecal incontinence in patients undergoing Robot-Assisted Ventral Mesh Rectopexy

Tutor: U. Grossi
9. Fournier’s gangrene in patient with IBD: clinical case and review of the literature

10. The utility of postoperative MRI to evaluate SNS efficacy in patients with fecal incontinence,

11. Safety of Titanized Polypropylene Mesh in Transabdominal Pelvic Floor Surgery

12. Robot-assisted Ventral Mesh Rectopexy efficacy in the treatment of patients with rectal prolapse and severe obstructed defecation syndrome: a single-center experience.

Tutor: F. Cantarella

13. Continence disturbance, failure and complications of four sphincter-sparing techniques for the treatment of fistula-in-ano: a systematic review and proportion meta-analysis

14. Micro-fragmented autologous adipose tissue injection to treat proctological diseases. Our initial experience

15. Water Holding Test: predictive test of anal sphincter function. A substitute to preoperative anorectal manometry? Preliminary results

16. Preliminary experience of a multidisciplinar proctological equipe in the evaluation of patients with ODS symptoms

17. Tecnica FilaC con fistuloscopia diagnostica (VAAFT)

S. Lazzari E. Sinatti

C. Nacci B. Salmaso

A. Di Vittori M.C. Gervasi G. La Greca A.A. Marra

A. Pecorino A.A. Marra

G. La Greca A.A. Marra

L. Selvaggi

G. La Greca A. Baglioni F. Farnesi F. Tumminelli

QUALITY OF LIFE (QOL) AFTER SIGMOID RESECTION FOR DIVERTICULAR DISEASE

Lazzari S., Bertoni M., Grego A., Mammano E., Vittadello F., Tessari E., Sarzo G., Passuello N. Chirurgia Generale OSA, Azienda Ospedale – Università Padova

Introduction

Sigmoid resection for recurrent diverticular disease is currently proposed to improve quality of life (QoL) rather than to prevent recurrence. The aim of this study is to identify any risk factors predictive of poor functional outcomes and quality of life in the post- operative period
and to modulate the surgical indication accordingly.

Materials and Methods

All patients who underwent elective sigmoid resection for acute uncomplicated recurrent diverticulitis at the OSA General Surgery Unit of Padua University Hospital between May 2018 and February 2024 were included. The SF-36 questionnaires and DV-QoL were used to evaluate postoperative QoL, while post-operative defecation disorders were assessed using the Wexner Incontinence score and Obstructed Defecation Score (ODS) score questionnaires. Patients also underwent rigid rectoscopy and high-resolution anorectal manometry (HR-ARM). Three comparison based on sex, age and type of ligation of the inferior mesenteric artery (IMA) were performed.

Results

64 patients included in the study, of these 35 responded to the questionnaires, while only 25 agreed to also undergo rectoscopy and 22 underwent manometry. In univariate and multivariate analysis, the female sex showed a significantly better QoL than the male sex on the DV-QoL (p=0.03, OR 11.76, 95%CI 1.24-111.28). In the functional scores, there weren’t significant differences, while the manometric data in female patients highlighted a lower squeeze pressure increase (p=0.04). Age over 65 years old also resulted as a risk factor for worse QoL tests in univariate and multivariate analyses (p=0.03, OR 12.48, 95%CI 1.18- 131.82). It’s interesting to note that in older people it was more often necessary to perform left hemicolectomy instead of sigmoidectomy, maybe this fact can be the cause of the worst intestinal QoL. The type of IMA ligation showed no differences in either QoL or functional scores, and wasn’t found to be a risk factor for worse QoL. No significant endoscopic differences were found between the groups in the various comparisons.

Discussion and Conclusion

Age over 65 years old and male sex are correlated with worse postoperative QoL after colonic resection for diverticular disease, while the type of IMA ligation does not impact either QoL or the defecation mechanism. The DV-QoL is a reliable tool to evaluate QoL after

sigmoid resection differently from the SF-36 questionnaire that seems to be useless in this field. The HR-ARM in centers of specific expertise can provide interesting information in patients who report poor postoperative QoL.

URGENT CLINICAL PRESENTATION
OF COLORECTAL CANCER:
RISK FACTORS FOR WORSE OUTCOMES AFTER SURGERY

Sinatti E., Franzò M., Rella A., Mammano E., Vittadello F., Frasson A., Sarzo G., Passuello N. Chirurgia Generale OSA, Azienda Ospedale – Università Padova

Introduction

Urgent surgical treatment that is mandatory in some cases of colorectal cancer (like in bleeding or obstructing tumors) can lead to a worse prognosis. The aim of this study is to show in our experience, which are risk factors for worse outcomes after surgery in these patients.

Materials and Methods

Data of 502 patients operated for colorectal cancer at our Unit between July 2018 and February 2024 were collected: the cases of patients admitted to the emergency room or other departments with urgent clinical presentation of colorectal cancer were identified (group A) and compared with patients with non-urgent clinical presentation (group B): demographic and tumor characteristics, postoperative complications and 30-day and long- term survivals were then analyzed and compared individually. We eventually searched for risk factors for worse outcomes in patients of group A.

Results

112 patients (22%) had an urgent clinical presentation, while 390 (78%) had a non-urgent presentation. The two groups differed in patient-related and tumor-related data (p<0.001). Patients in group A had a lower rate of laparoscopic surgery (77 vs 95%, p<0.001) and a higher rate of open conversion (15 vs 7.5%, p=0.026). Furthermore, in group A there was a greater length of hospital stay (11 vs 8 days), rate of deaths (11 vs 1.5%) and prolonged hospitalizations (9.8 vs 4.1%) at 30 days (p<0.001). Severe medical complications (Clavien- Dindo > or = 3) were higher in group A (p=0.006), while surgical complications showed no differences. The difference in terms of overall survival (OS) between the two groups was large (p<0.0001) with the same disease-free survival (DFS) with a median follow-up of 12 months. The onset of medical complications and death/prolonged hospitalisation within 30 days were hypothesised as the worst outcomes: open surgery and a higher Charlson Comorbidity Index can be considered risk factors at univariate analysis. In multivariate analysis, only laparoscopic surgery plays a clear protective role against death at 30

days, as we can see analyzing the OS difference observed between patients operated on laparoscopy and open surgery in group A (p <0.0001).

Discussion and Conclusion

In conclusion, laparoscopic surgery can be considered as a protective factor for better outcomes and OS in patients with an urgent clinical presentation of CRC, especially if performed in high-volume centres with adequate expertise in mini-invasive technique.

BENEFITS OF MINIMALLY INVASIVE SURGERY FOR T4 COLORECTAL CANCER: STILL ANY DOUBTS?

Nacci C., Padoan V., Mammano E., Vittadello F., Frasson A., Tessari E., Sarzo G., Passuello N. UOC Chirurgia Generale OSA, Azienda Ospedale – Università Padova

Introduction

The use of minimally invasive surgery in pT4 colon cancer is still controversial in the Literature nowadays. The aim of this work is to demonstrate the real competitiveness of the video-laparoscopic technique in oncological outcomes and both short-term and long term surgical outcomes for these tumors.

Materials and Methods

Data of 502 patients who underwent resective colorectal surgery in our Unit between July 2018 and February 2024 were collected. The cases of patients with pT4 tumor at
the definitive histological examination were identified and were divided into two groups: those operated laparoscopically and those operated by open surgery. Demographic characteristics, tumor characteristics, postoperative complications, 30-day outcomes and survivals were then individually analyzed and compared.

Results

76 pT4 patients were analyzed, 53 pT4a (70%) and 23 pT4b (30%): 22 operated by open technique and 54 with video laparoscopic technique (VLS).
A higher oncological radicality (p= 0.05) and lymphnode radicality (p= 0.03) were found in VLS group, a lower post-operative severe medical complications (p=0.01) was found in VLS group with an equal rate of severe surgical complications (p=n.s.). The VLS technique presented better results at 30 days, in terms of discharge and mortality (p< 0.001). Preoperative evidence of stage cT4 influenced the choice of the surgical technique to be adopted (71% of patients treated with open surgery were cT4, p=0.002). Overall survival (OS) with a median follow-up of 12 months was significantly better in patients of VLS group (p=0.001) with the same disease free survival (DFS).
When comparing the T4a and T4b subgroups, no differences were found in terms of length of hospital stay, complications and outcome at 30 days; the rate of laparoscopy was higher in pT4a tumors. OS survival was the same in the two groups.

Discussion and Conclusion

In this analysis we showed that the VLS approach for T4 colorectal cancers offers better results in terms of OS with a shorter length of hospital stay and less postoperative severe medical complications: similar results have been reported in the literature. As reported in the literature we also reached better results in terms of R0 radicality on the primary tumor with greater lymphadenectomies with VLS surgery. In conclusion, laparoscopic approach is always preferable for T4 CRC patients (in absence of technical and anesthesiological contraindications) because of the better results provided in terms of oncological radicality, post-operative complications and long-term survival.

GUT MICROBIOTA AND CHRONIC PAIN: OVERVIEW OF THEIR RELATIONSHIP AND POSSIBLE FUTURE NEW THERAPEUTIC APPROACHES

B. Salmaso1, A. Legnaro1, F. Pietrangeli1, V. Minardi2, L. Losacco1

1U.O.C. Chirurgia Generale, Ospedale “Santa Maria della Misericordia”, Rovigo, ULSS 5 Polesana
2U.O.C. Ostetricia e Ginecologia, Ospedale “Santa Maria della Misericordia”, Rovigo, ULSS 5 Polesana

Introduction

The gut microbiota is the subject of recent studies that correlate it with the development of multiple diseases or clinical conditions. To date, the role of the gut microbiota as a pain modulator is increasingly clear.
This is a narrative abstract on the role of the microbiota and its metabolites as peripheral and central mediators of chronic pain. Therefore becoming a new and innovative target for the therapeutic management of chronic pain, such as chronic pelvic pain.

Pain is defined “as unpleasant sensory and emotional experience associated with an actual or potential tissue damage”.
Acute pain represents a defense signal, to avoid risks, dangers and protect the individual’s tissues from damage. [1] While chronic pain is persistent pain triggered primarily by injury, disorder or illness. There may also be changes in pain conduction or neurotransmitter properties caused by damage to nerve fibers with sensitization of the nervous system

and continuation of pain in the absence of nociceptive stimuli. The mechanism underlying chronic pain is not been completely clarified. [2] But pain also involves emotional, cognitive and social components, in particular, chronic pain has a significant impact on the quality of life of patients. [2]

Microbiota-Gut-Brain Axis and the Mechanisms of (Chronic) Pain Regulation by the Gut Microbiota
There is a bidirectional communication between gut and brain which allows the integration of immunological, neural and hormonal signals, where today it is known that the gut microbiota plays a central role, thus defining the concept of the “microbiota-gut-brain axis”. [1]

Microbiota-derived mediators can directly regulate primary neuronal excitability of
sensory neurons in the dorsal root ganglia (DRG), through the activation or sensitization
of different types of pain-related receptors or ion channels (e.g. TLRs, GABA receptors or acid-sensitive ion channels). Metabolites produced by the microbiota can also indirectly regulate neuronal excitability through the activation of non-neuronal cells (such as
immune cells) by promoting the release of proinflammatory cytokines (e.g. TNF-α, IL). -1b, and IL-6), chemokines (e.g. CCL2 and CXCL1), anti-inflammatory cytokines (e.g. IL-4) or neuropeptides. [1] These aspects suggest how the gut microbiota may play a role in regulating pain, including chronic pain.

Different molecular models can be involved, here we summarize just some of the main ones [1] [2] [3] [4]:
– The release by the gut microbiota of pathogen-associated molecular patterns (PAMPs), such as lipopolysaccharide (LPS), lipoteichoic acid (LTA), peptidoglycan (PGN) and b-glucan, can cause peripheral sensitization by promoting the release of proinflammatory cytokines by immune cells or by directly activating central sensory neurons;

– Short-chain fatty acids (SCFA), produced by intestinal bacteria from the fermentation
of carbohydrates and proteins, act on their receptors, FFAR2/3, and regulate leukocyte functions, such as the production of cytokines (TNF-a, IL-2, IL-6 and IL-10), eicosanoids and chemokines, becoming themselves mediators for pain regulation;
– The gut microbiota plays a role in the production of kynurenic acid, which activates
the GPR35 receptor expressed in small neurons of the dorsal root ganglia, reducing their excitability with consequent analgesia;
– The gut microbiota has a crucial role in bile acid metabolism, activation of TGR5 by bile acids in peripheral macrophages leads to analgesia via the release of endogenous opioids; – Some neurotransmitters and neuromodulators, produced by the gut microbiota, can influence pain signaling, such as GABA and serotonin (5-HT).
– Neuroinflammation is crucial underlying the central sensitization of chronic pain,
recent work has suggested that several cell types in the brain, including endothelial cells, pericytes, microglia, astrocytes and infiltrated immune cells, are capable of receiving
input from the periphery, including the gastrointestinal tract, leading to their activation contributing to the development of neuroinflammation. The gut microbiota itself appears to play a role in regulating the maturation, morphology and growth immunological function of microglia, assuming that this aspect can also justify a direct role of the microbiota on neuroinflammation and therefore on central sensitization as an event underlying chronic pain;
– Gut dysbiosis, alteration of the gut barrier with bacterial translocation and the production and release of pro-inflammatory mediators by gut microbiota have been correlated with the long-term efficacy of opioids (among the drugs widely used to treat chronic pain). In particular, opioid tolerance has been observed in mice with depletion in Bifidobacteria and Lactobacillaceae and expansion of Enterococcus.

Discussion and Therapeutic Implications

In light of this recent scientific evidence which tends to clarify the role of the gut microbiota in the regulation of chronic pain, the possible therapeutic implications appear interesting.
Among these, the use of probiotics appears to have beneficial effects on managing chronic pain. In summary, several bacterial species have demonstrated, both in preclinical and in some clinical studies, the reduction of the intensity of abdominal pain, the frequency of pain episodes especially in patients suffering from IBS, visceral hypersensitivity, colorectal distension and improving the intestinal barrier. These bacterial species are for example:
L. reuteri, L. rhamnosus, L. plantarum, B. brevis, B. infantis, B. longum, R. hominis, C. butyricum. [1] [2] Given the key role of probiotics in regulating the functions of the immune system and the regulation of both pro-inflammatory and anti-inflammatory cytokines, it is likely that probiotics also have an analgesic effect on inflammatory pain. As well as having effects on the gene expression of pain-related receptors on epithelial cells, such as L. acidophilus which upregulates the expression of cannabinoid receptor 2 and the μ-opioid receptor of the colon, leading to a reduction in pain sensation. [1] Furthermore, probiotics

might also have significantly improving effects on chemotherapy-induced peripheral neuropathy (CIPN). [2] Prebiotics may also exert beneficial effects on chronic pain, such as the mixture of galactooligosaccharides capable of attenuating chronic visceral pain. [1]

Other possible measures are dietary, for example the low FODMAP diet may be useful
to reduce fecal LPS by modulating intestinal microbial composition, reducing mucosal inflammation, and to restore intestinal barrier function and relieving visceral pain. [1] Finally, fecal microbiota transplantation has also been proposed as a future therapeutic approach for the effects on chronic pain, determined by the competition between pathogenic bacteria and commensal microbiota, on the protection of the intestinal barrier, on the restoration of secondary biliary acids metabolism and stimulation of gut immune system. [1]

Conclusions

The gut microbiota has become one of the main topics of scientific interest due to its possible crucial roles in the development of clinical conditions, such as in the regulation of chronic pain, including chronic pelvic pain.
Alterations in the intestinal or urinary microbiota may present potential objective biomarkers to identify forms of chronic pelvic pain in both men and women, such as chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/bladder pain syndrome respectively. Some authors have hypothesized that the microbiota of adjacent organs, namely the intestine and the reproductive tract, could modulate pelvic pain through visceral sensory pathways that communicate between the organs. [5] The gut microbiota is closely related to psychiatry, influencing both depression and anxiety, often associated with chronic pain conditions. It could therefore become a therapeutic target also for the emotional management aspect. [4] Future investigations are certainly necessary both to deepen and clarify the molecular mechanisms underlying the gut microbiota that can modulate pain and to define the therapeutic targets and therefore the new promising therapies to improve the management of pain and the related emotional condition. The identification of personalized microbiota alterations could prove to be the real breakthrough for personalized therapies in the future.

References

[1] Pain regulation by gut microbiota: molecular mechanisms and therapeutic potential, R. Guo et al, British Journal of Anaesthesia, 123 (5): 637e654 (2019)[2] Gut microbiota in chronic pain: Novel insight into mechanisms and promising therapeutic strategies, L. Liu et al, International Immunopharmacology 115 (2023) 109685 [3] Gut microbiota, immunity and pain, Santoni M et al, Immunology Letters 229 (2021) 44–47

[4] Gut microbiota regulates neuropathic pain: potential mechanisms and therapeutic strategy, Lin B, The Journal of Headache and Pain (2020) 21:103[5] Gut microbiome and chronic prostatitis/chronic pelvic pain syndrome, Arora HC et al, Ann Transl Med 2017;5(2):30

TAILORED PELVIC FLOOR REPAIR AND OVERLAPPING SPHINCTEROPLASTY FOR POSTOPERATIVE ANAL INCONTINENCE: A CASE REPORT

Di Vittori A.1,2, Salvatore A.1,3, Realis Luc A.1, Trompetto M.1

1 Department of Colorectal Surgery, S. Rita Clinic, Vercelli
2 Division of General and Hepatobiliary Surgery, University of Verona, Verona
3 Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari

Introduction/Indications:

Anal incontinence (AI) presents a significant challenge to patients’ quality of life,
often arising from various factors such as surgical interventions in the perineal region. Postoperative anal sphincter injuries, resulting from surgical trauma or complications, contribute significantly to AI. Effective treatment necessitates accurate classification and evaluation of these injuries, often aided by imaging modalities like Endoanal Ultrasound (EAUS) and Magnetic Resonance Imaging (MRI). Conservative management and surgical interventions, tailored to the severity and extent of injury, form the cornerstone of treatment.

Case:

We present the case of a 59-year-old male with fecal incontinence following multiple surgical interventions for anal fistula and a parastomal hernia due to Hartmann procedure. Preoperative evaluation revealed significant sphincter defects, necessitating a tailored surgical approach. Anorectal manometry and EAUS confirmed the extent of injury, guiding treatment planning. Surgical reconstruction involved multi-layered perineal reconstruction with sphincter overlap repair involving even the puborectalis muscle, resulting in improved sphincter tone and voluntary contraction.
The patient showed no intraoperative or postoperative complications and was discharged on postoperative day 2.

Conclusions:

Tailored surgical reconstruction offers promising outcomes for patients with postoperative injuries, improving continence and quality of life. However, surgery alone is insufficient; a comprehensive approach involving preoperative assessment, surgical intervention, and postoperative rehabilitation is essential for optimal outcomes. Pelvic floor rehabilitation plays a crucial role in long-term continence management and should be integrated into the treatment pathway. This case underscores the importance of individualized care

in addressing postoperative anal sphincter injuries and highlights the role of surgical reconstruction as part of a holistic treatment strategy.

LAPAROSCOPIC VENTRAL MESH RECTOPEXY (LVMR) PLUS TRANSVERSE PERINEAL SUPPORT (TPS) COMPARED TO LVMR ALONE IN RECTAL PROLAPSE AND PERINEAL DESCENT TREATMENT

Background

M.C. Gervasi1, G. Brancato1, L. Crepaz1, G. Verlato2, A. Di Leo1

1 San Camillo Hospital, Trento, General Surgery Department 2 University of Verona

LVMR has become the preferred technique in Europe for the treatment of full thickness rectal prolapse, rectoceles and rectal intussusception. Nonetheless a simultaneous descending perineal syndrome may impair LVMR outcomes. TPS aims to correct pathological perineal descent. The aim of this study was to assess the safety and the functional outcomes of LVMR plus TPS compared to LVMR alone.

Materials and Methods

This is a retrospective study of 143 consecutive female patients treated with LVMR with
or without TPS at our Unit between 2018 and 2022. Patients with symptomatic rectal prolapse and perineal descent submitted to surgery were included. ODS and faecal incontinence were graded according to the Cleveland constipation score(CCS) and the St. Mark’s incontinence score(SMIS). Pathological perineal descent was defined as fixed and/or dynamic. LVMR and LVMR plus TPS were performed with the use of biological mesh.

Results Median age was 65.3 years and median BMI was 24.4. Eighty five(85%) had natural deliveries ( average number of 2.3 deliveries). TPS was performed in 110 patients(76.9%). No significant difference was recorded between TPS group and the other patients at baseline. Patients treated with LMVR plus TPS showed an increased post operative surgical morbidity (12.7% vs none, p=0.047) mainly due to the occurrence of seroma

(10% of all surgical procedures). All complications were mild(CD 1-2). In both groups, the need of digital aid in defecation(p=0,001), the prolonged lifting(p=0,004) and the hematochezia (p=0,001) nearly disappeared, constipation and use of laxatives persisted in 22%. Prevalence of incontinence decreased from 43 to 11% (p=0,001) after surgery. TPS was effective in reducing CCS, which was 5 points higher in the TPS group than the no-TPS group before surgery, while becoming superimposable after rectopexy. The CCS and the SMIS remained close to zero up to 24 months after surgery. Operative time was significantly higher in LVMR+TPS (20 minutes difference).

Conclusions LVMR appears to be safe and feasible. TPS may give better surgical outcomes compared to LVMR alone in patients with symptomatic rectoceles and descending perineum syndrome.

STAPLED PROLASSECTOMY: POSTOPERATIVE PAIN

CONTROL WITH INTRAOPERATIVE INTRAVENOUS

METHADONE. OUR EXPERIENCE
Running Title: Methadone for pain control after stapled prolassectomy

G. La Greca3, E.M. Nerina Compagnino1, G. Brivio2, M.V. Resta1, A. Stuto3, G. Trevisan1

1Department of Anaesthesiology at IRCCS Policlinico San Donato 2Department of Pathophysiology and Transplantation, University of Milan 3Coloproctological and Pelvic Floor Surgery Unit at IRCCS Policlinico San Donato

Background: Hemorrhoid and rectal prolapse are common pathologies and one of the possible treatments for both consists of surgical excision using a circular stapler. To date there is no strong evidence about the best analgesia and anesthesia to choose for stapled anorectal procedure. In our hospital IRCCS Policlinico San Donato, we routinely used intraoperative intravenous methadone bolus combined with subarachnoid anesthesia for postoperative pain management.

Objectives: retrospectively evaluate pain and its trend in the first 24 postoperative hours.

Patients and methods: A retrospective non-case-control observational study was conducted. The primary endpoint was the NRS pain 6, 12, and 24 hours after surgery. Secondary endpoints were the amount of opioid rescue and the presence of adverse events methadone related.

Results: We analyzed 70 cases of stapled procedures combined with lumbar subarachnoid anesthesia. All patients received intraoperative intravenous methadone bolus and Acetaminophen t.i.d. and NSAIDs b.i.d as postoperative pain therapy in ward. The median NRS (± Standard Deviation) pain evaluation was 3 ± 2.36 after 6h, 0 ± 1.85 after 12h, and 0 ± 1.86 after 24h. The difference between NRS at 6h and 12h and between NRS at 6h and 24h was statistically significant (p < 0.05). We found intraoperative respiratory depression in 2 cases (2.8%) and an incidence of 2.5% of opioid rescue used in the ward. Opioid-induced nausea and vomiting occurred in 11 patients (15.7%).

Conclusion: intraoperative intravenous single bolus methadone has interesting and promising results for pain management in stapled ano-rectal surgery combined with subarachnoid anesthesia.

What’s already known about this topic?

– Although stapled anorectal procedures are painful, there is no strong evidence about the best analgesia to choose;
– Poorly controlled pain has ethical, economical and clinical issue;
– Methadone is an old medicine but with a high potential due to its pharmacokinetic and pharmacodynamic properties;

What does this study add?

– It’s the first time that methadone has been evaluated for postoperative management after anorectal stapled surgery during subarachnoid anesthesia and result are promising.

ANALYSIS OF FACTORS ASSOCIATED WITH PERSISTENT SEVERE FECAL INCONTINENCE IN PATIENTS UNDERGOING ROBOT-ASSISTED VENTRAL MESH RECTOPEXY

A.A. Marra, MD,1 P. Campennì, MD,1 F. Litta, MD,1A. Parello, MD,1 C. Ratto, MD, Hon Int FASCRS1,2

1Proctology and Pelvic Floor Surgery Unit, Center of Excellence for Gastrointestinal and Endocrine-Metabolic Diseases, Isola Tiberina – Gemelli Isola Hospital, Rome, Italy 2Catholic University, Rome

Purpose/Background

Robot-assisted ventral mesh rectopexy (RVMR) is a well-established surgical procedure for rectal prolapse (RP) and obstructed defecation syndrome (ODS). However, this approach could also be effective in case of concomitant fecal incontinence (FI). Aim of this study was to assess the impact of RVMR in patients suffering from RP/ODS and FI, and identify factors associated to postoperative persistence of FI.

Methods/Interventions

This is a prospective single-center observational study on consecutive patients with external or internal RP, rectocele with/-out entero/sigmoidocele who underwent RVMR using Xi Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients’ baseline characteristics, intra- and postoperative data were collected. Symptoms of FI were assessed using the CCFI score. Uni- and multivariate analysis of factors affecting postoperative persistence of severe FI with a significant impairment of quality of life (CCSI score >9) was performed.

Results/Outcomes

From November 2020 to January 2024, 73 patients (70 females, 95.9%, mean age 58.7±13.0 years) who underwent RVMR were included. Thirty-two patients (43.8%) suffered from FI: in 18 of them (56.3%) FI was severe. Mean postoperative follow up was 21±11.2 months. At last follow up, an overall statistically significant reduction in CCFI score (4.2±5.8 vs 1.6±3.4, p<0.0001) was reported. Specifically in the 32 patients with preoperative FI, CCFI score decreased from 9.5±4.9 to 3.7±4.4 (p<0.0001). Sixteen of them (50%) reported no FI symptoms after RVMR, while 16 patients (50%) showed persistent FI (in 6 of them – 37.5% – it was severe). New-onset FI was found in one case after the procedure (CCFI score <9). In the overall sample, although age >65 years, external RP, presence of internal and external anal sphincter lesions, reduced resting, squeeze and endurance squeeze (ES) pressures at anorectal manometry were associated to postoperative FI, none of these factors showed

to be significant at multivariate analysis. Analyzing only patients with preoperative FI, age >65 years, reduced resting and ES pressures, and rectocele recurrence were correlated with severity of FI after RVMR, but only reduced ES pressure resulted significant at multivariate analysis (p=0.034).

Conclusion/Discussion

RVMR confirmed to be an effective option in the treatment of patients suffering from RP/ ODS and FI. A decreased preoperative anal sphincter function could predict severe FI after RVMR. Further multicentric studies on patients with RP and FI are needed to confirm these findings.

FOURNIER’S GANGRENE IN PATIENT WITH IBD: CLINICAL CASE AND REVIEW OF THE LITERATURE

Pecorino A., Picone T., Faccio L., Rella A., Frasson A., Tessari E., Sarzo G., Passuello N.

UOC Chirurgia Generale OSA, Azienda Ospedale – Università Padova

Introduction

Fournier’s gangrene (FG) is a perineal and abdominal necrotizing infection. Commonly reported predisposing factors are well known. Inflammatory bowel disease (IBD) may alter immune response but have rarely been associated with necrotizing infections of the perineum. Only 7 cases of Fournier’s gangrene in association with IBD have been reported in the literature, and none of them was a female with ulcerative colitis.

Case Report

A 34-year-old woman presented to the Emergency Department with fever and anal
pain. Her past history included ulcerative colitis in clinical remission never treated by immunotherapy, diabetes and multiple surgical treatment for anal abscess and fistulas. Laboratory investigation revealed leukocytosis (44.27 x 10^9/L), CRP elevation (461 mg/L) and PCT elevation (3.04 ug/L). Computed tomography scan revealed gas distribution in pelvic abscess in the recto-uterine space and emphysema in the left ischioanal fossa. The treatment was broad-spectrum intravenous antibiotics, extensive surgical debridement of the perineal area with drainage placement in pelvic abscess and a diverting colostomy. The patient was discharged from the Intensive Care Unit after 3 days. During surgery, a culture swab was performed and tested positive for K. Pneumoniae e S.Anginosus so the patient was treated with specific antibiotics.

In 5^ POD the patient needed a second perineal debridement. In 35^ POD the patient underwent closure of the internal anal fistulous orifice. Patient had an uneventful recovery and was discharged in 37^POD.

Discussion and Conclusion

Perianal disease is common in IBD and can affect up to one-third of patients, although it rarely progresses to severe necrotizing infection. Only 7 cases of FG in association with IBD have been described. In our patient, the primary source of infection were multiple treatments

for anal abscess and fistula. It is now recognized that immunosuppression associated with local trauma or urinary and colorectal infections are the most common etiologies of Fournier’s gangrene. The treatment of IBD, which includes immunosuppression and anti- TNF medications, can also interfere with the immune response and increase the risk for opportunistic infections. In the present case, the inciting event was clearly of colorectal origin, with peri-anal abscess and fistula, so we believe it was prudent to divert early the bowel to control sepsis.

In conclusion it is crucial to make a prompt diagnosis and treatment of FG especially in IBD patients.

THE UTILITY OF POSTOPERATIVE MRI TO EVALUATE SNS EFFICACY IN PATIENTS WITH FECAL INCONTINENCE

A.A. Marra, MD,1 M. Pierleoni, MD,2 C. Ratto, MD, FASCRS1,3

1Proctology and Pelvic Floor Surgery Unit, Center of Excellence for Gastrointestinal and Endocrine-Metabolic Diseases, Isola Tiberina – Gemelli Isola Hospital, Rome 2Diagnostic Imaging Unit, Center of Excellence for Oncology, Radiotherapy and Radiology, Isola Tiberina – Gemelli Isola Hospital, Rome
3Catholic University, Rome

Purpose/Background

Sacral nerve stimulation (SNS) is an effective therapy in patients with fecal incontinence (FI). Success rate is strictly related to the electrode placement. An inadequate electrode position can cause suboptimal clinical improvement and necessity of further settings reprogramming, generally using a trial-and-error approach. Recently, an MRI-compatible SNS system has been introduced. The aim of this study was to assess the utility of MRI in patient’s evaluation after SNS implant.

Methods/Interventions

This is a prospective observational study on consecutive patients undergoing an MRI- compatible SNS definitive implant for FI at a tertiary academic center from December
2022 to June 2023. SNS implant was performed adopting a standardized technique,
in local anesthesia, under the guidance of intraoperative X-ray imaging and sensory/
motor responses to the electrostimulation. Radiological data were assessed by a well- trained radiologist. Patients’ characteristics, SNS parameters, intra- and postoperative complications, number of FI episodes and CCFI score were collected. At 3-month follow up, patients underwent an MRI assessment of the electrode position.

Results/Outcomes

Five patients (4 females, 80%) who underwent MRI-compatible SNS implant were included. The standardized electrode placement procedure provided an adequate implant in all patients. At 3-months follow up, a significant reduction in mean FI episodes [4.0 (IQR: 4.0- 9.5) vs. 3.0 (IQR: 1.5-4.5), p=0.068] and CCFI score [11.0 (IQR: 8.5-14.5) vs. 8.0 (IQR: 5.0- 8.5), p=0.042] was reported in all patients. However, at MRI assessment, only 2 electrodes were detected in the correct position. One electrode was placed too medial to the sacral nerve root, into the mesorectal fat, while an electrode displacement was observed in

two patients (although the electrode was in the proximity of the target sacral nerve, patients reported a reduction of efficacy during the last month). Therefore, a SNS settings reprogramming was needed in these patients on the base of MRI findings. After performing MRI, the explant of an SNS system due to infection was necessary in one patient.

Conclusion/Discussion

A systematic postoperative MRI assessment could be able to explain suboptimal or lack of SNS efficacy and guide clinicians for reprogramming the SNS parameters. Further technical and settings adjustments should be adopted to increase the efficacy of SNS implant in patients suffering from FI.

SAFETY OF TITANIZED POLYPROPYLENE MESH IN TRANSABDOMINAL PELVIC FLOOR SURGERY

G. La Greca, F.l Alotaibi, P. Cellerino, P. Prestianni, F. Marazzi, P. Muselli, A. Stuto

IRCCS Policlinico San Donato Hospital, Milan, Italy

Aim: There is ongoing debate about the safety of using mesh in pelvic floor surgery due
to reported complications. Although the current literature suggests that complications related to synthetic mesh are rare, they still occur. Additionally, titanized polypropylene mesh has been found to be both safe and effective. This study aims to assess mesh-related complications in a large group of patients who underwent transabdominal pelvic floor surgery using titanium-coated polypropylene mesh.

Methods: A retrospective study was conducted on 187 patients who underwent transabdominal pelvic floor surgery from 2019 to 2022 with titanium-coated polypropylene mesh. The study aimed to investigate the incidence of mesh-related complications following the procedure. The medical records of the patients were reviewed to identify any mesh-related complications.

Results: The mean age of the study group was 65.5 years. The study found that no mesh- related complications were identified in any of the patients during the follow-up period.

Conclusion: Transabdominal pelvic floor surgery using titanium-coated polypropylene mesh appears to be a safe option, with no reported cases of mesh-related complications.

ROBOT-ASSISTED VENTRAL MESH RECTOPEXY EFFICACY IN THE TREATMENT OF PATIENTS WITH RECTAL PROLAPSE AND SEVERE OBSTRUCTED DEFECATION SYNDROME: A SINGLE-CENTER EXPERIENCE

A.A. Marra,1 P. Campennì,1 F. Litta,1. Parello,1 C. Ratto1,2

1Proctology and Pelvic Floor Surgery Unit, Center of Excellence for Gastrointestinal and Endocrine-Metabolic Diseases, Isola Tiberina – Gemelli Isola Hospital, Rome, Italy 2Catholic University, Rome, Italy

Purpose/Background

Robot-assisted ventral mesh rectopexy (RVMR) is a well-established surgical procedure for rectal prolapse (RP) and obstructed defecation syndrome (ODS). Aim of this study was to assess the efficacy of RVMR in patients with RP and ODS, identifying factors related to persistence of severe postoperative ODS.

Methods/Interventions

This is a prospective single-center observational study on consecutive patients with external or internal RP, rectocele with/-out entero/sigmoidocele who underwent RVMR using Xi Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients’ baseline characteristics, intra- and postoperative data were collected. Symptoms of ODS were assessed using the CCSS score. Uni- and multivariate analysis of factors that could be associated to persistent severe ODS after RVMR was performed.

Results/Outcomes

From November 2020 to January 2024, 73 patients (70 females, 95.9%; mean age 58.7±13.0 years) who underwent RVMR were included: 36 of them (49.3%) reported severe preoperative ODS (CCSS score >15). Mean postoperative follow up was 21±11.2 months.
At last follow up, an overall statistically significant reduction in CCSS score (14.5±5.4 vs 10.7±5.1, p<0.0001) was reported. However, 15 patients (20.5%) reported persistence of severe ODS symptoms after RMVR (new-onset severe ODS was found in 3 of them). Preoperative pelvic floor physiotherapy, previous abdominal open surgery, perineal descendant at defecography, slow colonic transit and severe preoperative ODS symptoms were significantly associated to severe postoperative ODS. All these factors, with the exception of severe preoperative ODS symptoms, were shown to be related to severe postoperative ODS also at multivariate analysis.

Conclusion/Discussion

RVMR has proven to be an effective option in the treatment of patients suffering from RP and ODS, specifically able to improve the severe obstructed defecation. Further multicentric, well-designed, randomized studies could confirm findings of this study.

CONTINENCE DISTURBANCE, FAILURE AND COMPLICATIONS OF FOUR SPHINCTER-SPARING TECHNIQUES FOR THE TREATMENT OF FISTULA-IN-ANO: A SYSTEMATIC REVIEW AND PROPORTION META-ANALYSIS

L. Selvaggi1, G. Fuschillo1, F. Selvaggi1 G. Pellino1,2

1Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy
2Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain

Background and aims: Several techniques are available to reduce the risk of sphincter injury for the treatment of anal fistula, as the Ligation of Intersphincteric Fistula Tract, the Video-Assisted Anal Fistula Treatment, the Fistula Laser Closure and the Endoanal Flap. The aim of this meta-analysis is to provide data on continence, safety, complications, and failure of these techniques.

Methods: The literature research was made on PubMed and Embase databases, including only studies published after 2017. Studies with patients undergoing at least one of the procedures for perianal fistula providing data regarding incontinence were included. Primary outcome was the incontinence rate; other outcomes were failure rate and complications.

Results: Thirty-two articles with 2302 patients were included. No patients undergoing Video Assisted Anal Fistula Treatment or Fistula Laser Closure reported worsening continence, while for Ligation of Intersphincteric Fistula Treatment the continence disturbance rate was 0.882% (95%CI 0.398 to 1.683 P<0.0001 I2 73.32%) and for Endoanal flap was 6.737% (95% CI 3.897 to 10.716 P=0.0077 I2 71.19%). The failure rates were 26,931% (95%CI 21,393 to 33,056 P < 0,0001 I2 84,06%) for Endoanal flap, 27,160% (95%CI 24,411

to 30,047 P < 0,0001 I2 93,05%) for Ligation of Intersphimcteric Fistula Tract, 22,973% (95%CI 19,156 to 27,152 P = 0,0001 I2 79,28%) for Video Assisted Anal Fistula Treatment
and 42,699% (95%CI 38,899 to 46,565 P < 0,0001 I2 89,30%) for Fistula Laser Closure. No major complications were observed. The most common minor complications were pain and bleeding.

Conclusions: Fistula Laser Closure, Video Assisted Anal Fistula Treatment, Ligation
of Intersphincteric Fistula Tract and Endoanal flap may represent a valid option in the treatment of anal fistula. Video Assisted Anal Fistula Treatment and Fistula Laser Closure was associated with no continence disturbance, while the lower rate of failure was associated to Video Assisted Anal Fistula Treatment. Further larger studies with a long follow-up are necessary to obtain more robust data.

MICRO-FRAGMENTED AUTOLOGOUS ADIPOSE TISSUE INJECTION TO TREAT PROCTOLOGICAL DISEASES. OUR INITIAL EXPERIENCE

G. La Greca, P. Cellerino, C. Casiraghi, A. Giori, P. Prestianni, F. Marazzi, P. Muselli, A. Stuto

IRCCS Policlinico San Donato Hospital, Milan

Purpose: The aim of the present study was to analyse the safety and effectiveness of autologous micro-fragmented adipose tissue injection in patients with proctological diseases.

Methods: A cohort of 22 patients with complex and recurrent proctological diseases were enrolled from November 2023 to Februay 2024 in our tertiary referral proctology center; 8 patients had complex anal fistula, 4 patients rectovaginal fistula, 4 patients recurrent pilonidal sinus, 5 patients fecal incontinence and 1 patient chronic pelvic pain. For all patients topical injection of micro-fragmented adipose tissue was performed. Follow-up consisted of out-patient visits scheduled at 7 days, 1 and 2 months after surgery.

Results: There were no cases of postoperative major discomforts, measured with the visual analog pain scale (2±1.2), and intraoperative or postoperative complications related to the procedure. There was no impaired anal continence. Only 1 case of fistula persistency, after 1 month, required a reoperation. The mean operative time was 55 ± 6 min (range 50–70 min). Surgeon experience was associated with significant reductions in operative time (p<0.05).

Conclusions: The injection of autologous micro-fragmented adipose tissue showed favorable safety and effectiveness in the treatment of many proctological diseases. This procedure seems promising but further larger scale studies and a longer follow-up are required to assess its clinical utility.

WATER HOLDING TEST: PREDICTIVE TEST OF ANAL SPHINCTER FUNCTION. A SUBSTITUTE TO PREOPERATIVE ANORECTAL MANOMETRY? PRELIMINARY RESULTS

A. Baglioni, A. Marotta, S. Ferro, E. Rossin, L. Chimisso, S. Ascanelli

U.O. Chirurgia – Azienda Ospedaliero-Universitaria Ferrara

Introduction: the study of pre and postoperative anal continence is based on anorectal manometry’s results, which is to date the predictive test of sphincter function in patients undergoing surgical procedures that may alter anal continence: proctological surgery, rectum resection for cancer, stoma reversal or ileostomy closure. Water Holding Test (WHT) is frequently performed in several surgical units before stoma reversal in place of anorectal manometry but, to date, there is no analysis on the role of this test in clinical routine. The purpose of the study is to evaluate the effectiveness of WHT in predicting anal continence correlating it with preoperative manometric pressures.

Materials and Methods: observational study conducted on 48 patients undergone anorectal surgery at “UO Chirurgia Azienda Ospedaliero-Universitaria Ferrara” from June to December 2023. Every patient undergone both WHT and anorectal manometry and they answered many questionnaires about anal continence before and after 3 months the surgery.
In WHT 150ml of water colored with methylene blue are instill in the patient rectum in three steps, with a range between one and another of 5-10 minutes, during which the patient
has to walk, holding the water in the rectum. We gave 0 point in case of water loss after 50ml, 1 point after 100ml, 3 points after 150ml and 4 points if there’s no water loss and the absorbent pant is dry.
Anorectal manometry is performed the same day of WHT using a pull-through technique, scoring it
Anorectal Manometry Scoring System (ARMSS): 0-1 points in a good anorectal manometry; 2-5 points in a decreased anorectal function.
We informed the patients with a low anorectal function rating at the manometry that there’s an high risk of anal incontinence after surgery.
We re-evaluated every patients after 3 months from surgery, with a new WHT, manometry and questionnaires (Wexner score).
Primary outcome was to correlated preoperative WHT results with preoperative manometric
pressure and volumetric values and Wexner score.
Secondary outcome was to correlate this preoperative results with the results of the same tests after 3 months from surgery.

Results: In case of sufficient WHT despite low manometric pressure levels, the risk of postoperative anal incontinence seemed to be low.

Conclusions: WHT is a good way to predict postoperative fecal continence. Patients with low pressures during manometric rest or dynamic fases but passed WHT, didn’t show post-operative fecal incontinence. WHT is an easy and reliable method to predict sufficient postoperative fecal continence in case of surgery that may alter anal continence.

PRELIMINARY EXPERIENCE OF A MULTIDISCIPLINAR PROCTOLOGICAL EQUIPE IN THE EVALUATION OF PATIENTS WITH ODS SYMPTOMS

F. Ghiglione, S. Marola, V. Tamburi, F. Farnesi

Ospedale Humanitas Gradenigo – Torino
Purpose: To evaluate the correlation between ODS symptoms and radiological data

obtained with Defecography – XR to guide to the best treatment.

Material and Methods: data from 96 patients who underwent defecographic examination from November 2021 to October 2022 were retrospectively collected. Defecographies were performed following the guideline of the “Consensus for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders”. Collected data included among the other: presence of rectocele, descending perineum syndrome, incontinence, constipation, sensation of incomplete evacuation, defecatory ARAs, alteration of muscular coordination, type of treatment recommended. Defecographic Oxford Scale was used to evaluate the rectal prolapse grade. Statistic correlation was calculated with the Pearson’s correlation coefficient.

Results: 96 patients (M=7; F=89, age 65,19 ± 12,25) presented in 67 cases a rectocele,
in 46 muscular incoordination and in 78 a rectal prolapse (27,1% Oxford grade II). Direct correlation was found between constipation and rectocele/rectal prolapse, sensation of incomplete evacuation and rectocele, referred incontinence and episodes of incontinence during the defecography; inverse correlation was found between the ARAs values and
the altered muscular coordination. No correlation was observed between the descending perineum syndrome and all the other data.
Has been observed that the presence of constipation and rectocele is followed by surgical indication to STARR procedure; the muscular incoordination, instead, is an indication to biofeedback therapy; at last, the presence of episodes of incontinence, confirmed during the defecography-XR, must be deepened to guide to the best treatment (in most cases Laparoscopic Ventral Rectopexy).

Conclusion: the Defecography-XR, performed after an accurate proctological examination, is an important step for the evaluation of the presence of rectocele, muscular incoordination, rectal prolapse and to confirm or change the type of treatment recommended.

TECNICA FILAC CON FISTULOSCOPIA DIAGNOSTICA (VAAFT)

F. Tumminelli

Dipartimento di Chirurgia Generale – ASFO-Pordenone

Il video descrive nel complesso la tecnica FiLaC® (Fistula Laser Closure), un intervento “sphincter preserving” per il trattamento mininvasivo delle fistole perianali che permette
di risolvere efficacemente la patologia senza danneggiare la muscolatura sfinterica. È una tecnica che non richiede l’escissione del tramite fistoloso o la necessità di confezionare un flap di avanzamento, è ripetibile, è combinabile con altri protocolli terapeutici e ha un tasso di successo descritto in letteratura che va dal 60 al 70%.
Nel complesso, la tecnica prevede l’utilizzo di una fibra ottica radiale che emette una
luce laser a una lunghezza di 1470nm in modalità continua a 12W, tale lunghezza d’onda all’interno del tramite fistoloso crea un fenomeno di “shrinkage” del tessuto e successivo “sealing”.
La tecnica è particolarmente adatta per le fistole trans-sfinteriche con tramite lungo e con diametro fistoloso di circa 2-3mm.
Il Kit della procedura contiene: un proctoscopio; una fibra laser monoring coassiale e un setone cavo per il passaggio della fibra nel tramite fistoloso.
La procedura è eseguita su paziente in posizione ginecologica, è divisa in quattro steps:
1) Curettage del tramite fistoloso con setone pluriannodato o con brush ed eventuale rimozione del granuloma cutaneo;
2) Introduzione della fibra ottica nel tramite fistoloso che può avvenire per mezzo di setone cavo (come nel primo metodo visualizzato) oppure per mezzo di ulteriore setone dedicato che ha lo scopo di fungere da guida alla fibra ottica. In tale fase, la fibra viene introdotta nell’orifizio fistoloso esterno e fuoriesce nell’orifizio fistoloso interno;
3) Dopo rimozione del setone guida, si procede alla fotoablazione con la trazione della fibra per circa 1mm/sec fino a completa obliterazione;
4) La procedura può concludersi con l’eventuale chiusura dell’orifizio fistoloso interno con punti riassorbibili.
Nella seconda parte del video si mostra un caso di fistola transfinterica complessa trattata per mezzo di tecnica FilaC con fistuloscopia diagnostica (VAAFT). La procedura inizia con l’ispezione dei tramiti fistolosi per mezzo di fistuloscopia, in cui si utilizza il fistuloscopio della VAAFT iniettando una soluzione di glicina/mannitolo che ha lo scopo di evidenziare
il tramite fistoloso principale e i tramiti secondari. Nel seguente caso, si può notare come
il setone sia stato inserito erroneamente creando un tramite fistoloso iatrogeno, notare il dettaglio del cambio di colore della parete che passa da un colore rosso (fistola primitiva
a fondo ceco) a un colore giallo/bianco riferibile alla fistola iatrogena che giunge fino
al canale anale. Dopo accurato curettage, tutti i tramiti fistolosi sono stati trattati con fotoablazione per mezzo di fibra ottica monoring coassiale a laser con una lunghezza d’onda di 1470nm in modalità continua a 14W. L’intervento si conclude con chiusura degli orifizi fistolosi interni tramite punto riassorbibile.

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