Editor’s Choice

High-resolution anoscopy, is there a benefit in proceeding directly to the operating room?

The development of high resolution anoscopy (HRA), though not original and borrowed from the gynecologic counterpart, is changing the way to deal with anal squamous cell neoplasia, and it is intuitive imagines that it will become an essential tool in its management.
Although anal squamous cell carcinoma represents only a small proportion in the burden of malignant diseases, two features are sufficient to focus the interest: its incidence is slowly rising without an improvement in survival rates, and its treatments, even the conservative ones as radiation therapy, could highly affect the patients’ quality of life. [3] Considering this, the possibility to detect its precursor or to diagnose it in early stages is noteworthy as well as necessary. Moeckli et al, from a scrutinous retrospective review of an already long experience, showed how HRA is an uncontested sensitive method to detect pre-cancerous lesions. The question of the best setting to perform it seems to us a relevant issue that need to be discussed.
The authors showed how HRAs performed in the OR exhibit a significantly higher correlation to anal cytology (82%) than procedures performed in the office (51%). The reasons underlying this finding, according to the Authors, could be several: a better exposition for the utilisation of a larger retractor allowed by the anaesthesia, positioning of the patient on the operating table, a more careful examination without the necessity to rush the procedure due to patients’ discomfort, and a larger number of biopsies.
Considering these results, the Authors proposed a diagnostic-therapeutic protocol for high-grade pathology (HSIL) managing it directly in the operating room by HRA with biopsy and ablation, with the purpose to avoid additional procedures and the discomfort of an office based HRA, such improving hopefully the patient’s compliance to follow-up.
Though we believe that the effort to standardize the best setting for the procedure is commendable, we have some remarks to do. Firstly, we think it should be better to standardize the procedure establishing, for example, a proper number of biopsies in order to improve its sensitivity despite the setting. Then, as a matter of fact, the protocol proposed by the author seemed to us time-consuming and did not take into account that it has to deal with the actual availability of the operating room that could not be immediate or spare for a sufficient time. Nevertheless, it is not to be forgotten that even the analysis of the biopsies is highly subject to interobserver variability and that even this factor must be enlisted among those that could have biased the results.
As last remark, although several retrospective studies have shown that treatment of high-grade anal dysplasia may be effective in preventing anal cancer, the actual benefit to treat HSIL has to be demonstrated yet and, to date, there is still a lack in the understanding of the natural history of AIN.
In conclusion, we hope that the introduction of a targeted screening program will be successful for anal cancer as it was for the cervical counterpart, and we think that HRA will be a useful tool for it, but still, in our opinion, some questions need to be answered to better define its role and further studies are needed to decide which might be the best setting to perform it.

Dr.ssa Monica Ortenzi & Dr. Stefano Mancini
Clinica chirurgica generale e d’ urgenza
AOU. OO.RR. Ancona


Marzo 2021

In 2006 D’Hoore e Penninckx described the technique of laparoscopic ventral recto(colpo)pexy for the treatment of rectal prolapse [D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 2006; 20: 1919-23]. A few years later, Reche e Faucheron wrote an editorial in Techniques in Coloproctology [Reche F, Faucheron JL. Laparoscopic ventral rectopexy is the gold standard treatment for rectal prolapse. Tech Coloprctol 2015; 19: 565-66] stating that this surgical technique became the gold standard treatment for rectal prolapse as: – it spares the parasympathetic component of the inferior hypogastric plexus avoiding the onset of de-novo constipation after surgery, – it is feasible by a laparoscopic approach, – it exhibits a similar effectiveness than laparoscopic resection-rectopexy with lower postoperartive morbidity, – it allows to treat any associated pelvic disease (deep Douglas, enterocele, vaginal vault prolapse, etc.).

Despite Cochrane review failed to identify the optimal operation for rectal prolapse due to the heterogeneity of published data [Tou S, Brown SR, Nelson RL (2015) Surgery for complete (fullthickness) rectal prolapse in adults. Cochrane Database Syst Rev 2015], laparoscopic ventral mesh rectopexy rapidly emerged as the most widely performed operation for full-thickness prolapse in Europe [Formijne Jonkers HA, Draaisma WA, Wexner SD et al. Evaluation and surgical treatment of rectal prolapse: an international survey. Colorectal Dis 2013; 15:115-9]. The indications have been progressively enlarged encompassig symptomatic “high grade” internal prolapse (3-4 Oxford grades) and rectocele. This is one of the reasons explaining the heterogeneity of the trials and observational studies reported in literature as almost always they include series with different pathological conditions.

Till now, any algorithm could be developed for the treatment of recurrent prolapse in general and particularly after laparoscopic ventral rectopexy. The latter is the subject of a original article published in the March 2021 issue of Techniques of Coloproctology [Laitakari KE, Mäkelä‑Kaikkonen JK, Kairaluoma M, Junttila A, Kössi J, Ohtonen P, Rautio TT. Redo ventral rectopexy: is it worthwhile?] reporting a multicentre retrospective Finnish experience. Data suggest that redo rectopexy is a safe operation with acceptable postoperative complications. Similarly to primary operation, revisional surgery seems to be more effective in improving quality of life and symptoms in patients suffering from internal than external prolapse.

Interesting technical details are analyzed: intraoperative findings showed a mesh detachment from sacrum in one third of patients, from rectum in 23.3% of case while in 20.9% of patients the mesh was found to be placed too proximally. The previous mesh was removed in the minority of cases whilst in about two thirds of patients a new one was implanted. However, the mean operating time (157 min) suggests that we are dealing with a technically demanding operation due to the mesh-related adhesion in the pelvis. The consistency of the study is limited by some weak points including the lack of available data on primary surgery and the high percentage of patients dropped out at the follow up questionnaire. Furthermore, the onset of de novo symptoms after surgery as well as the patient’s satisfaction (54.2%) seem worse than after primary surgery, two issues that were not specifically discussed by the Authors.

Gennaio 2021

Magnetic resonance imaging (MRI) is commonly performed in the workup for anal fistula (AF), both for diagnosis and follow-up, since it allows a good visualization of AF and its extension in all three dimensions, the possible presence of secondary branches and abscesses, the morphological condition of anal sphincters and the anatomy of the perianal and perirectal region. Moreover intravenous contrast medium helps differentiate active fistulous tract from fibrotic scar.

St James Hospital University classification (J Morris, JA Spencer, NS Ambrose. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 20;2000;623-635) is based on MRI findings and identifies 5 grade: inter-sphincteric fistula with or without abscess or secondary track (I & II), trans-sphincteric fistula with or without abscess or secondary track (III & IV), supraelevator and traslevator disease (V). This classification has been readily adopted by radiologists, but the clinical utility is quite low for surgery planning since infralevator fistulas are anatomically divided in two broad categories (inter- and trans-sphincteric fistulas) and the classification assumes that all trans-sphincteric fistulas are complex: we know from a clinical point of view that not all trans-sphincteric fistulas are complex and they could be easily managed and vice versa with inter-sphincteric fistulas (P Garg. Comparing existing classification of fistula-in-ano in 440 operated patients: is it time for a nwe classification? A retrospecitve cohort study. Int J Surg. 2017;Jun;42:34-40)

I Sudoł-Szopińska, GA Santoro et al. in Magnetic resonance imaging template to standardize reporting of anal fistulas. Tech Coloproctol 2021 propose a template for MRI report of AF with the purpose of improving AF characterization, enhancing surgical decision planning, facilitating re-evaluations during the follow-up and allowing a better interobserver comparison.

The proposed template for a uniform description of AF includes:
– Parks classification of primary tract, location on a clock dial, height and maximum cross-sectional diameter (mm);
– Secondary extensions type, location and number;
– Internal outlets and location;
– Abscess presence, location, type and extension;
– Internal and external sphincter morphology, the presence of defects, tinning, scars or atrophy.

The template include also a graphic representation of the AF in the three dimensions.

The proposed template may be an effective way to improve standardization of MRI AF report and it can certainly be useful in the follow-up of patients with complex and multi-treated perianal disease (such as in Crohn’s Disease) and in case patients need to be evaluated by different specialists.

A study is in progress (NCT04541238) to evaluate the feasibility and acceptability of the MRI template and, certainly the most important point of the question, whether it is effective in enhancing surgical decision planning.

Anna Maffioli, Chirurgia 1, ASST Fatebenefratelli Sacco, Milano

Dicembre 2020

This month we highlight two interesting papers published on the issue 12, December 2020 of Technique in Coloproctology.
The Editorial (P Christensen, NS Fearnhead, J Martellucci. Transanal irrigation: another hope for patients with LARS. Tech Coloprctol 2020; 24(12): 1231-1232) faced a still unsolved problem that affects the quality of life in a not negligible percentage of rectal cancer patients. As in the last decades multimodality therapies have improved significantly their oncologic outcomes, the number of survival patients has increased progressively leading to the need to pay a growing attention to the different aspects of their quality of life, both from the clinical and scientific point of view.
Low anterior resection, either laparotomic or laparoscopic or robotic, is however mutilating of a visceral structure although restorative of intestinal canalization.
In a functional perspective, the decreasing reservoir capacity of the neorectum, the biomechanical abnormalities of the neorectum-distal colon, the impairment of the afferent sensitive arch from the remnant anal mucosa as well as of sphincter muscles for the summation of effects of surgery and radiotherapy on neuromuscular structures, the small bowel radiation enteropathy should be considered.
Increased frequency of defecation, urge, fecal incontinence, poor discrimination between flatus or stool, and incomplete rectal evacuation outline the spectrum of symptoms defined as Low Anterior Resection Syndrome (LARS). Albeit with different severity, LARS affects from 50% to 80% of TME survivors.
The investigations for potential treatments of LARS is fervent but still unsatisfactory. Ranging from pharmacological to rehabilitation therapy, several proposals have been tested over time. In the last years, clinical research has tried to translate in the management algorithm of the LARS the experiences gained with TransAnal Irrigation (TAI) in the treatment of neurogenic bowel diseases. The main pros of the technique are its conservative approach and easy to use without meaningful cons.
As the authors pointed out, several published studies have already reported the effectiveness of TAI in LARS patients. In this context, the target of upcoming studies should be the identification of the groups of patients that could actually benefit from this treatment.

The article by Khan MF and Cahill RA (Carbon dioxide gas leaks during transanal minimally invasive surgery, Tech Coloprcotol 2020; 24(12): 1307-1308) addresses an emerging problem during the Covid-19 pandemic. Performing minimally invasive surgery requires precise movements and stable visualization of the operating field as crucial technical aspects. The limited space in which transanal procedures are carried out further emphasizes these requirements.
A billowing rectum and the narrowness of the operating field are not unfamiliar issues during transanal endoscopic surgery and probably they still represent one of the main causes why these techniques have not become widespread over the years outside specialized centers.
The carbon dioxide (CO2) flow escaping proximally towards the colon is regarded usually as the main cause of the rectal billowing. CO2 leakage through the valved trocars, the Gelseal Cap application or around the access channel can occur too and several technical solutions have been proposed to address this issue. The traditional TEM instrumentation, for example, is equipped with an insufflator capable of controlling continuously the pneumorectum.
As technology advances, new tools have been developed to ensure a high flow insufflation system and, more recently, an insufflation stabilization bag has been introduced.
The current epidemic has raised another relevant problem: as Coronavirus has been detected into the stool of the infected patients, gas leakage may hesitate in the diffusion of harmful pathogens into the air. So, it is no longer just a mere procedural drawback, but it may become a source of potential infective risks for the operating theatre personnel.
In this context, the demonstration of actual gas leakage, that could be even unnoticed and not relevant to carry out the procedure, could pose a real matter taking into account the forced strict proximity of the surgeons’ faces to the source of gas escape throughout the procedure.
Currently, the patients are screened for Covid-19 before surgery, but the final suggestion of the authors should be taken into consideration and it could constitute a valid subject for further investigations.

Dr. Stefano Mancini & Dr.ssa Monica Ortenzi
Clinica chirurgica generale e d urgenza
AOU. OO.RR. Ancona

Novembre 2020

Total mesorectal excision (TME) is considered the gold standard in the treatment of rectal cancer; laparoscopic TME (L-TME) is an alternative to open approach. Several randomized controlled trials have reported the feasibility and the oncological safety of colorectal laparoscopic surgery. Despite the proven benefit of laparoscopic colorectal surgery, surgeons are still far from considering it as the gold standard procedure, especially in rectal cancer (G Luglio, GD De Palma, R Tarquini et al. Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study. Ann Med Sur 4 2015 89-94). This is because L-TME is considered a technically demanding procedure, with a greater learning curved compared to right-sided colectomies and because technical problems encountered during surgery may translate into flawed clinical and oncologic results (PP Tekkis, AJ Senagore, CP Delaney and VW Fazio. Evaluation of the Learning Curve in Laparoscopic Colorectal Surgery – Comparison of Right-Sided and Left-Sided Resections. Ann Surg 242 1 2005).

Presently, little distinction is made regarding the technical difficulty of L-TME: pelvic anatomy, tumor localization, BMI and neoadjuvant radiation therapy are considered risk factors for technical difficult procedure (A Veenhof, AF Engel, DL van der Peet et al. Technical difficulty grade score for the laparoscopic approach of rectal cancer. Int J Colorectal Dis 20018 23 469-475).

A better definition of preoperative risk factors for a difficult L-TME procedure and subsequently a stratification of the patients could be useful for the colorectal surgeon in preparing for surgery, for patients’ safety and teaching purpose.

Is therefore interesting the study by D Krizzuz (D Krizzuk, S Yellinek, A Parlade et al. A simple difficultly scoring system for laparoscopic total mesorectal excision. Tech Coloproctol 2020 24 1137-1143) that proposes a scoring system to predict the difficulty of L-TME.

The study assesses the association between preoperative factors, such as sex, BMI, age, ASA class, neoadjuvant therapy, tumor distance from anal verge and MRI pelvimetry, and operation difficulty in 53 patients that underwent L-TME. A difficult procedure is defined if 3 or more of the following parameters are present: operation time > 320 minutes, blood loss > 250 ml, intraoperative complications, conversion to laparotomy, > 2 stapler applications, incomplete TME quality and subjective judgment of the difficult of the operation.

Univariate analysis shows that sex, BMI, and ASA grade are associated to the operation difficulty; moreover, on MRI pelvimetry, statistical significance is shown for transverse diameter (with a cut-off of 12.7 cm) and interspinous distance. At the multivariate analysis only BMI (> 30 Kg/m2) and male sex are associated to difficult operation. Therefore, a difficult scoring system (DSS) based on sex (female: 0 point; male 1 point) and BMI (< 30 Kg/m2: 0 point; > 30 Kg/m2: 1 point) is proposed:

– Total score = 0: difficult operation 10%
– Total score = 1: difficult operation 33.3%
– Total score = 2: difficult operation 77.8%

The results of the preoperative DSS may guide the choice of the surgical approach (trans anal open, robotic), surgical team, or the decision to refer the patient to a high-volume rectal cancer surgeon. Further large-volume prospective studies are indicated to validate this DSS.

Anna Maffioli
ASST Fatebenefratelli Sacco, Milano
Università degli Studi di Milano

Ottobre 2020

Abdominoperineal resection (APR) for many years was the treatment of choice for most patients with rectal cancer, in particular in cases of cancer located within 4–5 cm from the anal verge. This procedure completely removes the distal colon, rectum, and anal sphincter complex using both anterior abdominal and perineal incisions, resulting in a permanent colostomy. Obviously, this is a demolition operation which compromises the patient’s quality of life in a considerable way (Abdalla S, Valverde A, et al. Robotic-assisted abdominoperineal resection: technique, feasibility, and short-term outcomes. Mini-invasive Surg 2019;3:39).

Improved surgical techniques and the development of new technology have decreased the number of patients who require this radical and morbid procedure. Moreover, the use of neoadjuvant therapy increased the patient population who are eligible for sphincter-sparing procedures (Perry WB, Connaughton JC. Abdominoperineal resection: how is it done and what are the results? Clin Colon Rectal Surg. 2007 Aug;20(3):213-20).

In this sense, intersphincteric resection and coloanal anastomosis gained widespread acceptance, although according to the literature patients often have poor anal function.

It is therefore interesting the study proposed by Sun and his colleagues, analysing the conformal sphincter preservation operation (CSPO), a new surgical procedure which preserves more dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space.

They have previously published their initial experience of this procedure (Lou Z, Gong H, et al. Pull-through and conformal resection for very low rectal cancer: a more satisfactory technique for anal function after sphincter preserving operation. Ann Laparosc Endosc Surg 2016;1:24). In this paper they compared coloanal anastomosis, APR and CSPO, and they found no difference in surgical complication rate and no significant differences in daily fecal frequency. Moreover, there were no differences in local recurrence and distant metastasis among groups.

In this second work the aim was to analyse the short-term surgical results and long-term oncological and functional outcomes of CSPO. Obviously, this surgical technique is applicable in selected patients with very low, small and early-stage rectal cancer, but results of the paper considered suggest that CSPO is safe with acceptable oncological and functional outcomes. It has the advantage of achieving a balance between oncologic safety and functional results. In fact, fecal continence can be preserved without compromising oncological results.

Dr. Beatrice Pessia e Dr. Lucia Romano
Dipartimento di Chirurgia
Università degli studi dell Aquila

Settembre 2020

Surgical risk’s stratification remains one of the great challenges for the surgeon, especially in oncological patients. For this purpose, it appears fundamental to consider, side by side with the traditional prognostic factors related to the oncological disease and patient’s comorbidity, the nutritionals factors as well. It seems mandatory to evaluate and possibly to treat any nutritional derangement before surgery.
Several studies, such as the studi of Dolan et al. (Tech Proctol 2019), show that sarcopenia in colo-rectal cancer patients a is associated with worse surgical outcomes, poor survival and bad tollerance to chemotherapy.
Although potentially modifiable, as oppposed to pathological staging, there are few reported interventions to modify muscle mass and potentially improve patient outcomes in the surgical setting.

Bozzetti et al. (Ann Oncol 2017), states that sarcopenia is also involved in a vicious circle made of mutual negative interactions between sarcopenia itself and chemotherapy. Indeed, there is a wide agreement showing that sarcopenic patients show a decreased response to chemotherapy because they are often forced to reduce chemotherapy dosage (or to delay the cycles of administration) due to increased toxicity. Probably this happens because it is a common habit to dose chemotherapy only as function of the body surface area, without considering that fat mass, in sarcopenic patients, can accounts for a larger and unpredictable part of body weight.

The University of Michigan created the “Michigan Surgical Home and Optimization Program” to help those patients actively prepare for surgery. Using a technique called “Morphomic Analysis” patients are engaged in a customized intervention program.
Thus, this “training” program aims patients to understand their high-risk condition and to engage them in a pre-habilitation schedule based on the improvement of four strictly-dependent areas: increasing physical activity, improving the respiratory function – for example by quitting smoke habits, gaining a better alimentation and reducing psycho-physical stress trough special exercises. (Englesbe MJ. et al. Surgery. 2017)

Moug S.J et al, in a randomized control trial , titled Does prehabilitation modify muscle mass in patients with rectal cancer undergoing neoadjuvant therapy? A subanalysis from the REx randomised controlled trial show the results obtained by the two groups (ie those entrusted to pre-rehabilitation and those without) of rectal cancer patients undergoing neoadjuvant chemotherapy (NACRT)
Prehabilitation improved muscle mass in patients with rectal cancer who had NACRT

This is the first study which reports modification of muscle mass with prehabilitation in patients with colorectal cancer who have undergone neoadjuvant therapy. The graduated individualised walking programme provided sufficient muscle overload to increase psoas muscle mass in 65% of the intervention group in comparison to the controls, where 67% had the expected reduction in muscle mass as a consequence of having long-course chemoradiotherapy. With 14% of patients presenting with sarcopenia at diagnosis, prehabilitation may have a further role to play in the perioperative pathway.

Certainly, large-scale randomized clinical trials are required; however, it seems appropriate to underline that to treat a modifiable risk factor by means of rebalancing programs could offer a survival benefit in cancer patients, especially if they need chemotherapy.

Dr. Beatrice Pessia e Dr. Lucia Romano
Dipartimento di Chirurgia
Università degli studi dell Aquila

Agosto 2020

From the embryological point of view the colonic splenic flexure is a watershed between the right (foregut) and the left (hindgut) colon, resulting in its dual vascular supply and lymphatic drainage towards both superior and inferior mesenteric territories. Furthermore, several studies found that blood flow in the distal transverse colon and splenic flexure exhibits a highly variable anatomy. Griffith first reported that in most of the cases the blood supply to the splenic flexure is carried through the left colic artery and only in 11% of cases it is provided by the left branches of the middle colic artery. Subsequently, others reported that the middle colic artery is completely absent in 20% of cases, a ‘true’ middle colic artery could be found in only 46% of specimens and an accessory middle colic artery running towards the splenic flexure can be identified in about one third of patients, branching from the superior mesenteric artery in the majority of cases (Griffith JD Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 1956; 51: 241–56. Sakorafas GHG et al Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol 2006; 15: 243–55. Mike M et al Reappraisal of the vascular anatomy of the colon and the consequences for the definition of surgical resection. Dig Surg 2013; 30: 383–92). By means of laparoscopic scintigraphic mapping, lymphatic drainage in physiologic status was detected preferentially directed towards the left colic pedicle with 9:1 ratio whilst in patients with colon cancer conflicting results were reported (Vasey CE et al Lymphatic drainage of the splenic flexure defined by intraoperative scintigraphic mapping. Dis Colon Rect 2018; 61: 441–6). The majority of lymph node metastases were located along the paracolic arcade and the left colic artery in the series of Nakagoe, De Angelis failed to find metastatic nodes along the superior mesenteric territory whilst Watanabe using peritumoural injection of indocyanine green detected fluorescence along the accessory middle colic artery towards its origin when this branch was present (Nakagoe T et al Carcinoma of the splenic flexure: multivariate analysis of predictive factors for clinicopathological characteristics and outcome after surgery. J Gastroenterol 2000; 35: 528–35. De Angelis N et al Laparoscopic extended right hemicolectomy versus laparoscopic left colectomy for carcinoma of the splenic flexure: a matched case–control study. Int J Colorectal Dis 2016; 31: 623–30. Watanabe J et al Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence. Int J Colorectal Dis 2017; 32: 201–7). As standardized oncological resections are established according to the lympho-vascular anatomy, the optimal surgical treatment of splenic flexure cancer remains still debatable and both extended right hemicolectomy and left colonic resection have been proposed. Till now, pertinent literature fails to show any significant difference between the two procedures with regards to long-term oncological outcome.

In the last issue of Techniques in Coloproctology (volume 24, issue 8, August 2020) Yamaoka and coworkers report a mono-institutional retrospective study of a series of 538 patients submitted to curative resection for stage I-III cancer of the proximal transverse-splenic flexure-distal descending colon with the aim of investigating the distribution of lymphatic metastases. The paper shows a comprehensive and very detailed lymph node mapping pointing out the frequency of the metastatic involvement of every station. The subgroup of patients with splenic flexure cancer exhibited a significantly lower proportion of lymph node metastases in the intermediate and main region than proximal transverse or distal descending subgroups, as in more than 90% of pathological stage III patients metastatic nodes were found within the pericolic region. Furthermore, in the splenic flexure subgroup, no patient had node metastases neither at left colic level nor inferior mesenteric root. The analysis of the horizontal tumoral spreading demonstrated that in splenic flexure cancer it was mainly directed toward the oral than the anal side of the tumor with an incidence of pericolic metastases of 42.6% vs 16.7% respectively. Unfortunately, as no patients in this group underwent division of the root of the middle colic artery no data are available concerning the nodes’ involvement at that level.
The secondary end-point of the study is the long-term outcomes (disease-specific survival rate): no significant differences were found among the groups but no firm conclusion can be drawn due to the retrospective design of the study, the different proportion of D3 resections and the lack of a control arm.

Antonio Amato
SSD Colonproctologia
Dipartimento di Chirurgia – Ospedale di Sanremo

Luglio 2020

The July issue of Techniques in Coloproctology includes two papers about laser treatment of fistula-in-ano: an editorial by Giamundo (Laser treatment for anal fistulas: what are the pitfalls?) and an original article by de Bonnechose et al. (Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: “the ideal indication” is becoming clearer…).

The main indication of the technique is the treatment of high or complex anal fistulas, where other surgical procedures may impair the continence.

Since in Literature there is a great variability in the results of this technique – in particular Giamundo reports a healing rate of 71,1% [Giamundo et al. Colorect Dis 2014], while de Bonnechose of 44,6% – the aim of the Authors is to investigate the predictive factors of success or failure of laser treatment for fistula-in-ano.

There may be several explanations for the different success rates of the studies previoulsy published in the Literature.

The patients are not exactly comparable between studies: the main biases are the great variability in type, length and size of the fistulas, the size of the internal orifice and the proportion of inter-sphincteric, trans-sphincteric or supra-sphincteric tract.

Moreover, the shrinkage of fistula tracts caused by laser energy is linked to the following features:

  • fistula tract length
  • fistula diameter (less effective over 4-5 mm)
  • internal orifice size

that are difficult to estimate.

The Authors agree on the need of fistula tract preparation as a bridge-to-surgery with abscesses drainage, fistula curettage and placement of a loose seton, that may induce the formation of fibrotic tissue and fistula caliber.

Since LAFT is a blind procedure, another critical point is the evaluation of the amount of the necessary energy for the shrinkage, in terms of total amount of energy administered and of amount of energy delivered per centimeter of fistula. The last is difficult to be measured but Giamundo believes that is more significative than the total amount of energy administered during the procedure.

De Bonnechose identifies two fistulas categories based on the total amount of energy administered:

  • fistulas requiring less than 400 J
  • fistulas requiring more than 400 J

Fistulas requiring less than 400 J had a significantly higher healing rate (65%) compared to fistulas requiring more than 400 J (32%): this could be explained by larger diameter fistulas that require more energy to be closed or by the “overburning” effect of too much energy. De Bonnechose identifies a trend in favor of lower energy/cm, but without reaching statistical significance.

Another questionable point is the treatment of the internal orifice: in the study by Bonnechose the internal orifice was not closed, but in patients with wide internal orifice (larger than the probe) the heling rate was lower (15.4%). Since that both the Author suggest the closure of a wide internal orifice with an advancement flap.

Finally, when we consider as end point the recurrence rate, real recurrence must be differentiated from non-healing or persistent fistula.

In conclusion all the Authors confirmed that the fistula-in-ano laser treatment is an effective sphincter-saving technique and the success rate should be compared with the other complex anal fistulas sphincter sparing techniques (fibrin glue, plugs).

At the same time, this comparison is complex since the huge variability of the considered characteristics.

Stefano Mancini
SOS Coloproctologia e disfunzioni del pavimento pelvico
AOU.OO.RR. Ancona

Giugno 2020

Laparoscopic right hemicolectomy (LRHC) is a common performed procedure and is considered by many to be a standard of care in the treatment of benign and malignant diseases of the right colon, allowing faster recovery with analogous oncological results when compared with open procedure [van Oostendorp et al. Surg Endosc. 2017].

Extracorporeal (EC) and intracorporeal (IC) anastomosis have been described for ileocolic anastomosis: to perform EC anastomosis a greater mobilization of the colon inside the body, mesenteric tractions and exteriorization of the bowel through midline periumbilical incision are needed. On the other hand, IC anastomosis does not require bowel exteriorization and the resected segment of the colon can be delivered through a midline vertical incision or a Pfannenstiel incision; however, it is technically demanding and requires advances laparoscopic skills [Ricci C et al. Langenbecks Arch Surg. 2017].

Several observational studies assessed the safety and efficacy of IC versus EC anastomosis with discordant results. However, recent meta-analyses, reported reduced postoperative infectious and overall complications in the postoperative course in favour of the IC anastomosis technique. [Aiolfi A et al. J Laparoendosc ADV. 2020].

These results are limited by the quality of the analysed studies, in term of study design, sample size, lack of standardised surgical technique and postoperative management, and heterogeneity in definition of outcomes. Therefore, to date there are no guidelines on the indications for performing each type of anastomosis, and the selections of IC versus EC anastomosis depends on the personal expertise and preference of the surgeon [Emile S H et al. Tech Coloproctol. 2019].

A recent single-centre, double-blinded, randomized controlled study compared outcomes between IC and EC techniques in 140 patients (70 in each group). Intraoperative results recorded a non-significant IC anastomosis superiority over EC anastomosis, while postoperative results showed IC anastomosis to be better in recovery of bowel function (2 vs 3 days for median time to first flatus and 4 vs 4.5 days median time to first stool; p=0.003 and p=0.032 respectively) and postoperative pain (particularly on postoperative day 3; p=0.002), with similar overall 30-day morbidity rates and severity of complications in the two groups. However, the IC anastomotic leak rate was higher than the EC one (8.6% vs 2.9%), although this finding was not statistically significant [Allaix M E et al. Ann Surg. 2019].

In this volume (Volume 24, Issue 6, June 2020) of Techniques in Coloproctology, Bou Saleh N. and his colleagues reported the results of their retrospective, non-randomized, multicentric study, with the aim to compare the short-term post-operative results obtained in patients undergoing LRHC in tertiary centres using either IC or EC anastomosis.

Postoperative morbidity, including medical and surgical complications and postoperative outcomes, and mortality were analysed during the hospital stay or within 90 days after surgery in 597 patients undergoing LRHC. The indications for surgery were neoplasm in 451 cases (75.54%), polyps in 93 cases (15.58%) and inflammatory bowel disease in 53 cases (8.88%). An IC anastomosis was performed in 150 patients (25.13%) and an EC anastomosis in 447 patients (74.87%). The patients in the two groups were comparable except for BMI (higher in the IC group; p=0.003) and gender (there were more males in IC group; p=0.005). The results showed a shorter duration of the surgical procedure in IC group (150 vs 195 min; p>0.001); the incidence of medical complications (cardiac, vascular and pulmonary) was significantly higher in EC group (p=0.049) and was confirmed at the multivariate analysis. A shorter hospital stay was observed in the IC group (median of 7 versus 8 days; p=0.003), with no differences in terms of surgical outcomes and 90-day mortality.

Even if this multicentre study collected a great number of patients in tertiary centres involving experts in both anastomotic technique and the patients were collected in a relative short period of time (2005-2015) in which there have not been technical changes, prospective randomised trials with objective classification of postoperative complications “a priori” established are needed to confirm the postoperative advantages of IC anastomosis pointed out in the present study.

To date LRHC is considered the standard of care for benign and malignant diseases of the right colon, allowing a more rapid postoperative recovery and a lower rate of surgical wound infection with the same effective oncological radicality and most laparoscopic side-to-side ileocolic anastomoses are performed extracorporeally, due to technical difficulties. Available data do not allow to state that IC is superior to EC anastomosis. Several ongoing randomized studies are registered on https://clinicaltrials.gov and evidence from these studies will hopefully bring to definitive results.

Anna Maffioli
ASST Fatebenefratelli Sacco, Università degli Studi di Milano

Maggio 2020

Hartmann’s reversal (HR) is a complex surgical procedure with significant postoperative morbidity, which is designed to reduce the physical and psychological problems associated with a permanent colostomy. Minimally invasive techniques have become popular in colorectal surgery, but HR can be considered one of the most technically demanding procedures in these terms [Horesh N, et al. Tech Coloproctol. 2018].

In fact, the first Hartmann’s procedure is often performed in a “hostile” abdomen, with peritonitis, bowel ischemia or infection, and this causes adhesions and difficulty in recognizing anatomical structures. The surgical field may also be sometimes affected by radiotherapy and chemotherapy, and all these factors contribute to increase the difficulty in restoring bowel continuity [Celentano V, et al. J Laparoendosc Adv Surg Tech A. 2018].

Nevertheless, laparoscopic approach reduced morbidity compared with the conventional open procedure; laparoscopy has been associated with faster recovery and better outcomes when compared with open surgery [Toro A, et al. Gastroenterol Res Pract, 2014; Celentano V, et al. Int J Colorectal Dis, 2015].

In this volume (Volume 24, Issue 5, May 2020) of Techniques in Coloproctology, D’Alessandro A. and his colleagues reported the results of their retrospective, case-controlled study, with the aim to compare single-port laparoscopic Hartmann’s reversal (SP-HR) and the standard multi-port laparoscopic approach (MP-HR).

The idea of the single port laparoscopic variant was to augment the advantages of the standard laparoscopic surgery. In particular, with the SP-HR it is possible to reduce the number of abdominal accesses, with consequent reduction of the risk of surgical site infection, pain, abdominal wall hemorrhage, and possibly bowel adhesions.

Comparing two groups of patients (Group A: SP-HR; Group B: MP-HR), they found that conversion to open surgery did not occur in any patient in either group; mean operative time and median length of hospital stay was shorter in Group A than in Group B; the overall morbidity rate was lower in Group A than in Group B (11.4% vs 18.2%). They concluded that the SP-HR technique was safe, efficient and totally comparable to MP-HR.

Despite the limitations related to the low sample size and to the lack of long-term follow-up, the results obtained encourage the realization of further research in the field of single-incision laparoscopic surgery.

Aprile 2020

Eradicating sepsis and promote healing represent the end-point of anal fistula treatment, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional open surgery seems to be relatively safe and well accepted in clinical practice.
However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter with subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced for minimising the injury to the anal sphincters and preserving optimal function.
(Limura E et al. World J Gastroenterol. 2015)
Numerous surgical procedures have been introduced for the treatment of complex fistula in anus, including ligation of intersphincteric fistula tract (LIFT), anal advancement flaps, injection of fibrin glue, collagen paste or autologous adipose tissue, fistula plug, video-assisted anal fistula treatment (VAAFT) and fistula laser closure (FiLaC™). (Adegbola SO et al. Tech Coloproctol. 2017.)
Fistula-tract Laser Closure (FiLaC™), a new and promising sphincter-preserving treatment, might be a valuable treatment option in these patients, but the date literature are variable. (De Hous N et al. Tech Coloproctol. 2019.)
In the volume 24, issue 4 (April 2020) of Tech Coloproctol, Elfeki H. et al. in a systematic review , evaluate the outcomes in terms of healing and complications, to determine the efficacy and safety of FiLaC™. In total, 454 patients were reviewed where 67.4% were males. Regarding the clinical type of fistulae, the majority were transphincteric (69.16% of cases), intersphincteric in 20.93%, supra/extrasphincteric in 8.37%, only superficial in 7 (1.54%) patients. One hundred and fifty-nine (35.02%) patients had recurrent fistula after previous surgical treatment.
The systematic analysis showed that the rate of primary healing among the studies was 67.3%, with a recurrences rate of 32.7%. It should be noted that the percentage of primary healing does not differ significantly from that of most other techniques and therefore it is confirmed that we do not yet have a “gold standard”.
Rate of complications was 4%: all of them were minor complications and the weighted mean rate of continence affection was 1% in the form of minor soiling. It is noteworthy that most of the failures after FiLaC™ were in the form of non-healing of the fistula rather than recurrence, representing only 3%. The failure rate could be attributed to several factors, however in literature there is no shared definition of persistence / recurrence both in terms of chronological interval and dignity modalities: in this sense the overall data of “failure” could be more objective than a subdivision that could reflect the heterogeneity of the studies. Undetected secondary tracts and various calibres of the fistula lumen are key factors which may hinder the sealing effect of laser fiber. These promising results should place FiLaC™ in the surgical armamentarium for anal fistula treatment.
Future randomized trials should be done to compare efficacy and safety by comparing multiple sphincter preserving techniques.

Beatrice Pessia M.D.
Lucia Romano M.D.
Dipartimento di chirurgia
Università degli Studi dell’Aquila

Marzo 2020

We open a new section of our website with the aim to focus the attention on a paper chosen by the Editorial committee from the coloproctological literature. An article with a short comment will be reported monthly. We start this column right in the middle of the Covid19 outbreak, a dramatic event which is causing an untried burden for health systems. This will certainly stimulate a deep rethinking of political and social priorities, lifestyles and health management and strategies. This pandemic has been called a “war” and probably is the first one in the modern era during which surgery is “in quarantine” while microbiologists, pulmonologists and infectious disease specialists are at the forefront. However, in the near future when the surgical activity will resume regularly it will have to deal with a new economic and financial scenario.

Robotic rectal surgery is a procedure whose cost-effectiveness ratio is still an open question under investigation. Robotic surgery offers advantages on conventional laparosopy including dexterity and ambidextrous capability, lack of tremors and motion scaling potentially overcoming the anatomical difficulties of rectal resection in lower rectal cancer expecially in obese/male patients. The ROLARR trial found that robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy when performed by surgeons with varying experience in robotic surgery. Corrigan N et al. (Trials 2018; Jun 27;19(1):339) suggested that the learning effects could lead to biased comparison between treatments as surgeons participating to the trial were much more experienced in conventional laparoscopic than in robotic surgery. A subsequent systematic review of 1 RCT and 27 comparative studies (Jones K et al. World J Gastrointest Oncol 2018; Nov 15;10(11):449-464) failed to demonstrate any superiority of robotic over laparoscopic TME for many surgical outcomes except early passage of flatus, lower risk of conversion and shorter hospitalization.

In the volume 24, issue 3 (March 2020) of Tech Coloproctol, Quijano Y et al published an observational prospective mono-institutional study comparing robotic vs laparoscopic surgery for rectal cancer, with the aim to evaluate their cost-effectiveness. This comprehensive analysis estimated mean cost and QUALYs per patients based on the total direct hospital care costs, with the exception of the acquisition and maintanance of the robotic device. Through this model, the Authors foudn that overall mean costs are similar betweeen the two approaches demonstrating that robotic resection is a cost-effective procedure. They suggest further investigations to detect in which groups of patients it can be more advantageous under this aspect. On the other hand, narrowing the indications seems to be in contradiction with the aforementioned learning effects as the learning curve has been estimated completed after 40 robotic rectal resections (Ielpo B et al. Int J Colorectal Dis 2017; 32:1423–1429).

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