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The total visualization of the intestinal surface through wireless capsule endoscopy has furnished new insights for the diagnosis of intestinal diseases. The length, difficulty of access and particular morphology of this region makes a correct diagnosis of gastrointestinal diseases associated with bleeding possible only in 5% of cases. Our study was aimed at assessing the clinical impact and diagnostic outcomes of wireless capsule endoscopy through analysis of the first 50 cases observed in our Endoscopy and Coloproctology Unit. Fifty patients aged 23-85 years (mean age: 43.5) were selected for wireless endoscopy. The main indications were patients with a suspected or established diagnosis of inflammatory bowel disease or malabsorption, abdominal pain, chronic diarrhoea and obscure bleeding. Patients with a clinical or radiological diagnosis of gastrointestinal stenosis, Zencker's diverticula, or colonic diverticulosis were excluded from the study. In 2 out of 8 patients with abdominal pain, erosions of the intestinal wall were detected, while in the only patient with gastrointestinal bleeding a neoplastic lesion of the right colon was accidentally diagnosed. As far as inflammatory bowel disease is concerned, in all the cases of established diagnosis of ulcerative colitis no small bowel lesions were visible at wireless endoscopy, while all the cases with silent Crohn's disease of the terminal ileum were confirmed. No cases of neoplastic lesions of the small bowel were recorded in our series either in celiac-disease patients or in patients with familial intestinal polyposis. In celiac-disease patients (N = 24) wireless capsule endoscopy allowed accurate definition of the extent of the mucosal damage. On the basis of our preliminary experience wireless capsule endoscopy would appear to warrant an important role in the management of patients with small bowel diseases, supplementing information obtained with other diagnostic techniques.

Procedures involving the use of anal dilators or topical nitroderivatives for the treatment of anal fissure are efficacious, economic and safe. The aim of our study was to compare the efficacy of two conservative treatments - passive dilation with anal dilators or topical nitroderivatives - in reducing anal pressure and resolving anal fissures. A total of 40 patients with a clinical diagnosis of acute anal fissure in the absence of hypotonic anal sphincter, abscess or perianal fistula, haemorrhoidal thrombosis, chronic inflammatory bowel disease or lower gastrointestinal neoplasia were randomly assigned to treatment with dilators (20 patients) or topical nitroderivatives (20 patients). After 4 weeks of treatment, 90% of patients treated with dilators and only 45% treated with topical nitroderivatives showed complete resolution of their anal fissures and a reduction of sphincter hypertone. After 12 weeks, 2/18 patients successfully treated with dilators and 1/9 patients successfully treated with topical derivatives presented recurrence of the anal fissure. The use of anal dilators would appear to induce better resolution of acute anal fissures than topical nitroderivates, as confirmed by the low relapse rate at 12 weeks.

Objective: The Authors underline three clinical problems in coloproctology: the surgical access to the anal canal, the lacking aspects of the actual classification of hemorrhoids, the difficult choice of the surgical treatment in case of coexisting III degrees and IV degrees degree of hemorrhoids. They propose a new anal retractor which enables the surgeon to better calibrate all the surgical procedures inside the anal canal and to operate alone without the help of another operator. A new computerized software is able to rapidly guarantee a numeric score for hemorrhoids which is repetable before and after treatment of the disease. The Authors present a new surgical technique defined of transfixed stichtes for the resolution of the most advanced stage of hemorrhoids., Patients and Methods: The new anal retractor was used in fifthy consecutive patients operated on for proctological problems. A quickly computerized score coming from the new classification PATE 2000 Sorrento was evaluated in one hundred patients, while the surgical technique of transfixed stichtes was utilized in fifthy., Results: All the surgical procedures performed with the new device were concluded without complications. The highest values of the score from PATE 2000 Sorrento always fit with the surgical treatment of the disease, while transfixed stitches gave dysuria in five patients, but a better quality of life was referred by 38 over 50 patients treated., Conclusions: The Authors underline in this paper the results of the clinical implementation of these three new solutions in colon-proctology.

Hemorrhoidal thrombosis (HT) represents one of the most frequent complication of hemorrhoids. The two main modalities of clinical presentation are thrombosed of a single external pile or as massive thrombosis (MT), both representing an harmfull condition for the patient which can be usually treated with surgical intervention on an outptient basis. The etiopathogenesis of the disease is nowadays obscure and few investigated till now in the international literature. The Authors performed a prospective study on 22 patients with HT aimed at clarifying the ethiopathogenesis of the disease through the evaluation of the emocoagulative profile of these patients. All the main coagulopathy indexes such as aPT, APTT, Fibrinogen, AT III, XDP, aPCR and LAC resulted normal, while the products of prothrombin degradation (F1 + F2) showed higher values in respect of the control group (p < 0.0001). Our study seems to highlight that HT could not be considered a sistemic or local coagulopathy, so far surgical management of the disease remains the gold standard, as confirmed in our series.

Objective: To evaluate the quality of life after nerve sparing total mesorectal excision for rectal cancer., Patients and Methods: Crucial technical aspects of the procedure such as the preservation of genitourinary innervation and the achievement of optimal local control of the disease have been emphasized. It is known that local recurrences, sexual and urinary dysfunctions may have a significant impact on postoperative quality of life of the patients. Postoperative evaluation of functional outcomes of nerve sparing total mesorectal excision has been carried out utilizing the QLQ C30 (version 3) (All CR38)., Results: At one year follow-up 27.2% of the patients presented sexual activity related dysfunctions, 6.1% complained of urinary dysfunction and 21% of the patients complained of some significant psychologic disturbances., Conclusions: A correct surgical dissection with preservation of inferior hypogastric plexus and all genitourinary nerve supply yield the best results either in terms of quality of life and of oncologic control of the disease.

Purpose: Aim of this retrospective study is to report personal experience in the surgical management of substernal goitres emphasizing the guidelines for preoperative planning of sternotomy in selected cases., Patients and Methods: Medical records of all patients (n=355) submitted to thyroidectomy for struma in our Operative Unit, between 1993-2003, were analysed. A substernal goitre was defined as a goitre having a significant retrosternal extension (>50%) requiring mediastinal dissection., Results: A total of 18 out of 355 patients undergoing thyroidectomy for struma in our Operative Unit had substernal goitres. The most common symptoms, at presentation, were the presence of neck mass and respiratory disorders. Standard cervical incision was adequate to achieve total thyroidectomy in 17 cases while, in one patient with computed tomography images showing the presence of a huge goitre extending below the aortic arch, a sternotomic approach was inevitable to ensure safe removal. No major morbidity or perioperative deaths occurred. One patient with scleroderma experienced bilateral paralysis of laryngeal nerves for two months, with full recovery thereafter., Conclusions: While removal of the majority of substernal goitres can be achieved by means of cervical incision, this approach is not always safe. In a selected number of cases with an iceberg shaped substernal goiter and with >70% of the volume lying below the thoracic outlet, a sternotomic approach is inevitable. Preoperative diagnostic work-up should, thus, include chest X-ray and computed tomography. Overall results in the present patient population, have been excellent since morbidity has been minimal and mortality absent, and all patients are symptom free.

The Authors propose a simple, safe technical solution for an unusual event which can occurs during anal dilation, namely the jamming of the device in the rectum. The manual remedial procedure described here was successful in 5 out of 6 patients. No further treatment was necessary, and no other complications occurred.

Nowadays the proctologist has the opportunity to perform various different surgical techniques for the treatment of hemorrhoids. Circumferential mucosectomy with a stapler, diathermic hemorrhoidectomy with high frequency devices, and the HLA doppler II system have significantly modified the classical indications for the treatment of the disease. There is, however, still no general consensus as to the indications for the use of each of these techniques in clinical practice, giving rise to confusion among specialists and an inappropriate use of health care resources. For these reasons the authors propose a new technique for the treatment of haemorrhoids based upon a new classification system, named PATE 2000 Sorrento. The transfixed correction of haemorrhoids makes it possible to treat third degree internal piles in association with the Milligan-Morgan procedure for fourth degree piles in a simple, definitive and safe session. This technique seems to offer a valid alternative to stapled hemorrhoidectomy, on the one hand, and classical open or closed hemorrhoidectomy combined with rubber band ligation, on the other. The authors describe the technical feasibility of their technique and underline the good clinical results obtained in their initial experience with 20 consecutive patients.

In this paper the authors present the technical characteristics and clinical results of a new anal retractor designed and produced by them. This new instrument, made of disposable material, allows the proctologist to operate completely alone thanks to a system of rotating rings which are fixed directly to the patient's legs by means of Velcro bands. Twenty consecutive patients with proctological diseases have been operated on to date with the new device. No complications were registered in our series. The rotation movement and overall stability of the retractor were judged sufficient in 6 cases and good in 14. Opening of the device proved asymmetrical in 20% of the cases without this affecting the surgical technique. Our surgical team considered the prototype ideal, and the operative space available to the surgeon much greater than with previous retractor models. No limitations have been observed in treating any of the proctological diseases. The possibility of performing sutures in the anal canal was judged to be good. In conclusion, our new anal retractor would appear to guarantee greater autonomy in proctological surgery with much better clinical and therapeutic results and lower costs.

In 2000, the Italian Society of Coloproctology and the UCP (Coloproctology Units) devised a new haemorrhoid classification system, named PATE 2000 Sorrento, which is capable of defining all the main characteristics of the disease. Any new system should be able to predict the real extent of hemorrhoids by means of a specific index in order to help physicians in choosing the best therapeutic option. The authors present the results of a national multicentre study of 930 patients with symptomatic haemorrhoids. Nineteen patients (2%) could not be classified with the old haemorrhoid classification, while PATE 2000 Sorrento proved successful in classifying all patients. The difference was statistically significant. The new classification enables us to establish a specific score for the disease. In order to better evaluate the clinical impact of the scores obtained with PATE 2000 Sorrento, the authors analyzed the correlation between the score itself and the therapy chosen by each individual centre. The highest scores always corresponded to the choice of surgical hemorrhoidectomy, while in the case of lower values each centre seemed to be in doubt between medical therapy and other less invasive procedure such as sclerotherapy or rubber band ligation. These data were statistically significant (P < 0.0001). On the basis of our findings, PATE 2000 Sorrento seems to confirm its scientific and clinical relevance and could be a useful tool for the choice of the best treatment for each individual patient.

Background: The history of our proposal for a new classification of hemorrhoids is very old: 7 years of scientific debate had a big impact for the study and the definition of hemorrhoids., Methods: Nowadays many things have changed mainly in the field of treatment of hemorrhoids. New medical and surgical tools are available for the modern proctologist., Results: The new classification of the disease seems to fit the necessity of introducing these modern opportunities. Many authors recognize the fundamental role and claim for the routine use of a new classification, named PATE 2000 Sorrento. Nevertheless many problems are on debate. Their resolution needs the cooperation of all the experts in order to choose the best version of the classification., Conclusions: For these reasons the authors analyse all the work carried out till now in order to see what we still need to introduce a new classification of the disease.

The generally accepted classification of hemorrhoids presents some rather wide gaps which may either be due to expressions of intrinsic limits or recent moves of the Colonproctology field. The authors of this paper would like to present their proposal for a new classification that considers the results of the National Multicentric Study that was performed in collaboration with nineteen centres and a total of 1,494 patients. In addition, a comparative study was conducted on the two forms of classification. Nineteen patients (1.28%) were considered unclassifiable with the new classification system while 49 were (3.29%) with the presently used one. These results were found significant with the MacNemar Chi-Square test. The description of type 2 and 3 in the new classification system was found useful in 69% of 2nd degree, 77% of 3rd degree and 28% of 4th degree using the present system. Acute events (type 5,6 and 7) proposed with the new classification were found in the present system with several different rates. We have also included the data taken from a national and international survey we conducted on the usefulness of the new classification that provoked intense debate within two of the most important national institutes. The result was the elaboration of a design on the new classification.

Constipation after surgery is considered as a subgroup of patients in whom the disorder begins after pelvic surgery. A group of patients (median age 52 years with a range of 34-65 years) who had a hysterectomy underwent a retrospective study with the aid of a questionnaire and clinical records, to evaluate the incidence of constipation before and after the operation. Forty patients were operated on for benign pathology and 65 for malignant pathology. Forty-two patients underwent a Wertheim-Meigs, 39 had laparohysterectomy, 20 had a colpohysterectomy and 4 had a Schauta. The incidence of constipation increased from 25% preoperatively to 38% postoperatively (p < 0.05). There is no difference in the incidence of postoperative constipation among the various operations. Constipation after hysterectomy is associated with urinary disorders. These data confirm previous studies on the effect of hysterectomy on urinary and defaecatory functions and they show how a simple colpohisterectomy can cause constipation.

We describe a new accessory for rubber band ligation of hemorrhoids. By using the new instrument it is possible to abscind the elastic band applied to the base of the hemorrhoidal node without entailing traumatic interventions. Of a total of 62 elastic ligatures, this device was used in the last 18 procedures, and provided excellent results. This instrument enables the surgeon to carry out the technique in a more accurate way and, if necessary, rectify "dangerous mistakes" that can occur while accomplishing the procedure itself.

In the controversy regarding whether sphincter-saving resection (SSR) or abdominoperineal resection (APER) is more appropriate for the treatment of very low rectal cancer, local recurrence rates seem to play a fundamental role in patient outcome. In order to operate an effective patient selection, very low rectal cancer is defined herein as being located within 4.5 to 7.5 cm from the anal verge. This retrospective report investigates the incidence of local recurrence after curative surgery for very low rectal carcinoma in 24 consecutive patients treated by the same surgical team over a 15-year period using the above surgical procedures. In the APER group, the local recurrence rate was 45.5%, occurring in 5 of 11 cases; and in the SSR group 46.1%, occurring in 6 of 13 cases, with no significant difference between the two groups. Recurrence was found within one year of surgical treatment in all except one case. Despite the strict follow-up program, it was only possible to perform reoperation in two recurrent cases, both previously submitted to SSR and diagnosed by means of transanal ultrasonography and macrobiopsy. The high incidence of local recurrence in this series is explained by the advanced stage of disease in the majority of cases. Thus, as the choice between APER and SSR does not seem to affect the incidence of local recurrence, which is related more to tumor size, site, stage, and grading, preservation of the sphincters and restoration of digestive continuity should be achieved whenever technically possible.

In the last 12 years 25 patients affected with obstruction from colorectal carcinoma were treated. Mortality following simple colostomy was not different from that of surgical resections (25% vs. 14% in Authors' experience). Major surgery (subtotal colectomy) registered a reasonable mortality rate (5-6%).