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Lay Summary Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.

Background and aims Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts’ consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. Methods The discussion among the steering group of clinical experts and methodologists from the societies’ expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020–January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. Conclusions The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Malignant Pleural Mesothelioma (MPM) is a highly aggressive disease whose diagnosis could be challenging and confusing. It could occur with atypical presentations on every examined level. Here, we present three unconventional cases of the complex diagnostic process of MPM that we have experienced during routine practice: a patient with reactive mesothelial hyperplasia mimicking MPM, an unexpected presentation of MPM with persistent unilateral hydropneumothorax, a rare case of MPM in situ. Then, we review the relevant literature on each of these topics. Definitive biomarkers to confidently distinguish MPM from other pleural affections are still demanded. Patients presenting with persistent hydropneumothorax must always be investigated for MPM. MPM in situ is now a reality, and this raises questions about its management.

The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our private and professional routine. In particular, the lockdowns have severely affected the entire healthcare system and hospital activities, forcing it to rethink the protocols in force. We suggest that this scenario, in spite of the new challenges involving so far complex healthcare providers, may lead to the unique opportunity to rethink pathways and management of patients. Indeed, having to resume institutional activity after a long interruption that has completely canceled the previously existing schemes, healthcare providers have the unique opportunity to overcome obsolete and “we have always done in this way” model on the wave of the general desire to resume a normal life. Furthermore, the pandemic has highlighted some flaws in our health system, highlighting those critical issues that most need to be addressed. This article is a review of pre-pandemic literature addressing the use of Lean Six Sigma (LSS) and standardization processes in thoracic surgery to improve efficiency. Our goal is to identify the main issues that could be successfully improved along the entire pathway of a patient from the first referral to diagnosis, hospitalization, and surgical operation up to convalescence. Furthermore, we aim to identify the standardization processes that have been implemented to achieve significant improvements in patient outcomes while reducing costs. The methods and goals that could be used in the near future to modernize our healthcare systems are drawn up from a careful reading and interpretation in light of the pandemic of the most significant review articles in the literature.

Large-cell neuroendocrine carcinomas (NECs) of the colon are extremely rare aggressive tumors. A 79-year-old man presented at our hospital for muco-hematic diarrhea, weight loss and incarcerated hernia in his left groin. Colonoscopy revealed sigmoid stenosis. Computed tomography confirmed an incarcerated hernia containing sigmoid mass and massive abdominal adenopathy. In absence of colonic obstruction, the patient underwent elective palliative sigmoid resection and colostomy by laparoscopic approach, and direct hernia repair through inguinal access. Histopathological examination revealed a large cells sigmoid NEC. We report the first case of large-cell neuroendocrine colon cancer incarcerated in an inguinal hernia. Due to the advanced stage, we have performed a palliative laparoscopic resection in order to reduce surgical trauma, confirm pre-operative results and minimize post-operative complications, and direct hernia repair through inguinal access.

Background: Intimal sarcomas are rare malignant mesenchymal tumors arising from the heart and large blood vessels. Their intraluminal growth leads to vascular obstructive symptoms and peripheral neoplastic embolization. Direct infiltration of the lungs or metastases to the pulmonary system, occur in 40% of cases and extrathoracic spread is frequent, also in presentation. Intussusception is an unusual event in adults, accounting for Case Presentation: We describe a rare case of a 50-year-old man suffering of bowel obstruction due to intussusception sustained by a small bowel metastasis of a primary cardiac intimal sarcoma. One year and a half before the onset of abdominal symptoms, a grade II intimal sarcoma was removed from his left atrium and consequently he followed a chemotherapy protocol. Four months later a CT scan revealed local recurrence. Eighteen months after heart surgery he referred to the ER with abdominal pain. CT scan showed an ileal intussusception and the patient was scheduled for surgery. A tract of 10 cm ileus was removed containing an intramural polypoid solid mass. Histological analyses revealed a grade II intimal sarcoma consistent with his first diagnosis.Conclusion: Primary heart tumors are late found and often partially resected, therefore metastatic pathways are to be expected. Adult small bowel intussusception is a rare event and caused by a malignancy in one third of cases. Therefore, our recommendation is to always resect the tract involved in order to perform a proper diagnosis.

We report the rare case of a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation (ISSVA classification, 2008) in a 58 years old man. Diagnosis was obtained only after surgical removal that was complicated by a sudden massive bleeding (about 1,500 cc) requiring emergency conversion to median sternotomy. Difficulty in preoperative diagnosis, rarity of histologic pattern, and surgical challenges make this case very interesting for surgeons, pathologists and radiologist. Our message, dealing with mediastinal masses, is: (a) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered (b) preoperative angiography should always be performed in case of uncertain diagnosis (c) coil embolization should always be considered to reduce potentially fatal bleeding (d) histologic differentiation with other thymic neoplasms must be always considered.

SCOPO: Obiettivo dello studio descrivere l’incidenza, le caratteristiche radiologiche e anatomo-patologiche degli incidentalomi pancreatici. Nell’articolo, Inoltre, sono discusse le indicazioni chirurgiche di queste lesioni in base alla loro natura e localizzazione. PREMESSE: Le lesioni pancreatiche incidentali sono sempre pi frequentemente diagnosticate grazie alla larga diffusione di tecniche radiologiche di elevate qualit . Gli incidentalomi pancreatici possono essere cistici o solidi, benigni o maligni, coprendo un ampio spettro di variet istologiche. Le lesioni cistiche sono pi frequentemente di natura benigna o pre-maligna. L’asportazione chirurgica deve essere riservata solo in caso di variazioni sospette in senso degenerativo al follow-up oppure per le masse cistiche di larghe dimensioni (>3 cm). Tra gli incidentalomi pancreatici solidi l’adenocarcinoma duttale la neoplasia pi frequentemente diagnosticata, seguita per frequenza dei tumori neuroendocrini. Il trattamento chirurgico dipende dalla localizzazione dell’incidentaloma: la duodenocefalopancreasectomia dovrebbe essere eseguita per le lesioni a carico della testa, mentre la pancreasectomia distale indicata per quelle del corpo e della coda. La chirurgia del pancreas delicata e tuttora gravata da serie complicazioni. Entrambi gli interventi chirurgici possono eseguiti con tecnica mini-invasiva, che caratterizzata da un minor tasso di complicazioni, ma al momento attuale, non stata dimostrata una miglior sopravvivenza nei pazienti oncologici CONCLUSIONI: Gli incidentalomi pancreatici sono di riscontro sempre pi frequente nella pratica clinica, ma quando e come intervenire chirurgicamente ancora materia di dibattito. Attualmente mancano precisi criteri circa la strategia di trattamento e sono quindi necessarie linee-guida per definire il miglior approccio di queste lesioni del pancreas. AIM: The aim of this study is to describe the incidence, imaging characteristics and pathological features of pancreatic incidentalomas. Moreover, surgical indications are discussed according to the nature and location of the neoplasms. BACKGROUND: Pancreatic incidental lesions are more commonly diagnosed, due to the widespread of high quality cross sectional imaging. These lesions can be cystic or solid, benign, pre-malignant or already malignant and they cover a wide spectrum of histological diagnosis. Cystic lesions are more commonly benign or at least pre-malignant. Surgery should be reserved in case of unexpected changes in aspect during follow-up or for large cysts (>3 cm). Among solid pancreatic incidentalomas, ductal adenocarcinoma is the most common diagnosis, followed by neuroendocrine tumors. Surgical treatment of pancreatic incidentaloma depends on the location of the tumor: a Whipple's procedure should be performed for neoplasms of the head, while distal pancreatectomy is indicated for body and tail lesions. Pancreatic surgery is still delicate and burdened by serious complications. Both procedures can be performed with minimally-invasive technique which is connected to lower complications rate but, at present, they have shown no advantages in terms of mortality and oncologic outcomes. CONCLUSIONS: Pancreatic incidentalomas are becoming more and more common but when and how to operate them is still subject of debate. Precise criteria about treatment strategy are still lacking and definite guidelines are needed to clarify the best approach.

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Summary: Background/Objective: In the late's 90' a new surgical treatment, the stapled trans-anal rectal resection (STARR) was born to treat obstructed defecation syndrome (ODS). In this study we retrospectively analyze a series of 450 cases that underwent STARR in 10 years. Methods: Between January 2001 to December 2011, 450 patients, diagnosed with ODS syndrome caused by rectocele or intussusception, underwent to STARR procedure. The presence of rectocele and/or intussusception was verified by dynamic defecography. The preoperative evaluation was completed with anorectal manometry and colonoscopy. Follow-up visits were scheduled 1 week, 1 month, 3 months, 1 years, 3 years and 5 years after surgery. Results: Mean operative time was 30,2 min. In 408 cases (90.7%) hospital discharge occurred 24 hours after surgery. Among postoperative complications urinary retention was observed in 35 patients (7.8%). Five (1.1%) patients presented an early rectal bleeding and 8 (1.8%) patients presented a late bleeding. In 5 (1.1%) patients a stable pelvic hematoma was found. Six (1.3%) patients presented pelvic sepsis due to subperitoneal perforation. An asymptomatic partial dehiscence of stapler row occurred in 19 patients (4.2%).125 patients (27.8%) reported defecation urgency that completely vanished at 3 months follow-up in 83 patients (66,4%) and in further 42 patients (33,6%) at 6-months. The average preoperative ODS score was 14.1; 3.1 at one year; 4.3 at 3 years and 6.4 after five years. Conclusions: In expert hands, with right indications, STARR procedure is safe with good results in terms of improvement of the ODS score. Keywords: Obstructed defecation, Urgency, Rectal mucosal prolapse, Rectocele, Trans-anal rectal resection

Background The burden of disease caused by Streptococcus agalactiae has increased significantly among older adults in the last decades. Group B streptococcus infection can be associated with invasive disease and severe clinical syndromes, such as meningitis and endocarditis. Case presentation We present the case of a 56-year-old man who developed multiple mycotic aneurysms of the right hepatic artery and massive splenic infarction as rare complications of Streptococcus agalactiae infective endocarditis. The patient underwent urgent right hepatic artery ligation and splenectomy. The postoperative course was complicated by an episode of hemobilia due to the rupture of a partially thrombosed mycotic aneurysm into the biliary tree. Thus, selective radiological embolization of the left hepatic artery branches was necessary. Conclusion To our knowledge, this is the first case reported of infected aneurysms of visceral arteries caused by Group B streptococcus infection. Clinical and laboratory findings were non-specific, while imaging features with computed tomography scan and angiography were highly suggestive. In our case, early recognition, culture-specific intravenous antibiotics and urgent surgical treatment combined with interventional radiology played a decisive role in the final result.

BACKGROUND Several studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications. AIM To investigate the outcomes of RRH vs LRH with regard to age and comorbidities. METHODS We retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d. RESULTS LOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036). CONCLUSION RRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Stapling procedure for prolapsed hemorrhoids (PPh) is a widely accepted surgical procedure for third-degree hemorrhoids. intra-abdominal hemorrhage with retroperitoneal hematoma is an uncommon but possible complication. We report on the non-operative management of a case of intra-abdominal bleeding and retroperitoneal hematoma after PPh in a 56-year-old healthy woman presenting third-degree internal hemorrhoids. On the first postoperative day, the patient developed acute back pain, abdominal pain, abdominal distension with clinical signs of peritoneal irritation at left iliac fossa and hypogastrium and a drop in hemoglobin (hb 7.6 mg/dL). Computed tomography (CT) of the abdomen showed intra-abdominal free blood and an anterior intraparietal hematoma of the rectum. She was treated conservatively with intravenous fluids, antibiotics and analgesia. at the third postoperative day, the hematoma drained through surgical wound spontaneously. The patient was discharged 7 days after the operation with normal bowel movements. At 2 weeks after surgery a CT of control pointed out total resolution of perirectal hematoma. No evidence of clinical problems one month after surgery. The non-operative management of intra-abdominal hemorrhage with retroperitoneal hematoma can be successful in selected patients with hemodynamic stability and no evidence of arterial blushings or pneumoperitoneum at CT.

BACKGROUNDSeveral studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.AIMTo investigate the outcomes of RRHvsLRH with regard to age and comorbidities.METHODSWe retrospectively analyzed 123 minimally invasive procedures (68 LRHsvs55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.RESULTSLOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8]vs7 (IQR 6-10.5) d,P= 0.028; median 2 (IQR 1-3)vs3 (IQR 2-4) d,P< 0.001; median 4 (IQR 3-5)vs5 (IQR 4-6.5) d,P= 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8-vs7 -IQR 6-12- d,P= 0.013) and later TFF (median 2 -IQR 1-3-vs3 -IQR 2-4- d,P= 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8-vs7 -IQR 6-14.5- d,P= 0.036).CONCLUSIONRRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Summary: Background: Fistula-in-ano is one of the most commonly presenting anorectal diseases. Sphincter sparing treatment options should be considered in patients with complex fistulas. Salvecoll-E gel is a native collagen deantigenated and purified, non-cross-linked equine dermal extract, with an amino acid composition identical to human collagen. Methods: The multicentric trial study was a prospective, single-arm observational clinical study with the objective to assess the efficacy of Salvecoll-E gel for anal fistula repair in 70 patients. All patients had undergone preliminary surgical treatment consisting of positioning of a draining loosing seton that was maintained for a period of 4–6 weeks. After seton removal, a gentle debridement and washing of the fistula track was performed. The scar tissue was removed from the internal orifice. Internal opening was covered by a side-to side mucosal suture. Salvecoll-E was injected through the external opening into the fistula track, the external opening it has been opened. Results: Twelve months after surgery, 55 patients demonstrated a clinically healed fistula (78,5%), 15 patients have a recurrence (21,5%). Most of the recurrences were observed in the first 6 months of treatment (13/15, 86.6%). We don't observe any worsening in CCF score. The results obtained at 1 year certainly seem satisfactory and in line with the best results published in literature using mini-invasive techniques. Conclusion: Salvecoll-E gel is a promising non-invasive technique for conservative treatment of anal fistulas, it's well tolerated by the patients and, in case of recurrence, reinjection or all other known techniques are feasible. Keywords: Complex ano-rectal fistula, Non cutting technique, Mini-invasive treatment

Background: Perianal giant condyloma acuminatum (gCa) is a rare clinical condition related to low-risk human papillomavirus (hPV) characterized by a circumferential, exophytic, cauliflower-like mass. GCA is not a malignant lesion by histologic criteria but often shows a propensity to compress or infiltrate adjacent tissues and harbor tumor foci with high potential for malignant transformation (30-56%). Local extent of tumor invasion, not malignant histology, had the greatest impact on morbidity. Local full thickness surgical excision with 1 cm macroscopically negative margins is presently considered the most appropriate treatment for this type of lesion. Methods: This study reports successful treatment of 13 patients (11 males, 2 females, mean age 38.5 years old) with a new surgical approach. This technique consists in the removal of a mucocutaneous cylinder containing the entire lesion with 1 cm of disease-free margin both on the perianal skin and on the mucosa of the anal canal. Subsequently, the mucosa of the anal canal is sutured to the external margin of the internal sphincter with detached points in absorbable material. The anesthetic technique was spinal anesthesia. Results: The early postoperative period was uneventful in all 13 patients. Complete healing occurred in 40 days. Two months from surgery, no findings of anal stenosis were reported except for 2 patients (due to an incorrect postoperative management). No findings of mucosal ectropion two months after surgery. at the 1-year follow-up, there was no recurrence of condylomatosis in any patient. Conclusions: This procedure seems to combine technical simplicity, rapid discharge, low complication rates (no anal stenosis nor mucosal ectropion) and without recurrence of condylomatosis after 1-year follow-up. For all these reasons we think it might be a valid therapy for gCa.

INTRODUZIONE: La colpo-cisto entero defecografia rappresenta oggi il gold standard per l’identificazione e la stadiazione dei disordini morfologici e funzionali della regione retto-anale e del pavimento pelvico nelle sindromi da defecazione ostruita. MATERIALI E METODI: Tra Gennaio 2010 e Gennaio 2013 88 pazienti sono stati sottoposti a procedura di STARR per sindrome da defecazione ostruita (ODS) causata da rettocele e intussuscezione retto-anale. Abbiamo analizzato retrospettivamente i dati raccolti ed in particolare rivisto i risultati defecografici pre-operatori. RISULTATI: 30 pazienti (34%) alla colpo-cisto entero defecografia pre-operatoria, avevano un’apertura del canale anale compresa tra 0 e 5 secondi, 44 (50%) tra 6 e 10 secondi e 14 pazienti (16%) superiore ai 10 secondi. Le immagini hanno mostrato presenza di enterocele in 30 pazienti (34%). In 25 pazienti (28,4%) si trattava di enterocele dinamico, in 5 (5,6%) di enterocele stabile. 53 pazienti avevano un rettocele di II° (60,2%) e 35 pazienti un rettocele di III° (39,7%). I’ ODS score medio preoperatorio era 14. Il punteggio medio di ODS rivalutato a 1 anno è stato di 3,1, 4,3 a 3 anni e 6,4 dopo 5 anni. Il miglioramento del punteggio ODS era inferiore nel sottogruppo di pazienti che presentavano un’apertura lenta del canale anale (> 10 sec): 7,5 a un anno, 9,1 a 3 anni e 11 dopo 5 anni di follow-up. Anche nel sottogruppo di pazienti con enterocele stabile (5,6%) il miglioramento era meno evidente: 6,7 a 1 anno, 8 a 3 anni e 9,7 dopo 5 anni di follow-up. DISCUSSIONE E CONCLUSIONE: I dati ottenuti ci hanno dimostrato che la coesistenza di un lungo periodo di apertura del canale anale e / o la presenza di un enterocele stabile sono fattori che riducono significativamente l’efficacia della chirurgia riducendo il miglioramento dell’ODS score nel breve e lungo periodo. Consigliamo pertanto nel primo caso l’associazione di fisoterapia perineale mentre nel secondo una plastica del cavo del Douglas. INTRODUCTION: The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS: Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS: At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION: We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.

Since the 1970s, in the USA, we witnessed a progressive increase of one-day surgical procedures. This attitude soon gained ground in Europe as well. In proctology, this kind of clinical approach has always been limited by the acute sensitivity of the anal- perineal area and by difficulties in attaining a complete sphincter relaxation with local anesthesia. Posterior perineal block seems to be associated with both a good pain control and an effective sphincter relaxation.Between January 2017 and January 2018, we enrolled in our study 33 patients suffering from hemorrhoidal disease. They were all subjected to posterior perineal block. We measured anal resting pressure and squeeze pressure before and after anesthesia. Measurements where taken 5 minutes before and 15 minutes after the administration of local.We registered an average decrease of 39,2% of resting pressure and of 45,4% of squeeze pressure.We may state that perineal posterior block, while reducing striated muscle contractile activity, also causes a relevant reduction of anal basal tone. During surgical procedures done under regional anesthesia, we experienced a good sphincter relaxation, which was comparable, if not equal, to that induced by general anesthesia. In fact, 10 to 15 minutes after performing the block you could observe the elevation of the inferior margin of the exterior sphincter and the concomitant descent of the inferior margin of the internal sphincter (coaxial dislocation).Anorectal manometry, Anesthesia, Local-regional, Perineal block.A partire dagli anni 70 negli Stati Uniti si è assistito ad un progressivo aumento delle procedure chirurgiche in day surgery Questo processo si è diffuso anche nella maggior parte delle strutture sanitarie in Europa. In ambito proctologico le indicazioni sono sempre state limitate dalla particolare sensibilità della zona ano-perineale e da un difficile completo rilassamento dell’apparato sfinteriale dopo anestesia locale. Il blocco perineale posteriore sembra essere associato oltre che ad una buona analgesia ad un efficace rilassamento sfinterico.Da gennaio 2017 a gennaio 2018 sono stati arruolati 33 pazienti affetti da patologia emorroidaria. In tutti i pazienti è stato eseguito un blocco perineale posteriore. Sono state misurate la pressione basale del canale anale e la contrazione massima volontaria prima e dopo l’anestesia. Le due rilevazioni manometriche sono avvenute in posizione litotomica 5 minuti prima e 15 minuti dopo l’esecuzione dell’anestesia.La diminuzione media del tono basale dopo blocco perineale posteriore è stata pari al 39,2% e la riduzione media della contrazione massima è stata del 45,4%.Possiamo affermare che il blocco perineale posteriore determina oltre alla riduzione dell’attività contattile della muscolatura striata, anche un rilevante decremento del tono anale di base. Durante interventi proctologici eseguiti in anestesia locoregionale con il blocco perineale posteriore si è riscontrato notevole rilasciamento della parete sfinteriale dell’ano paragonabile, anche se non uguale, a quello che si verifica durante un’anestesia generale. Infatti dopo circa 10-15 minuti nella quasi totalità dei casi si osserva sia la risalita del margine inferiore dello sfintere esterno che la concomitante discesa del margine inferiore dello sfintere interno (dislocazione coassiale).

Direct inguinal blunt trauma is an uncommon but possible cause of bowel perforation in patients with groin hernia. in this case report we want to describe bowel perforation in a 67-year-old patient with bilateral groin hernia due to a directly inguinal blunt trauma managed with loop ileostomy with rod. This case reveals the importance of elective hernia repair and the value of clinical and instrumental evaluation of a patient with groin hernia after direct blunt trauma.

Background Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. Aim The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. Material and methods The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. Results The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. Discussion and conclusions The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

The incidence of full-thickness rectal prolapse is 1% in patients over 65 years of age. Risk factors are multiparity, previous pelvic surgery, and neurological or psychiatric disorders. IBS, constipation, and chronic straining are comorbidity factors. Symptoms and risk of complications are indications for surgical treatment. Among abdominal operations, ventral rectopexy recently seems to offer the best long-term results. Recurrence rate less than 3–4%, a net improvement of continence, is in up to 80–90% of cases; compared with traditional rectopexies, a greater improvement in constipation and a reduced risk of postoperative constipation are observed. Perineal procedures (Altemeier’s proctosigmoidectomy) are less demanding on the patients and are still the favorite technical choice in the elderly, mostly in high-risk patients. Morbidity and mortality are low and postoperative recovery is faster. If the technique is correctly performed, there seems to be no statistically significant difference in recurrence rate between abdominal and perineal procedures. However, in the last few years, there is a new emerging trend for a wider use of laparoscopic ventral rectopexy also in geriatric low-risk patients.

Summary: Background: We propose a new open mesh hernia repair procedure for the treatment of inguinal hernias in adults aiming to improve patients' comfort and to reduce the incidence of chronic neuralgia. Methods: From September 2012 to August 2015, 250 consecutive patients were treated with “all in-one” mesh hernioplasty procedure in our Institution. According to the devised technique, a new smaller prosthesis was placed on the floor of the inguinal canal in order to strengthen all areas of weakness from which hernias may originate. The mesh was enveloped by a fibro-cremasteric sheath avoiding contact with neural structures. Follow-up was carried out at 3, 6, 12, 18 and 24 months for evaluation of postoperative pain using Visual Analogue Scale score, need of medication, patients' comfort and short or long-term complications. Results: All patients were discharged within 24 h from surgery. Slight pain was reported by the majority of patients and 47.6% of them did not require pain medication at home. After the 1st postoperative week 96.8% reported no pain and no other symptoms. No relevant limitation of normal activities was reported. There has been no postoperative neuralgia. One recurrence was observed. Conclusions: This new hernioplasty technique respects the anatomy of the inguinal canal, uses a smaller mesh, and seems to avoid neuralgia with maximum comfort for the patients. Keywords: Inguinal hernioplasty, Tension free hernia repair, Hernioplasty technique, Mesh for groin hernia, Neuralgia post-hernioplasty

Background Pancreatic duct disruption is a challenging condition leading to pancreatic juice leakage and consequently to pancreatic fluid collections. The manifestations of pancreatic main duct leak include pseudocysts, walled-off necrosis, pancreatic fistulas, ascites, pleural and pericardial effusions. Pseudocyst formation is the most frequent outcome of a pancreatic duct leak. Case presentation We describe a case of a 64-year old man with large multiple pancreatic cysts discovered for progressive jaundice and significant weight loss in the absence of a previous episode of acute pancreatitis. Computed tomography scan showed lesion with thick enhancing walls. The main cyst dislocated the stomach and the duodenum inducing intra and extrahepatic bile ducts enlargement. Magnetic resonance cholangiopancreatography revealed a communication between the main pancreatic duct and the cystic lesions due to Wirsung duct rupture. Endoscopic ultrasound guided fine needle aspiration cytology did not show neoplastic cells and cyst fluid analysis revealed high amylase concentration. Preoperative exams were suggestive but not conclusive for a benign lesion. Laparotomy was necessary to confirm the presence of large communicating pseudocysts whose drainage was performed by cystogastrostomy. Histology confirmed the inflammatory nature of the cyst wall. Subsequently, the patient had progressive jaundice resolution. Conclusion Pancreatic cystic masses include several pathological entities, ranging from benign to malignant lesions. Rarely pseudocysts present as complex cystic pancreatic lesions with biliary compression in absence of history of acute pancreatitis. We describe the rare case of multiple pancreatic pseudocysts due to Wirsung duct rupture in absence of previous trauma or acute pancreatitis. Magnetic resonance showed the presence of communication with the main pancreatic duct and endoscopic ultrasound fine needle aspiration suggested the benign nature of the lesion.