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Francesco Gossetti,1 Nikolaus Zuegel,2 Pasquale Giordano,3 Rupert Pullan,4 Jochen Schuld,5 Paolo Delrio,6 Marco Montorsi,7 Olivier van Kerschaver,8 Jean Lemaitre,9 Ben Griffiths,10 Linda D’Amore1 1Department of Abdominal Wall Surgery, University Hospital (C/O Instituto Clinica Chirugica II), Rome, Italy; 2Visceral Surgery, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg; 3Department of Colorectal Surgery, Whipps Cross University Hospital, Leytonstone, UK; 4Colorectal Surgery, Torbay Hospital, Torquay, UK; 5Clinic for General and Visceral Surgery, Universitätsklinikum des Saarlandes, Homburg, Germany; 6Department of Abdominal Oncology, Istituto Nazionale Tumori, Napoli, Italy; 7General Surgery, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy; 8General Surgery, Algemeen Ziekenhuis Sint LUCAS, Gent, Belgium; 9Thoracic Surgery, CHU Ambroise Pare, Mons, Belgium; 10Colorectal Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UKCorrespondence: Francesco GossettiDepartment of Abdominal Wall Surgery, University Hospital (C/O Instituto Clinica Chirurgica II), Policlinico Umberto I, Rome, 00162, ItalyEmail gossetti@tiscali.itPurpose: Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases.Patients and Methods: A total of 114 patients underwent surgical treatment for CAWR with a Permacol™ (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12– 24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases.Results: The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations.Conclusion: A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).Keywords: Permacol, biologic surgical implant, complex abdominal wall repair

Endoscopic pilonidal sinus treatment (EPSiT) is a novel minimally invasive option for the treatment of pilonidal sinus disease (PSD). To optimise the postoperative wound management after EPSiT, an ultraportable negative pressure wound therapy (NPWT) device was used. The aim of this study was to assess the clinical outcomes of negative pressure-assisted (NPA) EPSiT. All patients with PSD treated by EPSIT from November 2017 to October 2019 were managed postoperatively with a commercially available NPTW dressing applied to the wound. All patients were prospectively entered into a dedicated database. Primary outcome measures were healing rate and return to normal activities. Secondary outcomes were postoperative complications and patient satisfaction. Thirteen male patients underwent NPA EPSiT (mean age 27.8 years, range 16–52 years). Two patients had previous surgery for PSD. The mean follow-up was 14 months (range 4–28 months). In two patients, only partial healing of the tract was achieved. One of these required a further successful NPA EPSiT, while the other one refused any other treatment because of the lack of symptoms. Eight patients were very satisfied and 5 were satisfied with this treatment. NPA EPSiT is a simple method for improving postoperative wound management, facilitating a quicker recovery and possibly improving overall patient satisfaction.

Funder: National Institute for Health Research (NIHR), Funder: Wellcome Trust, BACKGROUND: Multidisciplinary teams (MDTs) are widely used in cancer care. Recent research points to logistical challenges impeding MDT decision-making and dissatisfaction among members. This study sought to identify different types of logistical issues and how they impacted team processes. METHODS: This was a secondary analysis of a cross-sectional observational study. Three cancer MDTs (breast, colorectal, and gynaecological) were recruited from UK hospitals. Validated observational instruments were used to measure decision-making (Metrics of Observational Decision-making, MDT-MODe), communication (Bales' Interaction Process Analysis, Bales' IPA), and case complexity (Measure of Case Discussion Complexity, MeDiC), including logistical challenges (Measure of Case Discussion Complexity, MeDiC), across 822 case discussions from 30 videoed meetings. Descriptive analysis and paired samples t tests were used to identify and compare frequency of different types of logistical challenges, along with partial correlations, controlling for clinical complexity of cases, to understand how such issues related to the MDT decision-making and communication. RESULTS: A significantly higher frequency of administrative and process issues (affecting 30 per cent of cases) was seen compared with the frequency of equipment issues (affecting 5 per cent of cases; P < 0.001) and the frequency of the attendance issues (affecting 16 per cent of cases; P < 0.001). The frequency of the attendance issues was significantly higher than the frequency of equipment issues (P < 0.001). Partial correlation analysis revealed that administrative and process issues, including attendance, were negatively correlated with quality of information (r = -0.15, P < 0.001; r = -0.11, P < 0.001), and equipment issues with the quality of contribution to meeting discussion (r = -0.14, P < 0.001). More questioning and answering by MDT members was evident with the administrative and process issues (r = 0.21, P < 0.001; r = 0.19, P < 0.001). Some differences were observed in teams' socioemotional reactions to the administrative and process issues with the gynaecological MDT showing positive correlation with positive socioemotional reactions (r = 0.20, P < 0.001), and the breast cancer MDT with negative socioemotional reactions (r = 0.17, P < 0.001). CONCLUSION: Administrative and process issues were the most frequent logistical challenges for the studied teams. Where diagnostic results were unavailable, and inadequate patient details provided, the quality of decision-making was reduced.

The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2–32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

BACKGROUND Chronic constipation is a prevalent disorder that affects quality of life of patients and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. PURPOSE The present is the second of these reviews, providing contemporary perspectives and clinical challenges regarding behavioral, conservative, medical, and surgical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice.

Passive faecal incontinence and post-defecatory leakage can be difficult to treat as they do not appear to respond to neuromodulatory therapies. Bulking agents have been increasingly used over the last few years with the aim to augment the structure of the anal sphincter complex in order to achieve a better mechanical “seal”. The aim of this chapter is to describe the technique of implantation, the different types of materials used, and the report on their safety and efficacy.

Background Multidisciplinary teams (MDT) formulate expert informed treatment recommendations for people with cancer. We set out to examine how the factors proposed by the functional perspective of group decision making (DM), that is, interaction process, internal factors (factors emanating from within the group such as group size), external circumstances (factors coming from the outside of the team), and case‐complexity affect the quality of MDT decision making. Methods This was a cross‐sectional observational study. Three cancer MDTs were recruited with 44 members overall and 30 of their weekly meetings filmed. Validated observational instruments were used to measure quality of DM, interactions, and complexity of 822 case discussions. Results The full regression model with the variables proposed by the functional perspective was significant, R 2 = 0.52, F(20, 801) = 43.47, P, To the best of our knowledge, this is the first study to attempt to assess the factors proposed by the functional perspective in the context of cancer MDT meetings. Validated observational instruments were used to measure quality of decision making, interactions, and complexity of 822 case discussions across 3 cancer teams and 30 of their weekly meetings. One novel finding is unraveling the sociocognitive predictors of team DM quality, while another is the cognitive‐catch 22 effect

Colorectal cancer is the third leading cause of cancer related deaths and to date, the COVID-19 pandemic has led to major disruptions of the diagnosis and treatment pathways of this cancer, which may adversely affect survival outcomes for many years. Colorectal cancer pathways must be maintained at a near normal throughput with urgent attention to the backlog of patients to avoid a potential crisis of avoidable cancer deaths. A radical review and revamping of endoscopy services to improve efficiency during COVID-19 is urgently required. To date most endoscopy units have severely restricted their activity, except for time-critical diagnostic and therapeutic procedures. In the post- COVID-19 recovery phase, access to endoscopy services will increase but capacity will be reduced compared to before the pandemic, due to infection control measures. A pragmatic and safe strategy is urgently needed to clear the backlog of endoscopic procedures and for managing the new symptomatic referrals. We propose the use of non-invasive tests, such as FIT and mSEPT9 combined with “safety netting” to “rule out” colorectal cancer and to reduce the utilization of colonoscopy by up to 80% and limit the procedure to those patients at high risk of cancer.

Background: the novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery. Materials and methods: a panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020. Results: a total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks. Conclusion: the results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period. We have presented the results of a survey used to assess the global impact of coronavirus disease 2019 (COVID-19) on the delivery of colorectal surgery. Despite accessible guidance information, our results have demonstrated that COVID-19 has significantly affected the ability of colorectal surgeons to offer care to patients. We have also discussed practical adaptation strategies for use during the recovery phase., NA

AIM The SphinKeeper™ artificial bowel sphincter implant is a relatively new surgical technique for the treatment of refractory faecal incontinence. This study presents the first experience in two UK tertiary centres. METHOD This is a retrospective audit of prospectively collected clinical data in relation to technique, safety, feasibility and short-term effectiveness from patients undergoing surgery from January 2016 to April 2019. Baseline data, intra-operative and postoperative complications, symptoms [using St Mark's incontinence score (SMIS)] and radiological outcomes were analysed. RESULTS Twenty-seven patients [18 women, median age 57 years (range 27-87)] underwent SphinKeeper. In 30% of the patients, the firing device jammed and not all prostheses were delivered. There were no intra-operative complications and all patients were discharged the same or the following day. SMIS significantly improved from baseline [median -6 points (range -12 to +3); P

To present our single institution and surgeon’s complex abdominal wall reconstructions (CAWR) experience with Permacol™ mesh through a non-randomized study. Data of 51 consecutive patients were prospectively collected between 2003 and 2015. Patients had a median of 3 comorbidities (range 0–10) and 68% were Center for Disease Control class II–IV. The mean previous repair was 1.3 (range, 0–12), and 25 (44%) had a mesh in situ. The median defect size was 625 cm2. Among the 56 CAWR procedures, in 16 (29%) bowel resection/anastomosis was performed. The overall post-operative complication rate was 45%, and it was wound-related except from 1 patient dead for myocardial infarction. One was lost at follow-up. Five were re-operated for recurrence with a second Permacol mesh, leading to 14 (26%) overall recurrences at a mean follow-up of 44 months (range, 4–123). In 33 (59%) cases, fascial closure was achieved. The mesh placement was intraperitoneal in 89%, retro-muscular in 9% and supra-fascial in 1% of cases. A multivariate analysis showed that predictor risk for recurrence was more than 3 previous repairs, wound class III–IV, whereas age, type of comorbidities, defect size and fascial closure did not influence the recurrence. Median post-operative performance status was 0 (range; 0–3). A satisfaction questionnaire was obtained in 43 patients, and 86% of them were satisfied with the outcome. Biological materials have the potential to reduce morbidity and improve outcome of definitive repair of CAWR.

A 69-year-old man presented to the emergency department with a 2-day history of worsening right iliac fossa pain. He denied any associated nausea, fevers, change in bowel habit, urinary symptoms or recent weight loss. His previous medical history was of hypertension only. On examination, his

Ubiquitin-conjugating enzyme 9 (Ubc9) is required for sumoylation and inhibits apoptosis via Bcl-2 by unknown mechanism. Methionine adenosyltransferase 2A (MAT2A) encodes for MATα2, the catalytic subunit of the MATII isoenzyme that synthesizes S-adenosylmethionine (SAMe). Ubc9, Bcl-2 and MAT2A expression are up-regulated in several malignancies. Exogenous SAMe decreases Ubc9 and MAT2A expression and is pro-apoptotic in liver and colon cancer cells. Here we investigated whether there is interplay between Ubc9, MAT2A and Bcl-2. We used human colon and liver cancer cell lines RKO and HepG2, respectively, and confirmed key finding in colon cancer specimens. We found MATα2 can regulate Bcl-2 expression at multiple levels. MATα2 binds to Bcl-2 promoter to activate its transcription. This effect is independent of SAMe as MATα2 catalytic mutant was also effective. MATα2 also directly interacts with Bcl-2 to enhance its protein stability. MATα2's effect on Bcl-2 requires Ubc9 as MATα2's stability is influenced by sumoylation at K340, K372 and K394. Overexpressing wild type (but not less stable MATα2 sumoylation mutants) protected from 5-fluorouracil-induced apoptosis in both colon and liver cancer cells. Colon cancer have higher levels of sumoylated MATα2, total MATα2, Ubc9 and Bcl-2 and higher MATα2 binding to the Bcl-2 P2 promoter. Taken together, Ubc9's protective effect on apoptosis may be mediated at least in part by sumoylating and stabilizing MATα2 protein, which in turn positively maintains Bcl-2 expression. These interactions feed forward to further enhance growth and survival of the cancer cell.

AIM: Permacol™ collagen paste (Permacol™ paste) is an acellular cross-linked porcine dermal collagen matrix suspension for use in soft tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter-preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients.METHOD: Patients (N=100) with anal fistula were treated at ten European surgical sites with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6, and 12 months post-treatment, with the primary endpoint being healing at 6 months. Faecal continence and patient satisfaction were surveyed at each follow-up; adverse events (AEs) were monitored throughout the follow-up.RESULTS: At 6 months post-surgery, 56.7% of patients were healed, and the percentage healed was largely maintained, with 53.5% healed at 12 months. 29.0% of patients had at least one AE, and 16.0% of patients had one or more procedure-related AE. Most AEs reported were minor and similar to those commonly observed after fistula treatment, and the incidence of serious adverse events was low (4.0% of patients). Regardless of treatment outcome, 73.0% of patients were satisfied or very satisfied with the procedure.CONCLUSION: Permacol™ paste provides a promising sphincter-preserving treatment for anal fistulas with minimal adverse side-effects. This article is protected by copyright. All rights reserved.

Methionine adenosyltransferase (MAT) is an essential enzyme that is responsible for the biosynthesis of S-adenosylmethionine (SAMe), the principal methyl donor and precursor of polyamines. MAT1A is expressed in normal liver and MAT2A is expressed in all extrahepatic tissues. MAT2A expression is increased in human colon cancer and in colon cancer cells treated with mitogens whereas silencing MAT2A resulted in apoptosis. The aim of the current work was to examine the mechanism responsible for MAT2A-dependent growth and apoptosis. We found that in RKO (human adenocarcinoma cell line) cells, MAT2A siRNA treatment lowered cellular SAMe and putrescine levels by 70 to 75%, increased apoptosis and inhibited growth. Putrescine supplementation blunted significantly MAT2A siRNA-induced apoptosis and growth suppression. Putrescine treatment (100 pmol/L) raised MAT2A mRNA level to 4.3-fold of control, increased the expression of c-Jun and c-Fos and binding to an AP-1 site in the human MAT2A promoter and the promoter activity. In human colon cancer specimens, the expression levels of MAT2A, ornithine decarboxylase (ODC), c-Jun and c-Fos are all elevated as compared to adjacent non-tumorous tissues. Overexpression of ODC in RKO cells also raised MAT2A mRNA level and MAT2A promoter activity. ODC and MAT2A are also overexpressed in liver cancer and consistently, similar MAT2A-ODC-putrescine interactions and effects on growth and apoptosis were observed in HepG2 cells. In conclusion, there is a crosstalk between polyamines and MAT2A. Increased MAT2A expression provides more SAMe for polyamines biosynthesis; increased polyamine (putrescine in this case) can activate MAT2A at the transcriptional level. This along with increased ODC expression in cancer all feed forward to further enhance the proliferative capacity of the cancer cell.

Methionine adenosyltransferase 2B (MAT2B) encodes for two variant proteins (V1 and V2) that promote cell growth. Using in-solution proteomics, GIT1 (G Protein Coupled Receptor Kinase Interacting ArfGAP 1) was identified as a potential interacting partner of MAT2B. Here, we examined the functional significance of this interplay. Coimmunoprecipitation experiments examined protein interactions. Tissue expression levels of proteins were examined using immunohistochemistry and western blotting. Expression levels of proteins were varied using transient knockdown or overexpression to observe the effect of alterations in each protein on the entire complex. Direct interaction among individual proteins was further verified using in vitro translated and recombinant proteins. We found both MAT2B variants interact with GIT1. Overexpression of V1, V2, or GIT1 activated mitogen-activated protein kinase kinase 1 (MEK1) and extracellular signal-regulated kinase (ERK), raised cyclin D1 protein level, and increased growth, whereas the opposite occurred when V1, V2, or GIT1 was knocked down. MAT2B and GIT1 require each other to activate MEK1/ERK and increase growth. MAT2B directly interacts with MEK1, GIT1, and ERK2. Expression level of V1, V2, or GIT1 directly influenced recruitment of GIT1 or MAT2B and ERK2 to MEK1, respectively. In pull-down assays, MAT2B directly promoted binding of GIT1 and ERK2 to MEK1. MAT2B and GIT1 interact and are overexpressed in most human liver and colon cancer specimens. Increased expression of V1, V2, or GIT1 promoted growth in an orthotopic liver cancer model, whereas increased expression of either V1 or V2 with GIT1 further enhanced growth and lung metastasis. Conclusion: MAT2B and GIT1 form a scaffold, which recruits and activates MEK and ERK to promote growth and tumorigenesis. This novel MAT2B/GIT1 complex may provide a potential therapeutic gateway in human liver and colon cancer. (HEPATOLOGY 2012)

AIM: Permacol(™) collagen paste (Permacol(™) paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set to evaluate the clinical outcome of Permacol(™) paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial.METHOD: Patients (N=30) with anal fistula presenting to ten European academic surgical units were treated with a sphincter-preserving technique using Permacol(™) paste. Fistula healing was assessed at 1, 3, 6, and 12 months after treatment, with the primary endpoint of fistula healing at 6-months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up.RESULTS: Of the 28 patients with data at six months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol(™) paste was similar for intersphincteric to transsphincteric fistulas and primary or recurrent fistulas. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation.CONCLUSION: Permacol(™) paste is was shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects. This article is protected by copyright. All rights reserved.

Ubiquitin-conjugating enzyme 9 (Ubc9) is required for sumoylation and is overexpressed in several malignancies, but its expression in hepatocellular carcinoma (HCC) is unknown. Hepatic S-adenosyl methionine (SAMe) levels decrease in methionine adenosyltransferase 1A (Mat1a) knockout (KO) mice, which develop HCC, and in ethanol-fed mice. We examined the regulation of Ubc9 by SAMe in murine liver and human HCC, breast, and colon carcinoma cell lines and specimens. Real-time polymerase chain reaction and western blotting measured gene and protein expression, respectively. Immunoprecipitation followed by western blotting examined protein-protein interactions. Ubc9 expression increased in HCC and when hepatic SAMe levels decreased. SAMe treatment in Mat1a KO mice reduced Ubc9 protein, but not messenger RNA (mRNA) levels, and lowered sumoylation. Similarly, treatment of liver cancer cell lines HepG2 and Huh7, colon cancer cell line RKO, and breast cancer cell line MCF-7 with SAMe or its metabolite 5′-methylthioadenosine (MTA) reduced only Ubc9 protein level. Ubc9 posttranslational regulation is unknown. Ubc9 sequence predicted a possible phosphorylation site by cell division cycle 2 (Cdc2), which directly phosphorylated recombinant Ubc9. Mat1a KO mice had higher phosphorylated (phospho)-Ubc9 levels, which normalized after SAMe treatment. SAMe and MTA treatment lowered Cdc2 mRNA and protein levels, as well as phospho-Ubc9 and protein sumoylation in liver, colon, and breast cancer cells. Serine 71 of Ubc9 was required for phosphorylation, interaction with Cdc2, and protein stability. Cdc2, Ubc9, and phospho-Ubc9 levels increased in human liver, breast, and colon cancers. Conclusion: Cdc2 expression is increased and Ubc9 is hyperphosphorylated in several cancers, and this represents a novel mechanism to maintain high Ubc9 protein expression that can be inhibited by SAMe and MTA. (HEPATOLOGY 2012;56:982–993)

Background Various injectable bulking agents have been used for the treatment of faecal incontinence (FI). However, encouraging early results are not maintained over time. This study aimed to assess short- and medium-term results of a new bulking agent for the treatment of FI. Methods The Gatekeeper™ prosthesis comprises a thin solid polyacrylonitrile cylinder that becomes thicker, shorter and softer within 24 h after implantation. Fourteen patients with FI underwent treatment with Gatekeeper™ under local anaesthesia. Four prostheses were implanted in the intersphincteric space in each patient, under endoanal ultrasound guidance. Number of episodes of major FI, Cleveland Clinic FI score (CCFIS), Vaizey score, anorectal manometry, endoanal ultrasonography (EUS), health status and quality of life (Short Form 36 and Faecal Incontinence Quality of Life questionnaires) were assessed before and after treatment. Results Mean(s.d.) follow-up was 33·5(12·4) months. There were no complications. There was a significant decrease in major FI episodes from 7·1(7·4) per week at baseline to 1·4(4·0), 1·0(3·2) and 0·4(0·6) per week respectively at 1-month, 3-month and last follow-up (P = 0·002). CCFIS improved significantly from 12·7(3·3) to 4·1(3·0), 3·9(2·6) and 5·1(3·0) respectively (P < 0·001), and Vaizey score from 15·4(3·3) to 7·1(3·9), 4·7(3·0) and 6·9(5·0) respectively (P = 0·010). Soiling and ability to postpone defaecation improved significantly, and patients reported significant improvement in health status and quality of life. At follow-up, manometric parameters had not changed and EUS did not demonstrate any prosthesis dislocation. Conclusion The Gatekeeper™ anal implant seemed safe, reliable and effective. Initial clinical improvement was maintained over time, and follow-up data were encouraging.

Introduction The aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy (SH) for the treatment of second- and third-degree haemorrhoids. Methods Patients with second- or third-degree haemorrhoids who failed conservative treatment were randomly allocated to THD or SH. Preoperative and postoperative symptoms, postoperative pain, time until return to normal activities, complications, patient satisfaction and recurrence rates were all assessed prospectively. Patients were followed up at 2, 8 months and when the study was completed. Results Twenty-eight patients (43% third degree) underwent THD and 24 (38% third degree) underwent SH. There were no significant differences in terms of postoperative pain, expected pain and analgesia requirements, but more THD patients returned to work within 4 days (P

Recent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment.A retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX-FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading.Chemotherapy prolonged survival by 9 months (p = 0.001). In patients undergoing CHT, resective surgery did not prolong survival (p = 0.931), whereas in patients not undergoing CHT, it improved prognosis by 5 months (p = 0.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (p0.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (p = 0.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded.CHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

Several studies concluded that mechanical bowel preparation (MBP) does not confer any advantage on reducing the anastomotic leak rate or wound infections. The aim of this meta-analysis was to review all prospective randomised controlled trials on the use of MBP before colorectal surgery in order to find differences in the rates of abdominal and systemic complications in view of recent published articles. Review of all randomised prospective trials compare MBP vs. non-MBP. Primary outcome measures were anastomotic leakages, abdomino-pelvic abscesses and postoperative ileus. Secondary outcomes were wound infections, extra-abdominal complications (urinary infections, pulmonary infections, deep venous thrombosis or pulmonary embolism, cardiac events), sepsis and mortality. Twelve articles met the inclusion criteria with 4,919 patients. The non-MBP group showed no significant increase of the anastomotic leakages (3.4% vs. 4.1%; p = NS) and wound infections (8.7% vs. 9.6%; p = NS) but had a lower rate of postoperative cardiac events (2.5% vs. 4.0%; p = 0.04). The evidence from recent studies, combined with previous ones, further suggests that the dogma of the necessity of mechanical bowel preparation before elective colorectal surgery should be reconsidered.

The authors conducted a review of the available English literature to evaluate the advantages of three-dimensional ultrasound for assessing anorectal pathology, to provide a state-of-the-art approach, and to compare this technique with conventional endoluminal ultrasound and other imaging methods.All studies describing results obtained with three-dimensional ultrasound in the evaluation of anorectal pathologies, both alone and compared with other techniques, were selected.Since 1996, 32 articles have been published. In tumor staging, specific data derived by three-dimensional reconstruction for the assessment of T invasion and nodal involvement were more accurate than endoluminal ultrasound and computed tomography. For evaluating perianal sepsis, the detection of secondary fistula tracts and fluid collections and the location of internal openings were superior to endoanal magnetic resonance imaging. In the evaluation of anal incontinence, the results for sphincter defects were similar to those obtained with endoanal magnetic resonance imaging.Analysis of the literature confirmed that three-dimensional ultrasound is a valuable technique for assessing anorectal disorders, facilitating the interpretation of the images obtained, and providing additional data that in many cases have changed the operative approach.

Transanal haemorrhoidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorrhoidal plexus. The aim of this study was to assess the long-term efficacy of this treatment.The procedure was carried out using a proctoscope with a Doppler probe. The terminal branches were located with Doppler and then sutured.From January 2000 to May 2006, we performed THD in 330 patients (180 men; mean age, 52.4 years), including 138 second-degree, 162 third-degree and 30 fourth-degree haemorrhoids. There were 23 postoperative complications (7 cases of bleeding, 5 thrombosed piles, 4 rectal haematomas, 2 anal fissures, 2 cases of dysuria, 1 of haematuria and 2 needle ruptures). The mean postoperative pain score was 1.32 on a visual analog scale. 219 patients were followed for a mean of 46 months (range, 22-79), including 100 patients with second-degree, 104 with third-degree and 15 with fourth-degree haemorrhoids. The operation completely resolved the symptoms in 132 patients (92.5%) with preoperative bleeding and in 110 patients (92%) with preoperative prolapse.The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

Background The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies. Methods All patients who underwent surgery for a nonruptured infrarenal AAA of ≥5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed. Results Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of ≥5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P=NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% ( P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103) Conclusions With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.

Perianal giant condyloma acuminatum is a rare variant of condyloma acuminata and often represents a therapeutic challenge. We report a case successfully treated with surgical excision alone.

Background The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients. Methods Seventeen patients (13 women; median age 47 (range 20–67) years) with rectal evacuatory dysfunction and rectal intussusception, 13 of whom had a rectocele, were selected. The intussusception was corrected by external pelvic suspension of the rectum, using collagen strips attached to the rectal wall and pubis. The rectocele was repaired with a collagen patch. Patients were assessed before and 6 months after surgery by symptom and quality of life questionnaires, anorectal physiological investigation and proctography, and were followed up for a median of 12 months. Results Sepsis requiring exploration occurred in two patients but there was no extrusion or need to remove the collagen. Of the 15 patients assessed after surgery, total symptom scores were significantly decreased (P < 0·001) and quality of life scores improved (P < 0·001). Proctographically, the degree of intussusception was improved in ten patients; six patients had normal postoperative proctograms. The rectocele was reduced in size in all patients, and was not demonstrable in eight. Conclusion An effective procedure for rectal intussusception and rectocele has been developed in a selected group of patients with marked evacuatory symptoms.

The use of biological materials for the repair of complex abdominal wall defects has increased over the years; however, the role of these materials in routine practice remains unclear. The aim of the study was to evaluate clinical outcomes following the use of Permacol™ porcine collagen surgical implant in complex abdominal wall repair. This subset analysis of seven European sites from a multicentre retrospective study included patients undergoing open or laparoscopic surgery and treated with Permacol™ surgical implant. Inguinal, parastomal, diaphragmatic, perineal, and hiatal repairs were excluded. Only patients with at least 12 months of follow-up after surgery were included. A total of 109 patients (56 males and 53 females) were included. Patients had a median of two comorbidities (range 0–6). Thirty-three per cent of patients were treated for recurrent hernia. All but one case used an open approach. Sixty-six per cent were Center for Disease Control wound class II–IV at the time of surgery. Fascial closure was achieved in 69%. Median follow-up length was 720 days (range 368–2857). Recurrence rates at 1 and 2 years were 9.2 and 18.3 %, respectively, and were higher in cases without fascial closure. One-year recurrence was higher following use of an onlay technique (P = 0.025). In a multivariate analysis, among 16 comorbidities examined only fascial closure significantly impacted 1-year recurrence (P = 0.049). Data from this large retrospective multicentre European study strongly suggest the use of Permacol™ porcine collagen surgical implant to be safe and effective for complex abdominal wall repair. The recurrence rate was impacted by fascial closure.

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and 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 with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

PURPOSE: As many as 60 percent of patients present with recurrent symptoms of fecal incontinence after anterior overlapping anal sphincter repair. The aim of this study was to assess the outcome of repeat overlapping anal sphincter repair. METHODS: All female patients with obstetric sphincter damage who underwent anterior overlapping sphincter repair between November 1988 and June 2000 were reviewed. All patients were preoperatively assessed by anorectal manometry, electromyography, and pudendal nerve terminal motor latency; manometry was repeated during follow-up. Preoperative endoanal ultrasonography was available only after 1990. Clinical outcome was assessed according to the Cleveland Clinic Florida Incontinence Score. RESULTS: One hundred fifty-one patients were available for analysis, 115 without previous surgery and 36 after at least one previous sphincter repair. The median follow-up was 13 (range, 1–64) months and 20 (range, 2–96) months, respectively. The median incontinence score improved from 18 to 5 (P < 0.0001) in patients without previous repair and from 17.5 to 7 (P < 0.0001) in patients after previous repair. In the former group, the outcome was good in 67 (58 percent) patients, adequate in 19 (16.5 percent), and poor in 29 (25.5 percent). In the group with previous sphincter repair, the outcome was good in 18 patients (50 percent), adequate in 4 (11 percent), and poor in 14 (39 percent; P = 0.2646). The mean resting pressure increased from 20 (range, 3–43) mmHg to 24 (range, 10–44) mmHg and from 27 (range, 4–56) mmHg to 32 (range, 16–45) mmHg, respectively. The mean squeeze pressure increased from 60 (range, 23–63) mmHg to 67 (range, 33–114) mmHg and from 54 (range, 25–90) mmHg to 70 (range, 34–95) mmHg, respectively. CONCLUSION: Previous sphincter repair does not affect clinical outcome. Repeat anterior overlapping sphincter repair yields a significant improvement in the continence score and should be considered as the treatment of choice in patients with fecal incontinence who have had previous sphincter repair and residual anterior sphincter damage.

Background The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. Methods Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. Results Median follow-up time was 649 days (max: 2857), median age 57 years (range 23–91), and BMI 32 kg/m 2 (range 17.6–77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives–Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan–Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. Conclusions Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. Clinical trial registration number NCT01214252 (http://www.clinicaltrials.gov).

The main purpose of the Italian Society of Colorectal Surgery (SICCR) is to enhance the science and standard of care of patients with colorectal diseases in our Country. The Annual Report (AR) from the Coloproctology Units (UCP) affiliated to the Society was introduced in 1993 in order to monitor their activity and includes four sections covering the most important colo-rectal diseases and their different possibilities of care. From its introduction, it has been improved, being now more articulated and including not only simply the figures of surgical procedures but also alternative treatments, the ratio between observed and operated patients, the percentage of the most common complications (i.e. anastomotic dehiscence). The overall data are analysed and compared with those from the previous years, and results are presented at the annual UCP Club meeting, where co-ordinators of the UCP are requested to attend. This meeting, that is considered very important in the society-life, aims to favour discussion and comparison amongst UCP co-ordinators, to highlight possible differences amongst centres and to address possible issues of wrong practice. The goal is to recall the attention of the coordinators on the standard of the surgical management of their patients. In the same direction, debating at the conclusion of the 2011 UCP meeting, which was held last May in Venice, we thought that a judgment given by some international experts in colo-rectal surgery would have been beneficial. Pasquale Giordano was then asked to comment the Proctology section (condylomata, fissures, haemorrhoids and fistulae), Andrew Zbar commented the Functional Diseases section (megacolon, obstructed defecation, proctalgia, entero-rectocele, rectal prolapse), Steven Wexner the IBD section (ulcerative colitis, Crohn’s disease and also diverticular disease) and Francis Seow-Choen the Cancer section (anal cancer, colon and rectal carcinoma and polyps).

PURPOSE: Transanal hemorrhoidal dearterialization consists of a Doppler-guided ligation of the distal branches of the rectal arteries. The aim of this review is to assess the current evidence on dearterialization, establish the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations. METHODS: All published studies on dearterialization without language restrictions were reviewed systematically. Primary outcome measures were postoperative pain and hemorrhoidal recurrences. RESULTS: Seventeen articles including a total of 1,996 patients were analyzed. In general, the quality of the studies was low. Operating time ranged between 5 and 50 minutes. Hospital stay was one day for most patients, whereas the return to normal activities was between two and three days in most cases. Postoperative pain was present in 18.5% of patients. Three patients experienced significant postoperative hemorrhages. There were no other major complications. The overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding, and 4.7% for pain at defecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding, and 8.7% for pain at defecation. When reported as a function of the hemorrhoidal grade, the recurrence rate was higher for fourth-degree hemorrhoids (range, 11.1–59.3%). CONCLUSION: Transanal hemorrhoidal dearterialization appears to be a potential treatment option for seconddegree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

A proportion of patients with chronic anal fissure have persistent symptoms and pathology despite optimum conservative therapies. Lateral anal sphincterotomy, the standard surgical treatment, is associated with functional compromise in a minority of patients. Sphincter-sparing anoplasty has been advocated as an alternative procedure for those with “low pressure” sphincters. The aim of this study was to determine the efficacy of simple cutaneous advancement flap anoplasty (SCAFA) when applied to consecutive patients with chronic anal fissure irrespective of anal tone and the patient’s gender. This was a prospective outcome study of 51 consecutive patients treated with SCAFA over a 6.5-year period. Surgery was well tolerated. There were three (5.9%) early flap dehiscences, all of which were treated with repeat SCAFA, and one of those three patients remained symptomatic at 2 months. All fissures healed in the short term. Three other patients subsequently developed fissures at sites remote from the original pathology. Continence was unaffected by the procedure. Simple cutaneous advancement flap anoplasty should be considered as a first-line surgical treatment of chronic anal fissure, irrespective of patient gender and anal tone.

External pelvic rectal suspension (EXPRESS procedure) is a newly developed operation aimed at restoring the anatomical position of the internal rectal prolapse whilst hopefully improving the underlying physiological abnormality. The procedure is carried out transperineally with limited rectal mobilisation, and where appropriate, it can be combined with surgical correction of a rectocele. The operation consists of “hitching up” the rectum and reinforcing the rectovaginal wall utilising a commercially available, long-lasting collagen biomaterial (Permacol, Tissue Science Laboratories plc, Aldershot, UK).

Neurofibromatosis type 1 (NF1) is an autosomally dominant inherited disorder characterized by neurocutaneous and bony lesions with multisystem vasculopathy in the form of stenotic and aneurysmal disease. The multisystemic nature of NF1 aneurysmal disease can have potentially serious clinical sequelae and complicated management. A 55-year-old woman with NF1 presented acutely with severe abdominal and back pain, diarrhea, and hypotension with a delayed fall in her hemoglobin. Imaging demonstrated a retroperitoneal bleed from a superior rectal artery aneurysm. The inferior mesenteric artery was coiled with cessation of bleeding. She became unstable again and underwent a successful laparotomy for aneurysm exclusion and evacuation of hematoma. Vessel position and relatively nonspecific symptoms on presentation make awareness among front-line clinicians critical. Endovascular management can be difficult, and the clinician should be prepared for open surgery if the patient displays signs of recurrent bleeding.

Introduction Historically, the treatment of anal fistulas has required a compromise between successful fistula healing and preservation of continence. The aim of this study (NCT01624350) is to evaluate clinical outcomes of anal fistulas treated with Permacol™ collagen paste. Method Patients (N = 98) with magnetic resonance imaging-confirmed intersphincteric or transsphincteric anal fistulas, cryptoglandular primary or recurrent, from ten European sites were treated with Permacol™ collagen paste. Fistula healing, adverse events, and patient satisfaction were assessed up to 12 months post-surgery, with fistula healing at 6 months confirmed by clinical assessment as the primary endpoint. Cox regression analyses were performed to determine if patient or fistula characteristics correlate with better healing. Results The median follow-up was 26.8 weeks (range 0.1–62.4 weeks), with 87 and 46 patients having healing data at 6 months and 12 months, respectively. At 6 months follow-up, 51 (58.6%) patients exhibited a clinically-healed anal fistula, including 20/35 (57.1%) that were recurrent at the time of treatment. At 12 months, 19 (41.3%) patients were healed. Younger patients and those with evidence of expulsion or leakage of Permacol™ collagen paste were the only variables associated with a significantly increased risk of failure (p = 0.0017 and p = 0.0068, respectively). A total of six serious adverse events were reported, four of which (perianal abscess, n = 2; non-healing fistula tract, n = 1; complex regional pain syndrome, n = 1) were possibly related to the device and/or the procedure. Continence was preserved throughout the follow-up. At their last visit, over 70% of patients reported being satisfied or very satisfied with their operation, indicating that some patients were satisfied even though their fistula did not heal. Conclusion These preliminary results demonstrate that Permacol™ collagen paste is a well-tolerated, sphincter-sparing technique for the treatment of anal fistulas with low morbidity. Disclosure of interest P. Giordano Grant/Research Support from: Covidien, Consultant for: Covidien, Speaker Bureau of: Covidien, P. Sileri Grant/Research Support from: Covidien, S. Buntzen Grant/Research Support from: Covidien, Speaker Bureau of: Medtronic, A. Stuto Grant/Research Support from: Covidien, J. Nunoo-Mensah Grant/Research Support from: Covidien, L. Lenisa Grant/Research Support from: Covidien, B. Singh Grant/Research Support from: Covidien, Speaker Bureau of: Covidien, O. Thorlacius-Ussing Grant/Research Support from: Covidien, B. Griffiths Grant/Research Support from: Covidien, D. Ziyaie Grant/Research Support from: Covidien, Speaker Bureau of: Covidien.

We report an incident of complete stapled closure of the rectal lumen following stapled hemorrhoidopexy. A patient with symptomatic prolapsing hemorrhoids underwent a stapled hemorrhoidopexy as a day-case procedure. After application of the pursestring suture and firing of the dedicated stapler the rectal lumen was found to have been completely obliterated. Endoscopic assessment using a flexible sigmoidoscope confirmed the absence of a rectal lumen. The patient was woken up and a gastrograffin enema performed. Contrast was injected under high pressure into the rectal lumen and a small defect in the mid point of the staple line was revealed. A fine guidewire was passed and endoscopic balloon dilatation achieved. This complication could have had catastrophic consequences and potentially required major surgical intervention. Although unlikely to occur, we believe that surgeons should be aware of this possible problem and a radiologic/endoscopic approach should be considered before more aggressive surgical intervention is undertaken.

Laparostomy wound management is a difficult problem especially with a stoma and the potential risk of infection. A case describing the use of a permanent porcine dermal collagen implant in the repair of a massive ventral hernia, in a patient with a large post-laparostomy defect and colostomy is outlined. The implant was not rejected, and after 12 months, there was no evidence of residual or recurrent hernia. The search for the ultimate biomaterial for reconstructing abdominal wall defects is ongoing. Collagen based implants appear to have many of the requirements that an ideal material should possess.

The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States.A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC.Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice.Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.