Classification and stratification in pilonidal sinus disease: findings from the PITSTOP cohort

AIM

Research in pilonidal disease faces several challenges, one of which is consistent and useful disease classification. The International Pilonidal Society (IPS) proposed a four-part classification in 2017. The aim of this work was to assess the validity and reliability of this tool using data from the PITSTOP cohort study.

METHOD

Face validity was assessed by mapping the items/domains in the IPS tool against tools identified through a systematic review. Key concepts were defined as those appearing in more than two-thirds of published tools. Concurrent and predictive validity were assessed by comparing key patient-reported outcome measures between groups at baseline and at clinic visit. The outcomes of interest were health utility, Cardiff Wound Impact Questionnaire (CWIQ) and pain score between groups. Significance was set at p = 0.05 a priori. Interrater reliability was assessed using images captured during the PITSTOP cohort. Ninety images were assessed by six raters (two experts, two general surgeons and two trainees), and classified into IPS type. Interrater reliability was assessed using the unweighted kappa and unweighted Gwet's AC1 statistics.

RESULTS

For face validity items represented in the IPS were common to other classification systems. Concurrent and predictive validity assessment showed differences in health utility and pain between groups at baseline, and for some treatment groups at follow-up. Assessors agreed the same classification in 38% of participants [chance-corrected kappa 0.52 (95% CI 0.42-0.61), Gwet's AC1 0.63 (95% CI 0.56-0.69)].

CONCLUSION

The IPS classification demonstrates key aspects of reliability and validity that would support its implementation.

The development of a cryptoglandular anal fistula quality of life scale (AF-QoL)

AIM

Quality of life (QoL) is a crucial and core outcome in assessing the effectiveness of treatments for cryptoglandular anal fistula. Despite its extensive impact, there is a lack of patient-centred, disease-specific QoL measurement instruments of adequate quality. The aim of this study is to develop a disease-specific measurement instrument that can accurately measure QoL for patients with cryptoglandular anal fistula.

METHOD

Semi-structured qualitative patient interviews and a systematic review of current instruments were used to generate items for the draft instrument. This underwent successive rounds of cognitive interviews to refine its wording and structure. Individual item and overall scale content validity were determined by asking experts to rate the relevance of each item and those deemed irrelevant were removed. The final instrument then underwent psychometric testing and test-retest analysis to determine its sensitivity and stability.

RESULTS

A total of 148 patients were involved in item generation, scale development and psychometric testing. A 22-item measurement instrument has been developed; it is scored on a scale of 0-100, where 0 indicates the worst QoL and 100 demonstrates perfect QoL. The scale demonstrates excellent internal consistency (Cronbach-α = 0.927), strong content and construct validity [correlation with Perianal Disease Activity Index = -0.713, Hospital Anxiety and Depression Anxiety (-0.659) and Depression (-0.673) subscales and Short Form-12 physical (0.609) and mental (0.589) component scales] and strong reliability and responsiveness.

CONCLUSION

We have developed a cryptoglandular Anal Fistula Quality of Life scale (AF-QoL), a comprehensive, disease-specific patient reported outcome measure assessing QoL in patients with cryptoglandular anal fistula.

Giant Villous Adenoma of the Rectum With Prolapse: Case Report

Colorectal polyps, frequently adenomas, are common in older adults, with villous adenomas being a notable subset due to their potential for significant malignancy risk. This case report highlights a rare instance of a giant villous adenoma in a 79-year-old female patient, challenging in both diagnosis and treatment. The patient, with a history of untreated essential arterial hypertension, was hospitalized for severe anemia following a massive rectal hemorrhage. An irreducible, prolapsed rectal mass was evident upon examination, and further investigations, including rectoscopy and abdominopelvic computed tomography scan, confirmed a villous adenoma with severe dysplasia. Given the tumor's substantial size, circumferential nature, and proximity to the dentate line, an abdominoperineal resection using the Miles technique was performed. The histopathological examination post-surgery confirmed the presence of a villous adenoma with high-grade epithelial neoplasia and localized areas of well-differentiated tubular adenocarcinoma. This case underscores the diagnostic and management complexities of large villous adenomas, emphasizing the need for meticulous surgical decision-making to ensure oncological safety and patient welfare, particularly when conservative resection may be inadequate.

Current and future perspectives on the utility of provocative tests of anal sphincter function: A state-of-the-art summary

BACKGROUND

The maintenance of fecal continence depends upon coordinated interactions between the pelvic floor, anorectum, and anal sphincter complex orchestrated by central and peripheral neural activities. The current techniques to objectively measure anorectal function rely on fixed diameter catheters placed inside the anal canal with a rectal balloon to obtain measurements of anal resting and squeeze function, and rectal compliance. Until recently it had not been possible to measure the distensibility of the anal canal, or in other words its ability to resist opening against an increasing pressure, which has been proposed as the main determinant of a biological sphincter's function. Anal acoustic reflectometry (AAR) and the functional lumen imaging probe (FLIP) are two novel, provocative techniques that dynamically assess the anal sphincter complex under volume-controlled distension. In doing so, both provide information on the viscoelastic properties of the anal canal and offer new insights into its function.

PURPOSE

This review details the current and potential future applications of AAR and FLIP and highlights the unanswered questions relevant to these new technologies.

Women with Cervical High-Risk Human Papillomavirus: Be Aware of Your Anus! The ANGY Cross-Sectional Clinical Study

Anogenital human papillomaviruses (HPV) are highly prevalent in sexually active populations, with HR-HPV being associated with dysplasia and cancers. The consequences of cervical HPV infection are well-known, whereas those of the anus are less clear. The correlation of cervical and anal HPVs with the increasing number of anal cancers in women has not been studied yet. The objective of our prospective study was to determine whether cervical and anal HPV correlated in a cohort of women recruited in a university hospital in Switzerland. Recruitment was conducted in the gynecology clinic, the colposcopy clinic, and the HIV clinic. Cervical and anal HPV genotyping and cytology were performed. Overall, 275 patients were included (360 were initially planned), and among them, 102 (37%) had cervical HR-HPV. Patients with cervical HR-HPV compared to patients without cervical HR-HPV were significantly younger (39 vs. 44 yrs, p < 0.001), had earlier sexual intercourse (17.2 vs. 18.3 yrs, p < 0.01), had more sexual partners (2.9 vs. 2.2, p < 0.0001), more dysplastic cervical cytology findings (42% vs. 19%, p < 0.0001) and higher prevalence of anal HR-HPV (59% vs. 24%, p < 0.0001). Furthermore, the HR-HPV group reported more anal intercourse (44% vs. 29%, p < 0.015). Multivariate analysis retained anal HR-HPV as independent risk factor for cervical HR-HPV (OR3.3, CI 1.2−9.0, p = 0.02). The results of this study emphasize that it is of upmost importance to screen women for anal HR-HPV when diagnosing cervical HR-HPV.

Fecal Incontinence: The Importance of a Structured Pathophysiological Model

Fecal incontinence has an enormous social and economic impact and may significantly impair quality of life. Even though fecal incontinence is a common complaint in (aging) adults, a structured pathophysiological model of the clinical presentations of fecal incontinence is missing in current literature. The most frequent manifestations of fecal incontinence are passive fecal loss, urge incontinence, or mixed fecal incontinence. At our institution, we treat 400 patients per year with defecation disorders, including a significant number of patients with fecal incontinence. On the basis of this experience, we have tried to create a concept that merges current insight in causes and treatment options in a clinically useful algorithm. By applying the system of anamnesis and physical examination described in this article and expanding it with simple additional anorectal examination, in most patients, one can determine the type of fecal incontinence and choose a targeted therapy.

Sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy) for the Treatment of Second- and Third-Degree Hemorrhoidal Disease: Feasibility and Short-Term Outcomes

BACKGROUND

Sclerobanding is a novel technique combining rubber band ligation with 3% polidocanol foam sclerotherapy for the treatment of hemorrhoidal disease (HD). The aim of this study is to evaluate the feasibility, safety and short-term outcomes of sclerobanding in the treatment of second- and third-degree HD.

METHODS

A retrospective analysis of second- and third-degree HD cases from November 2017 to August 2021 was performed. Patients on anticoagulants or with other HD degrees were excluded. Follow-up was conducted at 1 month, 3 months, 6 months, 1 year and then every 12 months.

RESULTS

97 patients with second- (20 pts; 20.6%) and third-degree (77 pts; 79.4%) HD with a mean age of 52 years (20-84; SD ± 15.5) were included. Fifty-six patients were men (57.7%) and forty-one women (42.3%). Median follow-up was 13 months (1-26 months). No intraoperative adverse events or drug-related side effects occurred. Minor complications occurred in four patients (4.1%) in the first 30 postoperative days and all resolved after conservative treatment at the 3-month follow-up visit. No mortality or readmissions were observed.

CONCLUSIONS

Sclerobanding is a safe technique with a low rate of minor postoperative complications. Further studies on larger samples are necessary to establish the effectiveness and long-term outcomes of the technique.

Fissurectomy and anoplasty in posterior normotensive chronic anal fissure

PURPOSE

Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there's a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS.

METHODS

We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity.

RESULTS

All patients healed within 40 days after surgery. We didn't observe any "de novo" post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn't record statistically significant differences in pre- and post-operative manometry findings.

CONCLUSION

At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Patients' Perceived Satisfaction Through Telephone-Assisted Tele-Consultation During the SARS-CoV-2 Pandemic Period: Observational Single-Centre Study at a Tertiary-Referral Colorectal Surgery Department

Introduction: The pandemic produced by SARS-CoV-2 has obliged us to set up the tele-assistance to offer a continuity of care. This implies an innovation, being the degree of satisfaction of patients unknown. Methods: A telephonic survey was conducted with the validated in the Spanish tool Telehealth Usability Questionnaire (Telehealth Usability Questionnaire; rating from 1-7) of all candidate patients assisted consecutively in the Coloproctology Unit. We included demographic variables, education level, job status, diagnosis and consultation type. A descriptive study was done. The relationship between the willingness of consultation model in the future (telemedicine vs traditional) and the categorical variables was analysed through the chi-squared test. Results: A total of 115 patients were included. The average age was 59.9 years, being 60% women. The average score in each of the survey items was higher than 6 in all the questions but 1. 26.1% of the surveyed patients confessed being advocated to tele-assistance in the future. The only factors related to greater willingness to tele-assistance were male gender (37% vs 18.8%; P = .03) and a higher academic preparation level in favour of higher technical studies (35.9%) and university studies (32.4%) opposite to the rest (P = .043). The rest of variables studied, job status, labour regimen, diagnostic group and consultation type did not show any relationship. Conclusions: A vast majority of patients answered favourably to almost all the items of the survey. However, only 26.1% of them would choose a model of tele-assistance without restrictions.

Economic Burden and Health Care Access for Patients With Inflammatory Bowel Diseases in China: Web-Based Survey Study

Background

The increasing incidence of inflammatory bowel disease (IBD) has imposed heavy financial burdens for Chinese patients; however, data about their financial status and access to health care are still lacking. This information is important for informing patients with IBD about disease treatment budgets and health care strategies.

Objective

The aim of this study was to evaluate the economic status and medical care access of patients with IBD through the China Crohn’s & Colitis Foundation web-based platform in China.

Methods

Our study was performed in 14 IBD centers in mainland China between 2018 and 2019 through WeChat. Participants were asked to complete a 64-item web-based questionnaire. Data were collected by the Wenjuanxing survey program. We mainly focused on income and insurance status, medical costs, and access to health care providers. Respondents were stratified by income and the associations of income with medical costs and emergency visit times were analyzed.

Results

In this study, 3000 patients with IBD, that is, 1922 patients with Crohn disease, 973 patients with ulcerative colitis, and 105 patients with undetermined colitis were included. During the last 12 months, the mean (SD) direct and indirect costs for per patient with IBD were approximately US $11,668.68 ($7944.44) and US $74.90 ($253.60) in China. The average reimbursement ratios for most outpatient and inpatient costs were less than 50%. However, the income of 85.5% (2565/3000) of the patients was less than ¥10,000 (US $1445) per month. Approximately 96.5% (2894/3000) of the patients were covered by health insurance, but only 24.7% (741/3000) of the patients had private commercial insurance, which has higher imbursement ratios. Nearly 98.0% (2954/3000) of the patients worried about their financial situation. Thus, 79.7% (2392/3000) of the patients with IBD tried to save money for health care and even delayed their medical treatments. About half of the respondents (1282/3000, 42.7%) had no primary care provider, and 52.2% (1567/3000) of the patients had to visit the emergency room 1-4 times per year for the treatment of their IBD. Multivariate analysis revealed that lower income (P=.001) and higher transportation (P=.004) and accommodation costs (P=.001) were significantly associated with the increased number of emergency visits of the patients.

Conclusions

Chinese patients with IBD have enormous financial burdens and difficulties in accessing health care, which have increased their financial anxiety and inevitably influenced their disease outcomes. Early purchase of private insurance, thereby increasing the reimbursement ratio for medical expenses, and developing the use of telemedicine would be effective strategies for saving on health care costs.

Assessment of sexual dysfunction in patients with perianal Crohn's disease

AIM

Over the past 10 years, several studies have focused on sexuality in patients with Crohn's disease. Very few of them specifically focused on perianal disease (PD). This study aimed to compare the prevalence of sexual dysfunction (SD) in Crohn's disease patients with active PD versus controls without active PD.

METHOD

Patients from 14 French centres with active PD, defined by the presence of symptomatic ulceration, fistula or stenosis, were arbitrarily included. They were compared with controls from the existing SEXIA cohort. Men completed the International Index of Erectile Function (IIEF) and women the Female Sexual Function Index (FSFI). The primary end-point was SD defined by FSFI < 26.55 in women and IIEF < 42.9 in men.

RESULTS

Ninety-seven patients (64 women, 33 men) and 238 controls (131 women, 107 men) were included. SD was found in 66% of the female patients versus 50% of the controls (P = 0.04). In the male population, SD was found in 30% of the cases versus 16% of the controls (P = 0.06). Erectile dysfunction affected 46% of the male patients and 43% of the controls (P = 0.8). On multivariate analysis, the predictive factor most strongly associated with SD in women was severely active anal PD defined by a perineal disease activity index > 4 [OR = 13.05 (2.32-73.44)].

CONCLUSION

Women with active PD had an increased prevalence of SD compared with controls without active PD. In the male population, the study was unable to determine whether there was a difference as it was underpowered.

Ligasure Hemorrhoidectomy: Updates on Complications After an 18-Year Experience

BACKGROUND

Hemorrhoidal disease represents one of the most common anorectal disorders in the general population. Energy devices, such as LigaSure^TM scalpel, have reshaped the concept of hemorrhoid surgery and in turn, have improved patient outcomes and simplified the work of surgeon.

OBJECTIVE

The study aims to evaluate the outcomes of LigaSure^TM hemorrhoidectomy (LH) analyzing main post-operative complications rate, length of stay, operating time, and time to return to work.

METHODS

In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed. Complications were classified in early, late, and long-term if they occurred within 1 month, between 1 and 2 months or after 2 months, respectively.

RESULTS

90.2% of patients were treated in day surgery regimen and the mean operating time was 14.3 minutes. The post-operative pain decreased from 3.7 mean VAS on the 1st postoperative day to 0.1 mean VAS on 30th post-operative day. Early complications rate was 2.1%: urinary retention accounted for 1.8% of patients. 0.3%-of patients experienced postoperative bleeding and only one required reoperation. Late complications rate was 5.8%: anal stenosis, incomplete healing, and anal fissure were detected in 3.6%, 1.2%, and 1% of patients, respectively. The long term complications rate was 5.3%: anal fistula, soiling, perianal abscess, and recurrence were identified in 0.2%, 0.1%, 0.3%, and 4.8% of patients, respectively.

CONCLUSION

LH is a safe and fast procedure with a proven minimal complication rate.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter

PURPOSE

The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Internet and social media use among patients with colorectal diseases (ISMAEL): a nationwide survey

AIM

Social media are used daily by both healthcare workers and patients. Online platforms have the potential to provide patients with useful information, increase their engagement and potentially revolutionize the patient-physician relationship. This survey aimed to evaluate the impact of the Internet and social media (I&SM) on patients affected by colorectal and proctological diseases to define a pathway to develop an evidence-based communications strategy.

METHOD

A 31-item anonymous electronic questionnaire was designed. It consisted of different sections concerning demographics and education, reason for the visit, knowledge of the diseases, frequency of I&SM use and patients' opinions about physicians' websites.

RESULTS

Over a 5-month period, 37 centres and 105 surgeons took part in the survey, and a total of 5800 patients enrolled. Approximately half of them reported using the Internet daily, and 74.6% of the study population used it at least once per week. There was a correlation (P < 0.001) between those who used the Internet for work and those who had knowledge of both symptoms and the likely diagnosis before consultation. Patients who used the Internet daily were more likely to request a consultation within 6 months of symptom onset (P < 0.0001). Patients with anorectal diseases were more likely to know about their disease and symptoms before the visit (P < 0.001).

CONCLUSION

Colorectal patients use I&SM to look for health-related information mainly after their medical visit. Surgeons and hospital networks should plan a tailored strategy to increase patient engagement, delivering appropriate information on social media.

Postoperative Complications in Hemorrhoidal Disease and Special Conditions

BACKGROUND

Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications.

OBJECTIVE

To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease.

METHODS

During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE.

CONCLUSION

Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Photodynamic Therapy for the Treatment of Complex Anal Fistula

BACKGROUND AND OBJECTIVES

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula.

STUDY DESIGN/MATERIALS AND METHODS

This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J).

RESULTS

In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively.

CONCLUSION

i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation

PURPOSE

To evaluate long-term functional outcomes of Internal Delorme's Procedure (IDP) in patients refractory to conservative treatment for Obstructed Defecation Syndrome (ODS), and to compare those who received postoperative rehabilitation with those who did not.

MATERIALS AND METHODS

All patients with ODS refractory to nonoperative therapy were identified across three regional pelvic floor referral hospitals, and IDP was performed. Postoperatively selected patients received biofeedback therapy. Functional outcomes were established using the Cleveland Clinic Constipation (CCC) score and obstructed defecation score (OD score) preoperatively at 12 months and at the last available follow-up. Patient satisfaction was assessed with a visual analogue score.

RESULTS

From October 2006 to September 2013, IDP was performed in 170 patients: 77 received postoperative biofeedback and 93 did not. Mean follow-up was 6.3 years (range 1-8 years). CCC and OD scores improved significantly in both groups after 12 months and at the last follow-up (p > 0.05). When comparing two groups while there was no significant difference between CCC and OD scores at 12 months, score was significantly better in the group that received rehabilitation at the last follow-up (p = 0.001). Patient satisfaction was higher in the rehabilitation group (67%) compared with those without rehabilitation (55%). Clinical recurrence was recorded in nine patients who did not have postoperative rehabilitation.

CONCLUSIONS

It has been demonstrated that IDP is associated with good long-term functional outcomes. Patients receiving rehabilitation had a better long-term follow-up, a higher overall satisfaction, and lower recurrence rate when compared with the patients who did not receive postoperative rehabilitation.

Prospective pilot study of anorectal fistula closure with the OTSC Proctology

AIM

The OTSC Proctology is a surgical device for anorectal fistula closure. It consists of a super-elastic nitinol clip, which is placed (with the aid of a transanal applicator) on the internal fistula opening to achieve healing of the fistula track. A prospective, two-centre clinical pilot study was undertaken to assess the efficacy and safety of the OTSC Proctology in patients with a complex high anorectal fistula.

METHOD

In patients with a complex anorectal fistula the primary track was debrided using a special brush and the clip was applied to the internal fistula opening. After 6 months the postoperative clinical course and fistula healing were assessed.

RESULTS

Twenty patients with a cryptoglandular anorectal fistula (14 with a transsphincteric fistula and six with a suprasphincteric fistula) were included in the study. There were no intra-operative technical or surgical complications. Postoperatively no patient reported intolerable discomfort or a sensation of a foreign body in the anal region. At 6 months after surgery, 18 (90%) patients had no clinical signs or symptoms of fistula and were considered healed, whereas in two the fistula persisted. In 13 (72%) of these 18 patients, the clip was still in place without causing problems, whereas in three patients the clip had spontaneously detached. In the two remaining patients it was necessary to remove the clip due to discomfort and delayed wound healing.

CONCLUSION

Anorectal fistula closure with the OTSC Proctology is an innovative, sphincter-preserving minimally invasive procedure with promising initial results and a high rate of patient satisfaction.

A simple tool to evaluate common disorders: validation of a "proctological symptom scale"

PURPOSE

Proctological symptomatology is of little complexity and therefore appears particularly suitable for comparative evaluation by visual scales. We devised a "proctological symptom scale" (PSS) with separate scales for four cardinal proctological symptoms: pain, itching/irritation, discharge/moisture, and bleeding. The objective of this study was to evaluate the PSS among proctological patients and non-proctological controls.

METHODS

This was a single center non-interventional observational study on 229 proctological patients and 133 controls. The main outcome measures investigated were age- and sex-stratified comparison of the non-proctological cohort and the controls, effect of therapeutic intervention on scale values in a subset of patients with haemorrhoidal disease, and sensitivity of the PSS to detect therapeutic failure in this subset of patients.

RESULTS

The PSS was found to significantly differentiate between proctological patients and controls. Gender and age had no significant influence on PSS values in the proctological cohort. The intervention (one session of rubber band ligation in patients with haemorrhoidal disease) was reflected by a significantly improved overall PSS. In 16 cases within this group, the PSS got worse. A case-by-case follow-up of these patients showed that 14 of the 16 patients ended up with surgery (or with the advice to have surgery).

CONCLUSIONS

The PSS reliably differentiates proctological patients from non-proctological controls. Following intervention, the PSS reliably differentiated therapeutic success from failure. We find the PSS to be a simple and useful tool in our clinical routine since it provides an easily obtainable and reproducible basis for the visit-by-visit assessment of proctological patients. The PSS may also be suitable for studies to measure and compare symptomatic improvement and success of different therapies in proctology.