Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.

In functional bowel disorders short-term sacral nerve stimulation seems to be a useful diagnostic tool to assess patients for a minor invasive therapy alternative to conventional surgical procedure.

Stapling procedure is a new technique for the surgical management of third-degree hemorrhoids. Even if long-term experience has not been reported, this new technique is generating a lot of interest and its use is becoming more common in Europe. Some articles have just been published about severe adverse effects of this operation, and in the present article we describe a case of a life-threatening complication that occurred with the use of the stapling technique for hemorrhoidectomy. A patient with perineal descensus and third-degree hemorrhoids underwent a stapling procedure for the treatment of hemorrhoids. Retropneumoperitoneum and pneumomediastinum developed on postoperative Day 2 and a colostomy was performed, allowing a quick recovery of the patient. After six months the colostomy was closed and bowel function restored. Our experience, taken together with some other cases previously published of severe complications after such an operation, suggests caution in the use of this new technique for the treatment of a benign disease.

In this long term follow-up study, end colostomy and younger patients had a lower incidence of complications. A large prospective trial is needed to confirm our results.

Neuromodulation can be considered an option for fecal incontinence. However, an accurate clinical and instrumental evaluation and careful patient selection are required to optimize outcome.

Long-term follow-up data showing improvements in scores on the visual analog pain scale and quality of life questionnaire indicate that, before adopting more aggressive surgical procedures, SNS should be considered for patients with chronic idiopathic anal pain in whom pharmacologic and biofeedback treatments have failed to produce effective results.

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univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity. Results There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07). Conclusions Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies. Keywords Anastomotic leaks · Low anterior resection · Rectal cancer · Outcome studies IntroductionAnastomotic leakage (AL) is the most significant surgical complication following resection for rectal cancer [1], affecting perioperative mortality and possibly longterm survival [2,3]. The rate of AL after anterior resection (AR) varies from 3% to 19% [4][5][6][7][8][9][10][11], being clinically significant in 2.9-15.3% of patients. Mortality following a leak may be 6.0-39.3% [12]. Most of the reports of complications after surgery for colorectal cancer come Abstract Background The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR). Methods Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by ing factors predicting the gravity of AL among patients with AL this classification was simplified to mild to moderate (grades 1 and 2) and severe (grades 3 and 4).Categorical variables were evaluated using either Fisher's exact test or Pearson's chi-squared test depending on sample size. Numerical variables were evaluated using Student's t-test. P values <0.05 were considered significant. All variables which were associated with the incidence or gravity of AL in the univariate analysis were entered into a multivariate logistic regression model. Data were analysed using the STATA program (release 8.0, 2003; Stata Corporation, College Station, TX). ResultsOf 108 centres contacted, 44 (40.7%) participated. Information on 682 patients with rectal cancer who had undergone surgery was collected. Sphincter-saving surgery was performed in 579 patients (84.9%). After excluding abdom...