Annals of Coloproctology

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Guideline

Anorectal physiology & pelvic floor disorder

The Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of obstructed and ineffective defecation syndrome: Adolfo Renzi, Luigi Brusciano, Pasquale Talento, Luigi Marano, Francesca Iacobellis, Antonio Vallo, Giovanna Frezza, Maurizio Grillo, Alessio Palumbo, Elisa Palladino, Benedetto Neola, Fabrizio Foroni, Michele Lanza, Massimo Antropoli, Carmine Antropoli, Mauro Natale Maglio, Maria Laura Sandoval Sotelo, Gianluca Pagano, Maria Michela Di Nuzzo, Luciano Vicenzo, Michele Schiano di Visconte, Gabriele Naldini, Leonardo Lenisa, Marcello Gasparrini, Giuseppe Candilio, Massimo Pezzatini, Francesca Ascari, Alberto Di Leo, Monica Urbani, Simona Ascanelli, Alessandro Bussotti, Natale Calomino, Domenico Izzo, Roberto Peltrini, Michele D'Ambra, Giovanni Greco, Giuseppe D'Oriano, Alfredo Giordano, Claudio Gambardella, Diletta Paola Iovino, Andrea Grego, Luigi Pellecchia, Luigi Monaco, Ilaria Ferrante, Giovanni Luca Lamanna, Vinicio Mosca, Sergii Girnyi, Gianluca Minieri, Luigi Losacco, Giacomo Sarzo, Giuseppe Calabrò, Francesco Ghiglione, Sergio Agradi, Michele Pinto, Andrea Marazzi, Mariangela Desantis, Federico Maria Mongardini, Massimo Mongardini, Aurora Marotta, Andrea Lauretta, Giovanni Ferreri, Alfredo Annicchiarico, Francesca Da Pozzo, Alfredo Ansalone, Matteo Zuin, Nadine Osman, Paolino Mauro, Corrado Rispoli, Tomasz Cwalinski, Roberto Rizzato, Nando Gallese, Marta Mozzon, Alessandro Stazi, Luana Franceschilli, Angelo Stuto, Eugenio Cudazzo, Silvia Malerba, Riccardo Brachet Contul, Antonio Canero, Nicola Antonacci, Francesca Milazzo, Costantino Magnani, Cristina Folliero, Francesca Babic, Silvia Marola, Andrea Braini, Guido Benegiamo, Umberto Cocozza, Bruno Masci, Rita Laforgia, Angela Pezzolla, Antonio Colangelo, Carmelo Geremia, Raffaella Marina Di Renzo, Claudio Pagano, Roberto Picheo, Umberto Favetta, Fabrizio Gambarini, Laura Chimisso, Gianmattia Terracciano, Adelaide Andriani, Giovanni Marino, Patrizia Liguori, Carmen Formisano, Izabela Zofia Paszkiewicz, Alfonso Reginelli, Francesco Tumminelli, Martina Caruso, Marianna Pennacchio, Francesco Antonio Ciarleglio, Nicola Lizza, Francesco d’Aniello, Lorenzo Asciore, Pierluigi Bianchi, Emanuela Tessari, Eleonora Rossin, Maria Paola Menna, Giampiero Ucchino, Fabrizio Vittadello, Monica Oliva, Francesca Gatto, Raffaella Ferrando, Ilaria Granese, Mario Cicconi, Massimiliano Mistrangelo, Giovanna Ioia, Valeria Gianfreda, Ettore Greco, Adriana Maria Landolfi, Giandomenico Di Sarno, Vincenzo Landolfi, Carolina Bartolini, Luciano Onofrio, Domenico De Vito, Salvatore Napolitano, Vincenzo Bottino, Antonio Longo, Antonio Brescia, Chiara Casiraghi, Alfonso Alderisio, Mario Massimo Mensorio, Ludovico Docimo, Antonio Brillantino; Ann Coloproctol. 2026;42(2):151-178. Published online April 28, 2026; DOI: https://doi.org/10.3393/ac.2025.00899.0128

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Abstract PDF: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) on the diagnosis and management of obstructed defecation syndrome (ODS), with the purpose of guiding physicians in the selection of the most appropriate treatment option. A panel of experts was appointed by the Board of the SIUCP to develop key questions addressing the main topics related to the management of ODS and to perform an accurate literature search for each topic, in order to provide evidence-based answers and to summarize them in structured statements. All clinical questions were discussed by the expert panel over multiple rounds using the Delphi approach, and consensus among the experts was achieved for each statement. The questions were formulated according to PICO (patients, intervention, comparison, outcome) criteria, and the statements were developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In patients with ODS refractory to first-line medical therapy, rehabilitation may be considered as a therapeutic option, particularly in cases of dyssynergic defecation, whereas a surgical approach may be indicated in patients with a high symptom score and an Oxford prolapse grade system score ≥3 on defecography (using magnetic resonance imaging or another modality). Surgical options include stapled transanal rectal resection and ventral mesh rectopexy, eventually combined, respectively, with pelvic organ prolapse suspension and sacrocolpopexy in the presence of multicompartment pelvic prolapse. A transverse perineal support procedure may be considered in the presence of excessive perineal descent. In patients with recurrent symptoms after surgery, transanal irrigation may represent a useful therapeutic option.

Original Article

Anorectal benign disease

Validation of a novel imaging-guided and anatomy-based classification system for anorectal fistulas: a retrospective clinical evaluation study: Antonio Brillantino, Francesca Iacobellis, Luigi Marano, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Claudio Gambardella, Umberto Favetta, Michele Schiano Di Visconte, Luigi Monaco, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palumbo, Maria Laura Sandoval Sotelo, Luciano Vicenzo, Elisa Palladino, Giovanna Frezza, Maria Paola Menna, Paolino Mauro, Stefano Picardi, Mario Massimo Mensorio, Vinicio Mosca, Vincenzo Bottino, Giovanna Ioia, Corrado Rispoli, Marco Di Serafino, Martina Caruso, Roberto Ronza, Barbara Frittoli, Daria Schettini, Luca Stoppino, Franco Iafrate, Giulio Lombardi, Carmine Antropoli, Salvatore Cappabianca, Ludovico Docimo, Roberto Grassi, Alfonso Reginelli; Ann Coloproctol. 2025;41(3):207-220. Published online June 16, 2025; DOI: https://doi.org/10.3393/ac.2024.00675.0096

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Graphical Abstract Abstract PDF

Purpose
This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.
Methods
This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.
Results
When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).
Conclusion
The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.

Citations

Citations to this article as recorded by

Comparison of the proposed new classification of anal fistulas with the Garg classification
Pankaj Garg, Nicola Clemente, Kaushik Bhattacharya, Sattyadeep Garg
Annals of Coloproctology.2026; 42(1): 145. CrossRef
Histological architecture of the intersphincteric region of the anal canal: implications for the anatomical basis of anal fistula pathways
Satoru Muro, Yasuo Nakajima, Akimoto Nimura, Keiichi Akita
International Journal of Colorectal Disease.2026;[Epub] CrossRef

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