Abstract Colonoscopy has a substantial learning curve, and inadequate training is associated with missed pathology and avoidable complications. Virtual reality (VR) simulation training has increasingly been adopted to supplement early colonoscopy training. To evaluate the evidence published from 2019 to 2024 on the effectiveness of VR-based simulation training in colonoscopy. A systematic search was conducted on PubMed, Medline, Embase, and the Cochrane Library. Eligible studies were synthesized qualitatively, and quantitative outcomes were pooled using random-effects meta-analysis. In total, 12 publications met inclusion criteria, of which 7 contributed quantitative data. Meta-analyses demonstrated statistically significant improvements in colonoscopy performance favoring VR simulation training, with large between-group effects (Cohen's d = 1.005; p < 0.001) and very large pre-post improvements (Cohen's d = 1.750; p = 0.033). The present review found that VR simulation training represents a safe and effective adjunct to early colonoscopy training and supports integration into modern endoscopy education.
Abstract Anal stenosis is a pathological narrowing of the anal canal, most commonly following hemorrhoidectomy. Moderate and severe cases usually require surgery, as conservative measures are often ineffective. Conventional procedures, such as flap anoplasty, are effective but associated with relevant morbidity. The role of carbon dioxide (CO2) laser surgery remains insufficiently explored. To evaluate the feasibility and early clinical and functional outcomes of CO2 laser anal stenotomy in patients with acquired anal stenosis. Adults (≥ 18 years) undergoing CO2 laser anal stenotomy for acquired anal stenosis between January 2021 and December 2024 were included. Patients with congenital stenosis, infection, neoplasia, trauma, or requiring flap anoplasty were excluded. Stenosis location and severity were clinically assessed. Three radial CO2 laser incisions (3, 7, and 11 o'clock) were performed. Follow-up at 10, 30, 60, and 120 days assessed healing, pain, symptoms, continence, and reintervention. In total, 16 patients were included (mean age: 55.3 ± 9.2 years; 62.5% of female subjects). Difficult evacuation was present in all patients, and 50% had severe stenosis. Previous anorectal surgery was reported in 93.8%, predominantly hemorrhoidectomy. Complete wound epithelialization was achieved in all patients by postoperative day 30. Improvement in evacuation was reported by 81.3% on day 10 and maintained in 87.5% on day 60. Also, two patients experienced transient fecal incontinence, and no reintervention was required. Anal stenotomy with CO2 laser appears to be a safe, minimally invasive option for moderate and severe low anal stenosis, providing rapid healing, sustained symptom improvement, and low postoperative morbidity. Larger prospective studies are warranted.
Abstract To review and synthesize current evidence regarding the main surgical approaches for anorectal fistula treatment, with emphasis on healing rates, recurrence, and complications, especially fecal incontinence. The present review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted in PubMed and Cochrane databases to identify clinical studies, randomized or not, including controlled trials, retrospective analyses, and meta-analyses. Inclusion criteria were adult patients (> 18 years) undergoing surgical treatment of anorectal fistulas with reported outcomes of healing, recurrence, and complications, particularly fecal incontinence. Only English-language articles published in the last 10 years were considered. The exclusion criteria were pediatric populations, Crohn's-related or rectovaginal fistulas, case reports, and studies with small samples or inconsistent data. In total, 38 studies met the inclusion criteria. While fistulotomy showed high healing rates in simple tracts, it was associated with a higher risk of incontinence. Sphincter-preserving techniques such as mucosal advancement flaps, ligation of the intersphincteric fistula tract (LIFT), loose seton placement, platelet-rich fibrin (PRF), and mesenchymal stem cell (MSC) therapy demonstrated varying degrees of efficacy and lower incontinence rates. Novel minimally invasive procedures, such as video-assisted anal fistula treatment (VAAFT), fistula-tract laser closure (FiLaC), and biomaterial plugs showed potential but require further supporting evidence. Surgical management of anorectal fistulas remains complex and individualized. No single technique is universally superior. Prospective standardized studies are essential to optimize outcomes and preserve continence.
Abstract To evaluate the diagnostic value of magnetic resonance imaging (MRI) in anal fistula and to assess the agreement between MRI findings and surgical results. In addition, we aimed to compare the St. James University Hospital classification and the Garg classification systems. The current cross-sectional descriptive study included 200 patients with anal fistula who underwent preoperative MRI between June 2024 and December 2025. The MRI findings, including the primary tract, internal opening, external opening, secondary tracts, and abscesses, were recorded and compared with the surgical findings as the reference standard. Fistulas were classified according to the St. James University Hospital and Garg classification systems. Diagnostic performance was evaluated using sensitivity, specificity, positive predictive value, negative predictive value, and Cohen's Kappa [κ] coefficient to assess agreement. The mean age was 40.4 ± 13.8 years, with a predominance of male subjects (89%). Magnetic resonance imaging demonstrated very high sensitivity to detect the internal opening (99.5%) and external opening (98.3%). For abscess detection, MRI showed a sensitivity of 87.1% and a specificity of 92.2%. Secondary tracts were identified with a sensitivity of 75% and a specificity of 100%. The agreement between the MRI and surgical findings ranged from good to very good (κ = 0.748–0.816), except for the internal opening, which showed moderate agreement (κ = 0.517). the St. James University Hospital and Garg classification systems demonstrated good agreement with the surgical findings (κ = 0.767 and 0.748 respectively). Direct intersystem agreement was moderate (weighted κ = 0.58; 95%CI: 0.42–0.74). Magnetic resonance imaging demonstrates high diagnostic accuracy in the preoperative evaluation of anal fistula, with good agreement with the surgical findings. The St. James University Hospital and Garg classification systems can be reliably applied on MRI for the preoperative assessment and classification of anal fistulas.
Abstract Major pelvic excision, including extralevator abdominoperineal excision (ELAPE) and total pelvic exenteration (TPE), creates a substantial perineal defect at high risk for empty pelvis syndrome. To evaluate the feasibility and early outcomes of an autologous, donor-site-free reconstructive technique: the pedicled colonic mucosectomy flap (CMF). A retrospective single-center analysis was conducted on 5 consecutive male patients, with locally advanced rectal cancer, who underwent CMF reconstruction following ELAPE (n = 3) and TPE (n = 2). All patients received neoadjuvant therapy. Outcomes assessed included operative parameters, complications (Clavien-Dindo classification), oncological margins, and short-term sequelae. All patients achieved R0 resection. The mean operative time was 514 minutes. There were no flap-related complications. The 30-day morbidity rate was 60%, with two major (Grade 3) complications: one pelvic collection requiring percutaneous drainage and one ureteroileal anastomotic leak requiring reoperation. No perineal hernia or chronic wound issues were observed during follow-up, with a median of 4 months. The CMF is a viable and safe autologous technique for reconstructing the perineum after major pelvic excision. It effectively utilizes native tissue without donor-site morbidity and shows promise in mitigating empty pelvis complications, warranting further investigation.
