Background and aims:Obstructed defecation syndrome (ODS) is a multifactorial condition that significantly impairs quality of life and presents diagnostic and therapeutic challenges due to the interaction of functional and anatomical factors. This initiative aimed to develop a Belgian consensus and a diagnostic-therapeutic algorithm to support effective clinical management of ODS. Methods:A Belgian steering group of gastroenterologists and colorectal surgeons (n=6) conducted a Delphi consensus process. Based on a structured literature review, 82 statements were drafted and discussed during three online voting rounds. Consensus was defined as ≥80% agreement, and evidence strength was graded using the GRADE system. Results:Thirty-one experts participated, including gastroenterologists, colorectal surgeons, gynecologists, and physiotherapists. Sixty-two final statements were formulated, of which 46 were endorsed. ODS was defined as a disorder of anorectal evacuation, with functional and structural components often coexisting. Symptoms overlap with functional constipation, IBS-C, and fecal incontinence, and quality of life is substantially impaired. Diagnosis requires multimodal evaluation, including digital rectal examination and anorectal testing. First-line treatment consists of conservative measures such as lifestyle optimization, laxatives, and pelvic floor re-education. Surgery is reserved for selected patients with refractory symptoms and significant anatomical abnormalities. Tailored surgical approaches are supported for rectocele, rectal prolapse, and pelvic organ prolapse, whereas sacral nerve stimulation is not routinely recommended. Conclusion:These consensus statements provide practical guidance for the diagnosis and management of ODS. Conservative therapy remains the cornerstone, with surgery reserved for selected cases. Areas lacking consensus warrant further research.

Introduction:Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods:A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results:Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions:The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

BackgroundChronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature.MethodsA search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included.Results17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT's (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes.ConclusionThe beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.

Endometriosis and pain: an overview with arguments for an individual and multidisciplinary approach This article provides a narrative overview of endometriosis-related pain. Pain due to endometriosis affects quality of life with an impact on professional, social, family and sexual functioning. Both neuropathic and inflammatory mechanisms are at the root of the pain, which is further modulated via central sensitization in the brain. Chronic pain due to endometriosis is associated with morphological changes in pain-processing areas of the central nervous system. These data reinforce the need to frame endometriosis therapy in a much broader sense than just local surgical removal and (hormonal) suppression. Both the diagnosis and the therapy of endometriosis benefit from a multidisciplinary and dedicated team. The literature on the treatment of endometriosis-related pain is characterized by large gaps, there are only a few prospective randomized or placebo-controlled studies. In addition to surgery, estrogestin combinations, progestogens alone, GnRH agonists and antagonists, aromatase inhibitors, selective estrogen and/or progestogen receptor modulators, NSAIDs (non-steroidal anti-inflammatory drugs), psychotherapy and physiotherapy can be used. Except for acupuncture, there are no good comparative studies on alternative treatments, like for example certain nutritional supplements, cannabis, osteopathy and other alternatives. In view of the interdependence of pain complaints in endometriosis patients and its effects on their social and personal experience and functioning, the approach must be based on a patient-oriented program, adapted to the personal needs and preferences of the patient. A multidisciplinary approach with a policy based on the needs and expectations of the patient can be an added value.

Introduction : Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods : A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results : Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions : The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Rectal prolapse is responsible for symptoms such as obstructed defecation and faecal incontinence. [1,2]Ventral mesh rectopexy, either laparoscopically or robotic assisted, is a commonly used technique for rectal prolapse. [1-3]Mesh erosion is a rare but important complication occurring in up to 4% patients and almost always demands surgical management. [1-5]We present a case of a 58-year-old woman who underwent a robot-assisted ventral mesh rectopexy and cystopexy for anterior rectocele with intussusception and cystocele with a polypropylene mesh fixed with non-absorbable sutures.

Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

Aim Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. Method A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. Results The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. Conclusion Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

The field of rectal cancer treatment is a dynamic and changing field, due to better understanding of the pathology and new medical treatment options, but perhaps mostly due to innovations in the surgical approach. Surgery is the cornerstone for rectal cancer treatment. Currently, Total Mesorectal Excision is the gold standard. After evolution towards laparoscopic TME, improving technology has led to the development of platforms that allow transanal TME and robotic TME. In addition, local excision can be performed safer and more accurately by means of Transanal Endoscopic Microsurgery (TEM), TransAnal Minimally Invasive Surgery or Endoscopic Submucosal Dissection (ESD), possibly avoiding TME. The aim of this review is to summarize the different surgical techniques and approaches for rectal cancer in function of tumor stage and describe the specifics of the technique.

Introduction: Many different approaches for the repair of a perineal hernia (PH) after abdomino-perineal rectum amputation (APR) have been described throughout the years. Literature shows us that the use of a mesh had the best results with relatively low rates of recurrence compared to primary suture. Yet there is still no consensus on the best technique for fixation of the mesh in the perineal cavity. Methods: We want to introduce an addition to the surgical repair technique, using laparoscopic glue to ensure a solid fixation of the mesh. This is to prevent small bowel from sliding into the perineal area due to the high abdominal pressure when standing and to avoid the difficulties and risks of laparoscopical suturing in this area. Results: This use of glue for fixation of the mesh has been successful in the three cases described, with no recurrence after one-year follow-up. Conclusion: A recurrent PH can be prevented by a solid fixation of the mesh using the technique of a glued mesh repair. This technique shows to be easy, fast and without recurrence.

Laparoscopic Roux-en-Y gastric bypass (RYGB) remains the gold standard procedure in obesity surgery and is mostly performed in young women of reproductive age. Since the worldwide prevalence of obesity is increasing and fertility improves after surgery, more complications in the pregnant population will emerge. The differential diagnosis of acute abdominal pain in patients with a history of gastric bypass is rather broad and includes mainly anastomotic ulcers, leaks, and small bowel obstructions. Early diagnosis and treatment of these complications is of utmost importance and should be performed on a multidisciplinary basis. Whether surgery should be performed by laparoscopy or laparotomy remains subject of discussion. We report a case of a 29-year-old pregnant woman at 33+5 weeks gestational age, presenting with an intussusception after RYGB. A successful surgical reduction was performed by laparotomy.

Intercostal lung herniation is a rare condition caused by a defect in the thoracic wall, high intrathoracic pressure, or both. The authors report a case of intercostal lung herniation after repeat thoracotomy, which was repaired with a synthetic patch. Etiology, symptoms, diagnostic techniques and treatment of intercostal lung herniations are discussed.