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Table 1 Statements

From: Anorectal emergencies: WSES-AAST guidelines

Anorectal abscess

1.A - In patients with a suspected anorectal abscess, what is the role of clinical examination and biochemical investigations?

 

- In patients with suspected anorectal abscess, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected anorectal abscess, we suggest to check serum glucose, hemoglobin a1c, and urine ketones in order to identify an undetected diabetes mellitus (strong recommendation based on low-quality evidence, 1C).

- In patients with suspected anorectal abscess and signs of systemic infection or sepsis, we suggest to request complete blood count, serum creatinine, and inflammatory markers (e.g., C-reactive protein, procalcitonin, and lactates), to assess the status of the patient (weak recommendation based on low-quality evidence, 2C).

1.B - In patients with a suspected anorectal abscess, what are the appropriate imaging investigations?

 

- In patients with suspected anorectal abscess, we suggest the use of imaging investigations in case of atypical presentation and in case of suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn’s disease. Suggested techniques are MRI, CT scan, or endosonography according to the specific clinical scenario and the available skills and resources (weak recommendation based on low-quality evidence, 2C).

1.C - In patients with an anorectal abscess, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with anorectal abscess, we recommend a surgical approach with incision and drainage (strong recommendation based on low-quality evidence, 1C).

- In patients with anorectal abscess, we suggest to base the timing of surgery on the presence and severity of sepsis (weak recommendation based on low-quality evidence, 2C).

- In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, we suggest considering an outpatient management (weak recommendation based on low-quality evidence, 2C).

1.D - In patients with an anorectal abscess, what is the role of wound packing after surgical drainage?

 

- No recommendation can be made regarding the use of packing after drainage of an anorectal abscess, based on the available literature.

1.E - In patients with an anorectal abscess and concomitant fistula, what are the indications for fistula treatment in the acute setting?

 

- In patients with anorectal abscess and an obvious fistula, we suggest to perform a fistulotomy at the time of abscess drainage only in cases of low fistula not involving sphincter muscle (i.e., subcutaneous fistula) (weak recommendation based on low-quality evidence, 2C).

- In patients with anorectal abscess and an obvious fistula involving any sphincter muscle, we suggest to place a loose draining seton (weak recommendation based on low-quality evidence, 2C).

- In patients with anorectal abscess and no obvious fistula, we suggest against probing to search for a possible fistula, to avoid iatrogenic complications (weak recommendation based on low-quality evidence, 2C).

1.F - In patients with an anorectal abscess, is there a role for antibiotic therapy and what is the appropriate antibiotic regimen?

 

- In patients with drained anorectal abscess, we suggest antibiotic administration in the presence of sepsis and/or surrounding soft tissue infection or in case of disturbances of the immune response (weak recommendation based on low-quality evidence, 2C).

- In patients with anorectal abscess, we suggest sampling of drained pus in high-risk patients and/or in the presence of risk factors for multidrug-resistant organism infection (weak recommendation based on very low-quality evidence, 2D).

Perineal necrotizing fasciitis (Fournier’s gangrene)

2.A - In patients with suspected Fournier’s gangrene, what is the role of clinical examination and biochemical investigations?

 

- In patients with suspected Fournier’s gangrene, we suggest to collect a focused medical history and a complete physical examination, including a digital rectal examination (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected Fournier’s gangrene and signs of systemic infection or sepsis, we suggest to request complete blood count and the dosage of serum creatinine and electrolytes, inflammatory markers (e.g., C-reactive protein, procalcitonin), and blood gas analysis, to assess the status of the patient (weak recommendation based on low-quality evidence, 2C). We also recommend to check serum glucose, hemoglobin a1c and urine ketones in order to investigate an undetected diabetes mellitus (strong recommendation based on low-quality evidence, 1C).

- In patients with suspected Fournier’s gangrene, we suggest to use Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score for an early diagnosis and Fournier’s Gangrene Severity Index (FGSI) for prognosis and risk stratification (weak recommendation based on moderate quality evidence, 2B).

2.B - In patients with suspected Fournier’s gangrene, which are the appropriate imaging investigations?

 

- In stable patients with suspected Fournier’s gangrene, we suggest to consider performing a CT scan (weak recommendation based on low-quality evidence, 2C).

- In patients with Fournier’s gangrene, we recommend that imaging should not delay surgical intervention (strong recommendation based on moderate quality evidence, 1B).

- In patients with Fournier’s gangrene and hemodynamic instability persisting after proper resuscitation, we suggest against CT imaging (weak recommendation based on low-quality evidence, 2C).

2.C - In patients with Fournier’s gangrene, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with Fournier’s gangrene, we recommend surgical intervention as soon as possible (strong recommendation based on low-quality evidence, 1C).

- In patients with Fournier’s gangrene we suggest planning repeat surgical revisions (exploration and debridement) according to patient conditions (weak recommendation based on low-quality evidence, 2C).

- In patients with Fournier’s gangrene, we suggest seriated surgical revisions until the patient is free of necrotic tissue (weak recommendation based on low-quality evidence, 2C).

2.D - In patients with Fournier’s gangrene, what is the appropriate surgical approach?

 

- In patients with Fournier’s gangrene, we suggest to remove all the necrotic tissue (weak recommendation based on low-quality evidence, 2C).

- In patients with Fournier’s gangrene, we suggest a multidisciplinary and tailored approach based upon the extent of perineal involvement, the degree of fecal contamination, and the possible presence of sphincter or urethral damage (weak recommendation based on low-quality evidence, 2C).

- In patients with Fournier’s gangrene, we suggest to perform orchiectomy or other genital surgery only if strictly necessary and possibly based on a urologic consultation (weak recommendation based on low-quality evidence, 2C).

- In patients with Fournier’s gangrene, we suggest planning the surgical management of early and delayed surgical sequelae with a multidisciplinary and skilled team (weak recommendation based on low-quality evidence, 2C).

2.E - In patients with Fournier’s gangrene, which is the appropriate antibiotic regimen?

 

- In patients with Fournier’s gangrene, we recommend starting an empiric antimicrobial therapy as soon as the diagnosis is suspected (strong recommendation based on moderate quality evidence, 1B).

- In patients with Fournier’s gangrene, we recommend that empiric antimicrobial therapy should include cover for gram-positive, gram-negative, aerobic and anaerobic bacteria, and an anti-MRSA agent (strong recommendation based on moderate quality evidence, 1B).

- In patients with Fournier’s gangrene, we recommend to obtain microbiological samples at the index operation (strong recommendation based on moderate quality evidence, 1B).

- In patients with Fournier’s gangrene, we recommend to base antimicrobial de-escalation on clinical improvement, cultured pathogens, and results of rapid diagnostic tests where available (strong recommendation based on moderate quality evidence, 1B).

Complicated hemorrhoid (thrombosed, strangulated, or bleeding)

3.A - In patients with suspected complicated hemorrhoids, what is the role of clinical examination and biochemical investigations?

 

- No recommendation can be made regarding the role of biochemical investigations in patients with suspected thrombosed or strangulated hemorrhoids, based on the available literature.

- In patients with suspected bleeding hemorrhoids, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected bleeding hemorrhoids, we suggest to check vital signs, to determine hemoglobin and hematocrit, and to assess coagulation to evaluate the severity of the bleeding (weak recommendation based on low-quality evidence, 2C). In case of severe bleeding, we suggest blood typing and cross-matching (weak recommendation based on very low-quality evidence, 2D).

3.B - In patients with suspected complicated hemorrhoids, which are the appropriate imaging investigations?

 

- In patients with suspected complicated hemorrhoids, we suggest to perform imaging investigation (CT scan, MRI, or endoanal ultrasound) only if there is suspicion of concomitant anorectal diseases (sepsis/abscess, inflammatory bowel disease, neoplasm) (weak recommendation based on low-quality evidence, 2C).

3.C - In patients with complicated hemorrhoids, what is the role of endoscopy?

 

- In patients with complicated hemorrhoids, we suggest to perform anoscopy as part of the physical examination, whenever feasible and well tolerated (low recommendation based on low-quality evidence, 2C).

- In patients with complicated hemorrhoids, we suggest to perform colonoscopy in case of concern for inflammatory bowel disease or cancer arising from patient personal and family history, or from physical examination (low recommendation based on low-quality evidence, 2C).

3.D - In patients with complicated hemorrhoids, which is the appropriate pharmacological regimen?

 

- In patients with complicated hemorrhoids, we recommend non-operative management as first line therapy, with dietary and lifestyle changes (i.e., increased fiber and water intake together with adequate bathroom habits) (strong recommendation based on moderate quality evidence, 1B).

- In patients with complicated hemorrhoids, we suggest to administer flavonoids to relieve symptoms (weak recommendation based on moderate quality evidence, 2B).

- In patients with thrombosed or strangulated hemorrhoids, we suggest the use of topical muscle relaxant (weak recommendation based on low-quality evidence, 2C).

- No recommendation can be made regarding the role of NSAIDs, topical steroids, other topical agents, or injection of local anesthetics for complicated hemorrhoids, based on the available literature.

3.E - In patients with complicated hemorrhoids, what is the role of office-based procedures?

 

- No recommendation can be made regarding the role of office-based procedures (i.e., rubber band ligation, sclerotherapy, infrared coagulation) in complicated hemorrhoids, based on the available literature.

3.F - In patients with complicated hemorrhoids, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with thrombosed hemorrhoids, we suggest to base the decision between non-operative management and early surgical excision on local expertise and patient’s preference (weak recommendation based on low-quality evidence, 2C).

- In patients with thrombosed hemorrhoids, we suggest against the use of incision and drainage of the thrombus (weak recommendation based on low-quality evidence, 2C).

- No recommendation can be made regarding the role of surgery in patients with bleeding hemorrhoids, based on the available literature.

3.G - In patients with complicated hemorrhoids, what is the role of angiography?

 

- No recommendation can be made regarding the role of angiography in complicated hemorrhoids, based on the available literature.

Bleeding anorectal varices

4.A - In patients with suspected bleeding anorectal varices, what is the role of clinical examination and biochemical investigations?

 

- In patients with suspected bleeding anorectal varices, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected anorectal varices, we suggest we suggest to check vital signs, to determine hemoglobin and hematocrit, and to assess coagulation to evaluate the severity of the bleeding (weak recommendation based on low-quality evidence, 2C). In case of severe bleeding, we suggest blood typing and cross-matching (weak recommendation based on very low-quality evidence, 2D).

4.B - In patients with suspected bleeding anorectal varices, which are the appropriate imaging investigations?

 

- In patients with bleeding anorectal varices, we suggest EUS +/- color Doppler evaluation as a second-line diagnostic tool, especially for deep rectal varices or when in doubt (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices and failed detection of bleeding site at endoscopy and EUS, or whenever EUS is not available, we suggest to perform contrast enhanced CT-scan (weak recommendation based on low-quality evidence, 2C).

- In pregnant patients with bleeding anorectal varices and failed US detection of bleeding site, we suggest to perform MRI angiography, if available and if allowed by the clinical scenario (weak recommendation based on low-quality evidence, 2C).

4.C - In patients with suspected bleeding anorectal varices, what is the role of endoscopy?

 

- In patients with suspected bleeding anorectal varices, we suggest the use of ano-proctoscopy or flexible sigmoidoscopy as the first-line diagnostic tool (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected bleeding anorectal varices and high-risk features or evidence of ongoing bleeding, we suggest to perform an urgent colonoscopy (plus upper endoscopy) within 24 hours of presentation (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected bleeding anorectal varices and risk factors for colorectal cancer or suspicion of a concomitant more proximal source of bleeding, we suggest to perform a full colonoscopy (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices, we suggest to use local procedures, such as endoscopic variceal ligation, endoscopic band ligation, sclerotherapy, or EUS-guided glue injection, to arrest bleeding in first instance where feasible (weak recommendation based on low-quality evidence, 2C).

4.D - In patients with bleeding anorectal varices, what is the role of non operative management?

 

- In patients with bleeding anorectal varices, we suggest multidisciplinary management, early involving the hepatology specialist team and focusing on optimal control of comorbid conditions (weak recommendation based on very low-quality evidence, 2D).

- In patients with anorectal varices and mild bleeding, we suggest intravenous fluid replacement, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension (weak recommendation based on low-quality evidence, 2C).

- In patients with anorectal varices and severe bleeding, we recommend to maintain an Hb level of at least > 7 g/dl (4.5 mmol/l) during the resuscitation phase and a mean arterial pressure > 65 mmhg, but avoiding fluid overload (strong recommendation based on moderate quality evidence, 1B).

- In patients with bleeding anorectal varices, we suggest the endorectal placement of a compression tube as a bridging maneuver, to help stabilization of the patient or to allow the transfer to a tertiary hospital (weak recommendation based on very low-quality evidence, 2D).

4.E - In patients with bleeding anorectal varices, which is the appropriate pharmacological regimen (including antibiotics)?

 

- In patients with anorectal varices, we suggest the use of non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding (weak recommendation based on very low-quality evidence, 2D). In case of acute bleeding, we suggest to temporarily suspended beta blockers (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices, we suggest to consider the use of vasoactive drugs, such as terlipressin or octreotide, to reduce splanchnic blood flow and portal pressure (weak recommendation based on very low-quality evidence, 2D).

- In patients with bleeding anorectal varices, we recommend a short course of prophylactic antibiotic (strong recommendation based on moderate quality evidence, 1B).

4.F - In patients with bleeding anorectal varices, what is the role for angiography?

 

- In patients with bleeding anorectal varices and failure of medical treatment and local procedures, we suggest a “step up” approach with radiological and then surgical procedures (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices, we suggest to use embolization via interventional radiological techniques for the short-term control of bleeding (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices and severe portal hypertension, we suggest to use percutaneous TIPS, if not contraindicated, to decompress the portal venous system and to reduce the risk for rebleeding (weak recommendation based on low-quality evidence, 2C).

- No recommendation can be made regarding the superiority of one embolization technique over the others in case of bleeding anorectal varices , based on the available literature.

4.G - In patients with bleeding anorectal varices, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, we suggest a “step up” approach with surgical procedures (weak recommendation based on low-quality evidence, 2C).

- In patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, we suggest against the use of “per anal” suture ligation (weak recommendation based on very low-quality evidence, 2D).

- No recommendation can be made regarding the role of Doppler-guided hemorrhoidal artery ligation and stapled anopexy in patients with bleeding anorectal varices and failure of medical treatment,local and radiological procedures, based on the available literature.

Complicated rectal prolapse (irreducible or strangulated)

5.A - In patients with a suspected complicated rectal prolapse, what is the role of clinical examination and biochemical investigations?

 

- In patients with suspected complicated rectal prolapse, we suggest to request complete blood count and the dosage of serum creatinine, and inflammatory markers (e.g., C-reactive protein, procalcitonin, and lactates) to assess the status of the patient (weak recommendation based on low-quality evidence, 2C).

5.B - In patients with a suspected complicated rectal prolapse, which are the appropriate imaging investigations?

 

- In hemodynamically stable patients with irreducible or strangulated rectal prolapse, we suggest to perform an urgent contrast enhanced abdomino-pelvic CT-scan, whenever available and without delaying appropriate treatment, to detect possible associated complications and to assess the presence of a colorectal cancer (weak recommendation based on low-quality evidence, 2C).

- In hemodynamically unstable patients with irreducible or strangulated rectal prolapse, we suggest against delaying appropriate and timely management to perform imaging investigations (weak recommendation based on low-quality evidence, 2C).

5.C - In patients with complicated rectal prolapse, what is the role of non-operative management?

 

- In patients with incarcerated rectal prolapse without signs of ischemia or perforation, we suggest to attempt conservative measures and gentle manual reduction under mild sedation or anesthesia (weak recommendation based on moderate quality evidence, 2B).

- In hemodynamically unstable patients with complicated rectal prolapse, we suggest against delaying surgical management to attempt a conservative management (weak recommendation based on low-quality evidence, 2C).

5.D - In patients with complicated rectal prolapse, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with complicated rectal prolapse and signs of shock or gangrene/perforation of prolapsed bowel, we recommend immediate surgical treatment (strong recommendation based on high-quality evidence, 1A).

- In patients with complicated rectal prolapse and bleeding, acute bowel obstruction or failure of non-operative management, we suggest urgent surgical treatment (weak recommendation based on low-quality evidence, 2C).

5.E - In patients with complicated rectal prolapse, what is the most appropriate surgical approach?

 

- In patients with complicated rectal prolapse and no signs of peritonitis or hemodynamic instability, we suggest to base the decision between abdominal and perineal procedures on the specific patient’s characteristics and on surgeon’s skills and expertise (weak recommendation based on moderate quality evidence, 2B).

- In hemodynamically stable patients with complicated rectal prolapse, in case of abdominal approach, we suggest to base the decision between open or laparoscopic surgery on patient’s characteristics and on surgeon’s skills and expertise (weak recommendation based on very low-quality evidence, 2D).

- In patients with complicated rectal prolapse and signs of peritonitis, we suggest an abdominal approach (weak recommendation based on low-quality evidence, 2C).

- In patients with complicated rectal prolapse and hemodynamic instability, we recommend an abdominal open approach (strong recommendation based on low-quality evidence, 1C).

- In patients with complicated rectal prolapse undergoing resectional surgery, we suggest to base the decision between primary anastomosis, with or without diverting ostomy, and terminal colostomy on the patient’s clinical condition and on the individual risk of anastomotic leakage (weak recommendation based on low-quality evidence, 2C).

5.F - In patients with complicated rectal prolapse, which is the appropriate pharmacological regimen (antibiotics, pain-control, others)?

 

- In patients with strangulated rectal prolapse, we suggest to administer empiric antimicrobial therapy because of the risk of intestinal bacterial translocation; the appropriate regimen should be based on the clinical condition of the patients, the individual risk for MDRO, and the local resistance epidemiology (weak recommendation based on low-quality evidence, 2C).

Retained anorectal foreign bodies

6.A - In patients with a suspected retained anorectal foreign body, what is the role of clinical examination and biochemical investigations?

 

- In patients with suspected retained anorectal foreign body, we suggest to collect a focused medical history and to perform a complete physical examination (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected retained anorectal foreign body, we suggest to perform digital rectal examination after the acquisition of an abdomen X-ray, whenever possible, to prevent accidental injury to the surgeon from sharp objects (weak recommendation based on low-quality evidence, 2C).

- In patients with suspected retained anorectal foreign body and no signs of bowel perforation, we suggest against routinely requesting of laboratory tests (weak recommendation based on very low-quality evidence, 2D).

- In patients with suspected retained anorectal foreign body and no signs of bowel perforation, we suggest to request the routine preoperative blood tests only in case manual extraction fails/is not feasible (weak recommendation based on very low-quality evidence, 2D).

- In patients with suspected retained anorectal foreign body and coexisting suspected bowel perforation, we suggest to request complete blood count and the dosage of serum creatinine, and inflammatory markers (e.g., C-reactive protein, procalcitonin, and lactates) to assess the status of the patient prior to surgery (weak recommendation based on low-quality evidence, 2C)

6.B - In patients with a suspected retained anorectal foreign body, which are the appropriate imaging investigations?

 

- In patients with suspected retained anorectal foreign body, we recommend lateral and anteroposterior plain X-ray film of the chest, abdomen, and pelvis to identify the foreign body position and determine its shape, size, and location and the possible presence of pneumoperitoneum (strong recommendation based on moderate quality evidence, 1B).

- In hemodynamically stable patients with suspected retained anorectal foreign body and a suspected perforation, we recommend a contrast enhanced CT scan of the abdomen (strong recommendation based on moderate quality evidence, 1B).

- In patients with retained anorectal foreign body and hemodynamic instability, we suggest against delaying surgical treatment to perform imaging investigations (weak recommendation based on low-quality evidence, 2C).

6.C - In patients with a retained anorectal foreign body, what is the most appropriate interventional approach (manual extraction vs endoscopy vs surgery)?

 

- In patients with low-lying retained anorectal foreign body without sign of perforation, we suggest an attempt of bedside extraction as the first-line therapy (weak recommendation based on low-quality evidence, 2C).

- No recommendation can be made regarding the superiority of one trans-anal extraction technique over the others in case of retained anorectal foreign body, based on the available literature.

- In patients with retained anorectal foreign body and failure of bedside extraction, we suggest pudendal nerve block, spinal anesthesia, intravenous conscious sedation, or general anesthesia to improve chances of transanal retrieval (weak recommendation based on low-quality evidence, 2C).

- In patients with retained high-lying anorectal foreign body (above rectosigmoid junction), we suggest an attempt of endoscopic extraction as the first-line therapy (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and suspect of drug concealment, we suggest against any maneuver that can disrupt the drug package, including endoscopic retrieval (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body, we suggest to perform a proctoscopy or flexible sigmoidoscopy after foreign body removal, to evaluate bowel wall status (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and signs and hemodynamic instability or perforation, we recommend against transanal extraction (strong recommendation based on low-quality evidence, 1C).

6.D - In patients with a retained anorectal foreign body, what are the indications for surgical treatment and what is the appropriate timing for surgery?

 

- In patients with retained anorectal foreign body and no signs of perforation, we suggest a surgical approach in case of failure of transanal extraction (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and no signs of perforation, we suggest a “step-up” surgical approach, starting with downward milking and proceeding to colotomy only when milking/transanal extraction fails (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and no signs of perforation, we suggest a laparoscopic approach if skills and instrumentation are available (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and bowel perforation with limited peritoneal contamination, we suggest primary suture only in case of small and recent perforation and if the colonic tissues appear healthy and well vascularized, and an approximation of perforation edges could be performed without tension (weak recommendation based on low-quality evidence, 2C)

- In patients with retained anorectal foreign body and bowel perforation, clinically stable and without risk factors for anastomotic leakage, when primary suture is not feasible, we suggest resection with primary anastomosis with or without a diverting stoma (weak recommendation based on low-quality evidence, 2C)

- In critically ill patients with retained anorectal foreign body and bowel perforation, or in selected patients with extensive peritoneal contamination and risk factors for anastomotic leakage, we suggest to perform a Hartmann’s procedure (weak recommendation based on low quality evidence, 2C)

- In patients with retained anorectal foreign body and hemodynamic instability, we recommend an emergent laparotomy and a damage control surgery approach (strong recommendation based on moderate quality evidence, 1B).

6.E - In patients with a retained anorectal foreign body, is there a role for antibiotic therapy?

 

- In patients with retained anorectal foreign body, we suggest against the routinely use of antimicrobial therapy (weak recommendation based on low-quality evidence, 2C).

- In patients with retained anorectal foreign body and signs of hemodynamic instability or perforation, we recommend broad spectrum antibiotic therapy according to the WSES guidelines on intra-abdominal infections (strong recommendation based on moderate quality evidence, 1B).

Acute anal fissure

7.A - In patients with suspected acute anal fissure, what is the role of clinical examination and biochemical investigations?

 

- No recommendation can be made regarding the role of biochemical investigations in patients with typical acute anal fissure, based on the available literature

- In patients with atypical acute anal fissure, we suggest to collect a focused medical history, perform a complete physical examination and laboratory tests based on the suspected associated illness, to rule out other causes (weak recommendation based on low-quality evidence, 2C).

7.B - In patients with suspected acute anal fissure, which are the appropriate imaging investigations?

 

- No recommendation can be made regarding the use of imaging investigations in patients with typical acute anal fissure, based on the available literature.

- In patients with atypical acute anal fissure, we suggest to perform investigations (endoscopy, CT scan, MRI, or endoanal ultrasound) only in case of suspected concomitant inflammatory bowel disease,anal or  colorectal cancer or occult perianal sepsis (weak recommendation based on low-quality evidence, 2C).

7.C - In patients with an acute anal fissure, what is the role of non-operative management?

 

- In patients with acute anal fissure, we recommend non-operative management as the first-line treatment (Strong recommendation based on moderate quality evidence, 1B)

- In patients with acute anal fissure, we recommend dietary and lifestyle changes, with increased fiber and water intake (strong recommendation based on moderate quality evidences, 1B).

- In patients with acute anal fissure, we recommend against the use of manual dilatation (strong recommendation based on moderate quality evidences, 1B).

- No recommendation can be made regarding the use of controlled anal dilatation in patients with acute anal fissure, based on the available literature.

7.D - In patients with an acute anal fissure, what is the appropriate approach for pain control?

 

- In patients with acute anal fissure, we suggest the integration of topical anesthetics and common pain killers in case of inadequate pain control (weak recommendation based on low-quality evidences, 2C).

- No recommendation can be made regarding the use of botulinum injections in patients with acute anal fissure, based on the available literature.

7.E - In patients with an acute anal fissure, is there a role for antibiotic therapy?

 

- In patients with acute anal fissure, we suggest the use of topical antibiotics in case of potential reduced therapeutic compliance or poor genital hygiene (weak recommendation based on very low-quality evidences, 2D).

7.F - In patients with an acute anal fissure, what are the indications for surgical treatment and what is the appropriate timing for surgery? If indicated, what is the most appropriate surgical approach?

 

- In patients with acute anal fissure, we suggest against surgical treatment (weak recommendation based on moderate quality evidences, 2B).

- In patients with anal fissure, we suggest surgical treatment in the chronic phase, if non responsive after 8 weeks non-operative management (strong recommendation based on moderate quality evidences, 1B).