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Highlights • Anastomotic leak is a common and potentially dangerous postoperative complication in colo-rectal surgery. • Low anastomotic leak conservative treatment requires five months or more for a complete resolution and a complex management. • The FiLaC laser diode technology could be a good option to reduce the healing time and to minimize patient’s discomfort., Introduction Anastomotic Leakage (AL) is one of the most important early postoperative complication of the adenocarcinoma’s surgical treatment. Fistula Laser Closure (FiLaC®) is a minimal invasive technique that use diode laser energy to obtain the fistula track obliteration and it is finding large application for other affection characterized by fistula tracts presence. Presentation of case A 56 years old male, with no clinical history of adenocarcinoma in his family, underwent a laparoscopic low anterior resection with ileostomy for a rectal adenocarcinoma. Approximately 3 months after the procedure an anastomotic leak with an associated abscess was found. The patient underwent an endoscopic FiLaC off-label procedure on the AL and after further 4 months, he obtained a complete resolution of the anastomosis dehiscence. Discussion The literature is poor about the minimal invasive AL treatment and there is no paper about the management of the AL with the FiLaC® procedure. For asymptomatic patients a conservative solution is preferred, it could be considered a drain positioning for emptying abscesses and for irrigation or the use of an Endosponge to decrease the resolution time. The FiLaC® procedure could be a more feasible technique that could also reduce the healing time as well with no discomfort for the patient. Conclusion Considering the results and our patient healing time, we think that an off-label application of FiLaC® procedure on asymptomatic low anastomotic leak could be an opportunity for a morbidity resolution shorter than the simple wait and see strategy, and more sustainable for the patient.

Highlights • Leiomyoma is a benign tumour deriving from the smooth muscle fibres. • Immunohistochemical pattern is fundamental to identify leiomyoma. • Leiomyomas are relatively insensitive to chemotherapy. • Complete surgical excision is the treatment of choice. • The best surgical approach should depend on the dimension and site of the lesion., Introduction Leiomyoma is a benign tumour which derives from the smooth muscle fibres and it may occurs in every site in which this type of muscle is present. Among all benign soft tissue tumours it represents almost 3.8% and its pathogenesis remains still unknown. Presentation of case The present case is about a 62 year old woman referred to our centre complaining anal and perineal pain which increase after defecation in association with the appearance of a nodule in the perianal region fixed to the anal sphincter. A 360° tridimensional transanal ultrasound was performed and it showed an anterior nodular thickening of the internal anal sphincter. After an inconclusive preoperative biopsy and a counselling with the patient, the surgeons decided to proceed with the surgical excision. The immunohistochemical examination confirmed the preoperative suspicion of leiomyoma. At 1 year follow-up the patient had not tumour-related symptoms or fecal incontinence and any signs of local recurrence at ultrasound imaging were demonstrated. Discussion Leiomyomas are relatively insensitive to chemotherapy whereby surgery is the treatment of choice and it should be adequate to the site and dimension of the lesion achieving a complete resection with free margins. A further close follow-up is needed too. Conclusion Nowadays there is not a gold standard technique to treat such kind of lesions and the decision of the best surgical approach should depend on the dimension and site. In fact, surgery aims to the oncological outcome trying also to minimize the possible post-operative functional complications.

Highlights • Mucocele is a variant of rectal pocket. • Mucocele is a rare complication after stapled procedure. • Mucocele has problems of differential diagnosis with paraectal lesion, especially abscess. • It is usually treated with transanal approach., Introduction Stapled hemorrhoidopexy is a safe and effective treatment for circumferential hemorrhoidal prolapse. The overall rate of complications ranges from 12,7% to 36,4% and the surgeon should be aware about their early identification and adequate treatment. Presentation of case Female patient, 57 years was treated with stapled hemorrhoidopexy. Two years after surgery she reported to our center the occurrence of perineal discomfort, anal spasm and tenesmus. The anal exploration showed a bulge of the right lateral wall of the rectum at the level of stapled line without any related pain. 3D 360° transanal ultrasound showed a pararectal fluid collection. A surgical operation was performed and a great amount of mucus was drained. After one year the patient is completely asymptomatic with normal defecation. Discussion Mucocele is a rare complication which usually occurs after months from the operation and it is considered a variant of rectal pocket and it is usually completely separated from the rectal lumen at the level of stapled line. The differential diagnosis between mucocele and pararectal lesions, especially abscess may be often difficult. Surgery is the treatment of choice with a transanal approach that is generally preferred to the trans-perineal. Conclusion Mucocele is a rare complication of stapled hemorrhoidopexy that may remain asymptomatic for a long period. In case of perineal discomfort after stapled procedure the physical examination combined with 3D 360° transanal ultrasound is necessary to reach the diagnosis. The knowledge of the possible rare complications is at the base of a correct treatment.