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202

A. Longo

Fig. 23.3 (a) Rectovaginal cloaca. (b) Dissection of rectovaginal synechia. (c) Reconstruction of rectal wall and anal canal. (d) Crossing ap and partial levatorplasty. (e) Vagina wall and perineum reconstruction

above the crossed aps. The vaginal wall is then reconstructed. If the ostium is too tight, two longitudinal incisions are made on the lateral vagina wall, and sutured transversally.

It is important to reconstruct the anterior perineal body by trying to plicate the supercial perineal fascia together with the supercial transverse muscle of the perineum. The two lateral cutaneous incisions are transversal U-shaped and sutured in order to restore the rectovaginal distance. The choice of a preoperative colostomy, when necessary, is determined by the severity and complexity of the case: in the most severe cases we perform colostomy. If the procedure fails, it becomes a permanent solution. After 1–2months, in the absence of surgical complications, the patients undergo anorectal manometry and X-ray cinedefecography with uid barium. If the patient shows sufcient continence, we restore the intestinal continuity.

23.5 Results

From March 2014 to March 2021 we treated 82 patients (69 women and 13 males) with CFPRM.The sphincter defects ranged from 80° to 360°. Follow-up ranged from 3months to 3years (average 14months). The follow-up assessments carried out at 3months, 1year and 3years included anorectal manometry and the Cleveland

23 Reconstruction of Wide Anal Sphincter Defects by Crossing Flaps of Puborectalis…

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203

Clinic Fecal Incontinence Score (CCFIS). The causes and types of sphincter injury and the associated pelvic injuries are reported in Tab le23.1.

The preoperative manometry values ranged from 0 to 15 at rest (average 6mmHg) and from 0 to 25 at squeeze (average 9mmHg). At 3months postoperatively, the range increased from 45 to 90 at rest (average 65mmHg) and from 95 to 125 at squeeze (average 107mmHg). No signicant variations were detected at 1year and 3 years. Preoperative CCFIS ranged from 14 to 20 (average 16.5). At 3 months postoperatively, it ranged from 0 to 2 (average 1.2). As with the manometric values, no signicant variations in CCFIS were detected at 1year and 3 years. Only ve patients (6%) failed to experience any postoperative improvement of FI, four of them among the rst 24 cases.

23.6 Conclusions

Before applying the technique to our patients, we tested the procedure on nine cadavers, seven women and two men. We started our experience with female patients presenting with a large anterolateral defect due to obstetric trauma. Subsequently, we enrolled other patients, including those with associated rectovaginal stula and rectovaginal cloaca. The results progressively improved and we learned that it is important to achieve perfect hemostasis, because muscular dissections bleed easily and postoperative perineal hematomas are not easy to drain and can predispose to wound infection and dehiscence. Moreover, reconstruction of the perineal body and the supercial perineal fascia is very advantageous in terms of anatomical and physiological results. The preoperative diagnostic accuracy and exclusion criteria are fundamental. We recommend adequate training and gaining more experience with the simplest cases.

References

1. Sharma A, Yuan L, Marshall RJ, etal. Systematic review of the prevalence of faecal incontinence: prevalence of faecal incontinence. Br J Surg. 2016;103(12):1589–97.

2. Vaizey CJ, Kamm MA.Injectable bulking agents for treating faecal incontinence. Br J Surg. 2005;92(5):521–7.

3. Efron J. The SECCA procedure: a new therapy for treatment of fecal incontinence. Surg Technol Int. 2004;13:107–10.

4. Tjandra JJ, Chan MK, Yeh CH, et al. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum. 2008;51(5):494–502.

5. Wong WD, Congliosi SM, Spencer MP, etal. The safety and efcacy of the articial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum. 2002;45(9):1139–53.

6. Pickrell KL, Broadbent TR, Masters FW, etal. Construction of a rectal sphincter and restoration of anal continence by transplanting gracilis muscle: report of four cases in children. Ann Surg. 1952;135(6):853–62.

204

7. Chapman AE, Geerdes B, Hewett P, etal. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg. 2002;89(2):138–53.

8. Shak A.A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. The external anal sphincter: a triple-loop system. Investig Urol. 1975;12(5):412–9.

9. Longo A.Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal rectal resection (STARR). Annual Cleveland clinic Florida colorectal disease symposium, 2004.

10. Corman ML, etal. Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation. Colorectal Dis. 2006;8:98–101.

11. Longo A, Crafa F, Boller B, etal. Longo’s original technique to correct multiorgan pelvic prolapses. Perspective trial. Preliminary results. In: Proceedings of the 23rd annual international colorectal diseases symposium. 14–22 February 2012, Fort Lauderdale, Florida.

12. Boccasanta P, Venturi M, Agradi S, etal. A minimally invasive technique for the 1-stage treatment of complex pelvic oor diseases: laparoscopic-pelvic organ prolapse suspension. Female Pelvic Med Reconstr Surg. 2021;27(1):28–33.

13. Norderval S, Delhi T, Vonen B.Three-dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classication of anal sphincter defects. Ultrasound Obstet Gynecol. 2009;33(3):337–43.

14. Gehrich AP, McClellan E, Gillern S.Surgical repair of an obstetric cloaca with review of the literature. BMJ Case Rep. 2021;14(1):e234321. https://doi.org/10.1136/bcr- 2020- 234321.

A. Longo

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-

NonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/

by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in

any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if you modied the licensed material. You do not have permission under this license to share adapted material derived from this chapter or parts of it.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Treatment Cost Reimbursement inItaly

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VincenzoLandolfi andAdrianaMariaLandolfi

24.1 Introduction

The Italian National Health Service (NHS) is a system of facilities and services that aim to guarantee all citizens, under equal conditions, universal access to health care [1].

Reimbursements for acute day surgery and inpatient hospitalizations are established by the Diagnosis-Related Groups (DRG) system, whereby procedures are not reimbursed based on the total days of hospitalization, but on a “service-provision” basis, according to a predened cost estimate [2]. The rate is an all-inclusive remuneration for the treatment prole on average associated with the corresponding hospitalization category. The DRG code is obtained by linking the ICD9-CM diagnosis code [3] with the procedure code. Furthermore, for the same DRG there are differences in the treatment cost reimbursement due to several factors:

• public or private nature of the facility;

• regional reimbursement rate;

• type of hospitalization (outpatient, day surgery, inpatient);

• days of hospitalization (increase over the threshold value).

The ICD9-CM code for fecal incontinence corresponds to 787.6.

Below we report the DRGs of surgical procedures for fecal incontinence, obtained by linking the main diagnosis code with the procedure codes.

V. Landol (*) Department of General Surgery, S.Giuseppe Moscati Hospital, Avellino, Italy e-mail: vincenzo.landol@tiscali.it

A. M. Landol Pelvic Floor Rehabilitation, Euromedica, Milan, Italy e-mail: adrianalandol@hotmail.it

https://doi.org/10.1007/978-3-031-08392-1_24

205

206

V. Landol and A. M. Landol

24.2 DRG Surgical Procedures forFecal Incontinence

Anal Cerclage

• DRG 158

• Diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 49.72 Anal cerclage

Other Repair of Anal Sphincter

• DRG 158

• Diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 49.79 Other repair of anal sphincter (including anal sphincter tear compli-

cating past delivery; excluding anal sphincter tear complicating recent delivery: code 75.62)

Implantation or Revision of Articial Anal Sphincter

• DRG 147

• Diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 49.75 Implantation or revision of articial anal sphincter/prosthesis

Removal of Articial Anal Sphincter Without Replacement

• DRG 147

• Diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 49.76 Removal of articial anal sphincter without replacement

Dynamic Graciloplasty

• DRG 171

• Diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 49.74 Gracilis muscle transplant for anal incontinence

• Secondary procedure code

– 04.92 Implantation or replacement of peripheral neurostimulator electrode

• Tertiary procedure code

– 86.94 Insertion or replacement of single-array neurostimulator pulse gen-

erator. Not specied as rechargeable

– 86.95 Insertion or replacement of multiple-array neurostimulator pulse gen-

erator. Not specied as rechargeable

24 Treatment Cost Reimbursement inItaly

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Electrode Review Without Replacement

• DRG 157

• Diagnosis code

– 787.6 Fecal incontinence

• Secondary diagnosis code

– 996.39 Other mechanical complication of device, implant and graft.

• Primary procedure code

– 49.92 Insertion of subcutaneous electrical anal stimulator

Sacral Neuromodulation System Implantation: First Step (PNE Test)

• DRG 532

• Primary diagnosis code

– 33.70 Idiopathic peripheral autonomic neuropathy – 33.79 Unspecied disorder of autonomic nervous system – 35.68 Other specied idiopathic peripheral neuropathy

• Secondary diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 03.93 Insertion/replacement of spinal neuromodulation

Sacral Neuromodulation System Implantation: Second Step

• DRG 8

• Primary diagnosis code

– 33.70 Idiopathic peripheral autonomic neuropathy – 33.79 Unspecied disorder of autonomic nervous system – 35.68 Other specied idiopathic peripheral neuropathy

• Secondary diagnosis code

– 787.6 Fecal incontinence

• Primary procedure code

– 86.94 Insertion or replacement of single-array neurostimulator pulse gen-

erator, not specied as rechargeable

• Secondary procedure code

– 86.95 Insertion or replacement of multiple-array neurostimulator pulse gen-

erator, not specied as rechargeable

207

Electrode Replacement

• DRG 532

• Primary diagnosis code

– V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve,

spinal cord)

• Primary procedure code

– 03.93 Insertion/replacement of spinal neurostimulator

208

V. Landol and A. M. Landol

Generator Replacement

• DRG 8

• Primary diagnosis code

– V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve,

spinal cord)

• Primary procedure code

– 86.94 Insertion or replacement of single-array neurostimulator pulse gen-

erator, not specied as rechargeable

• Secondary procedure code

– 86.95 Insertion or replacement of multiple-array neurostimulator pulse gen-

erator, not specied as rechargeable

Electrode + Generator Replacement

• DRG 532

• Primary diagnosis code

– V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve,

spinal cord)

• Primary procedure code

– 03.93 Insertion/replacement of spinal neurostimulator

• Secondary procedure code

– 86.94 Insertion or replacement of single-array neurostimulator pulse gen-

erator, not specied as rechargeable

– 86.95 Insertion or replacement of multiple-array neurostimulator pulse gen-

erator, not specied as rechargeable

Electrode Removal

• DRG 532

• Primary diagnosis code

– for ineffectiveness

V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve, spinal cord)

– for infection

996.63 Infection and inammatory reaction due to nervous system device, implant, and graft

– for mechanical complications

996.2 Mechanical complication of nervous system device, implant, and graft.

• Primary procedure code

– 03.94 Removal of spinal neurostimulator

Generator Removal

• DRG 35

• Primary diagnosis code

24 Treatment Cost Reimbursement inItaly

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– for ineffectiveness

V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve, spinal cord)

– for infection

996.63 Infection and inammatory reaction due to nervous system device, implant, and graft

– for mechanical complications

996.2 Mechanical complication of nervous system device, implant, and graft.

• Primary procedure code

– 86.05 Incision with removal of foreign body from skin and subcutane-

ous tissue

Electrode + Generator Removal

• DRG 532

• Primary diagnosis code

– V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve,

spinal cord)

• Primary procedure code

– 03.94 Removal of spinal neurostimulator

• Secondary procedure code

– 86.05 Incision with removal of foreign body from skin and subcutane-

ous tissue

209

Electrode/Generator Revision/Extension Without Replacement

• DRG 35

• Primary diagnosis code

– V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve,

spinal cord)

• Primary procedure code

– 86.09 Other incision of skin and subcutaneous tissue

24.3 Reimbursement ofDRGs

Annex 1 to the Decree of the Italian Ministry of Health of 18 October 2012 sets the rates for the remuneration of hospital care services for acute cases [2].

The national cost reimbursements for each DRG associated with fecal incontinence are presented in Table24.1. These reimbursements were subsequently modied by the Italian Regions and the differences are very interesting. For example: the reimbursement for inpatient care hospitalization for DRG 8 ranges from a minimum of €1581 in the Campania Region to a maximum of €3684 in the Autonomous Province of Bolzano; for DRG 35 ranges from €1412in Campania to €3735in the Autonomous Province of Trento; for DRG 532 ranges from €5284 in Molise to €14,419in Sicily.

210

V. Landol and A. M. Landol

Table 24.1

incontinence

DRG 8 Peripheral and cranial

35 Other nervous system

147 Rectal resection

157 Anal and stomal

158 Anal and stomal

171 Other digestive

468 Extensive OR

532 Spinal procedures

DRG diagnosis-related groups, CC complications and/or comorbidities, OR operating room

Italian national cost reimbursements for the DRGs of surgical procedures for fecal

Short-stay inpatient hospitalization ≤1day and day surgery hospitalization (€)

Days over threshold value (per day) (€)

Description

nerves and other nervous system procedures without CC

disorders without CC

without CC

procedures with CC

procedures without CC

system OR procedures without CC

procedure unrelated to principal diagnosis

without CC

Inpatient hospitalization >1day within the threshold value (€)

2326 2585 196

2077 234 163

7475 2311 274

3808 1007 192

1202 1007 126

4498 1578 193

10,158 3468 227

8413 2782 330

Patient costs as well are reported differently in each European country and may include a varying number of cost categories because of specic national costing and reporting standards.

24.4 Reimbursement ofPerineal Pelvis Rehabilitation

With regard to rehabilitation in fecal incontinence, we report below the codes for several treatments.

• Functional evaluation: 9301

• History and evaluation: 8903

• Manual evaluation of muscle function (PC test): 9304

• Exercises not elsewhere classied (awareness and relaxation) (postural): 9319

• Breathing exercises: 9318

• Active musculoskeletal exercises (Biofeedback): 9312

• Rehabilitation (pelviperineal): 9389

• Passive musculoskeletal exercises: 9317

• Assisted exercises (proprioceptive and awareness-raising): 9311

24 Treatment Cost Reimbursement inItaly

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211

• Resistance exercises: 9313

• Manipulative treatment (osteopathy for general mobilization): 9361

• Stretching of the perineal muscles: 9327

• Band stretch: 9328

• Manual tractions: 9321

• Spinal mobilization: 9315

Linking these codes with the diagnosis code for fecal incontinence (787.6) we obtain DRG 183: “esophagitis, gastroenteritis and miscellaneous digestive disorders”. This DRG would be inappropriate as the rehabilitation is provided only in an outpatient setting and not on an inpatient basis.

The procedure code used for rehabilitation for fecal incontinence, urinary incontinence and both fecal and urinary incontinence is PR35B (cycle of 10 sessions). The medical prescription must specify code PR35B.001 for fecal incontinence, PR35B.002 for both fecal and urinary incontinence and PR35B.003 for urinary incontinence. The reimbursement will amount to €162.30.

References

1. Ministero della Salute. I principi del Servizio sanitario nazionale [Italian Ministry of Health.

The principles of the National Health Service]. https://www.salute.gov.it/portale/lea/dettaglio-

ContenutiLea.jsp?lingua=italiano&id=5073&area=Lea&menu=vuoto. Accessed 25 Oct 2021.

2. Ministero della Salute. Decreto del 18 ottobre 2012 (pubblicato nella Gazzetta Ufciale, n.

23 del 28 gennaio 2013) [Italian Ministry of Health. Decree of 18 October 2012 (published

in the Ofcial Gazette no. 23 of 28 January 2013)]. https://www.gazzettaufciale.it/eli/

id/2013/01/28/13A00528/sg. Accessed 25 Oct 2021.

3. Ministero della Salute. Il manuale ICD9-CM [Italian Ministry of Health. ICD9-CM Manual].

https://www.salute.gov.it/portale/temi/p2_6.jsp?id=1278&area=ricoveriOspedalieri&menu=cl

assicazione. Accessed 25 Oct 2021.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-

NonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/

by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in

any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if you modied the licensed material. You do not have permission under this license to share adapted material derived from this chapter or parts of it.

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