In the present study, the WhatsApp tool used for direct day-by-day contact between proctological patients and surgeons during the first week after surgery has shown its usefulness in terms of perception of quality of health and positive postoperative outcomes.

WhatsApp is the most used application for Instant Messaging, and its role in telemedicine has been reported in several studies [1, 3, 10]. In particular, WhatsApp is a recent technology startup founded to build a better short message service alternative [11]. In several regions around the world, particularly in rural areas and low- and middle-income countries, WhatsApp has been shown to facilitate communication among healthcare professionals in terms of faster problem identification and immediate management [11, 12].

The need for healthcare professionals to find alternative methods to follow-up with their patients has dramatically risen due to the COVID-19 pandemic.

This has had a significant influence on the management of patients requiring proctological surgery due to the typically benign nature of their pathologies.

In a study by Campennì et al., telemedicine was adopted to follow-up patients on the waiting list for proctological surgery during the lockdown in Italy. The results showed patients' satisfaction with a telemedicine program [16]. However, some limitations were highlighted, including the inability to perform a physical examination, even if partially possible with video assistance. Uncertainty about data collection and self-reported objective data was found to be another limitation.

Knaus et al. reported their experience of a bowel management program of telemedicine for pediatric patients with congenital or chronic intestinal diseases during the pandemic. Most patients were satisfied, especially because of the lower degree of stress due to fewer trips to the hospital. [17]

A relevant e-consensus on telemedicine in colorectal surgery highlighted how telemedicine represents an important tool, especially in the follow-up, diagnosis, and "decision making" process once the patient has completed the necessary examinations. [18]

A review performed by Colbert et al. underlined some relevant benefits brought by telemedicine to the patients and the healthcare workers, like a reduction in the expenses, no travel costs, less time off work, and potentially lower childcare costs. The risk of communicable diseases is also reduced, as the patient will have limited exposure. [12]

Our results are consistent with other reports, showing the relevance of a user-friendly tool of telemedicine for improving the perception of good health quality. [1,2,3,4] Our population was retrospectively evaluated in a pre-COVID period. Therefore, we investigated a "naïve" population in which telemedicine was an alternative rather than a necessity. We wanted to explore a period in which hospital activity was not affected by a severe reduction in services mainly in terms of proctological surgery. Consequently, we tried to minimize the biases potentially caused by selecting patients enrolled during the pandemic.

We found that use of WhatsApp improved patient perception of a positive outcome after surgery, after adjusting the results for potential confounders of this perception, e.g. age, sex, level of instruction, and employment.

When we compared the validity of a postoperative approach based only on general instructions vs. a day-by-day diary to collect patient data, in all cases, the results of the latter approach were superior in terms of perception of quality of care, of safety, and even perception of a positive outcome after surgery.

The necessity to send the results to the surgeon by WhatsApp apparently leads patients follow discharge recommendations carefully, resulting in a feeling of security and high quality of care received.

Our study has some limitations. It is retrospective, and the sample size is small. Nevertheless, we adopted a rigorous statistical approach to avoid potential biases. The sample size limitation was also due to our intention to compare two homogeneous groups of patients receiving or not a telemedicine tool without any bias caused by the COVID-19 pandemic.

Another limitation is that the group B patients answered the phone survey later than the group A patients the patients (median time of 1 vs. 5 months after surgery). This is a critical point of our study, potentially adding some bias to the observed results. Unfortunately, the decision to implement a telemedicine tool was not prospectively implemented with a randomized controlled approach. Only a prospectively designed study would be able to clarify this aspect without any risk of potential bias definitively. Nevertheless, we can assume that a median time of 5 months is not so long to impede a person from remembering a relevant event of his/her life, like some form of discomfort experienced shortly after surgery. Therefore, we are confident that our results should be considered as only slightly inflected by potential biases.

Lastly, we could not clarify if the use of WhatsApp also impacted on the improvement of surgical quality. This impossibility derived from the absence of relevant complications reported in the postoperative course of our series. We can only postulate that direct contact with the surgeon can accelerate his/her intervention in the case of complications.