Post-hemorrhoidectomy pain: can surgeons reduce it? A systematic review and network meta-analysis of randomized trials.

PURPOSE: Hemorrhoidectomy remains the gold standard treatment for grade III-IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery, post-operative pain has been a limitation to the widespread inclusion of this condition in day surgery programs. The aims of the study were to analyze and compare the post-operative pain of conventional open hemorrhoidectomy, considered the reference technique, against other surgical procedures such as closed hemorrhoidectomy, open hemorrhoidectomy using bipolar or ultrasonic sealant, hemorrhoidopexy, or HAL-RAR, when performed exclusively as outpatients. METHODS: A systematic review and meta-analysis was conducted according to PRISMA methodology. All prospective and randomized studies of patients operated on for hemorrhoids in day surgery and specifying the value of post-operative pain, using a validated scale, were included. Conventional meta-analyses and a random-effects network meta-analysis were carried out. RESULTS: Twenty-nine studies were included (3309 patients). None of the procedures described severe pain in the post-operative period. Hemorrhoidopexy was the least painful. Conventional open hemorrhoidectomy was the most painful on the first and seventh post-operative days. Pain was reduced after closed hemorrhoidectomy technique and when bipolar or harmonic scalpel was used. Furthermore, transfixive ligation of the hemorrhoidal pedicle was associated with increased post-operative pain. CONCLUSION: Hemorrhoidal surgery is feasible in day surgery units and post-operative pain can be adequately managed in an outpatient setting. Hemorrhoidopexy was the least painful; however, data should be carefully evaluated by the high rate of long-term recurrence described in literature. Closed hemorrhoidectomy, performed with bipolar or ultrasonic sealing, avoiding transfixive ligation of the hemorrhoidal pedicle, may improve post-operative pain control. TRIAL REGISTRATION: CRD42020185160.

Prospective study of sexual function and analysis of risk factors after rectal cancer surgery.

AIM: The aim of this study was to assess the evolution of sexual function over time after rectal cancer surgery and to identify risk factors that may have an impact on the deterioration of postoperative function. METHOD: This was a prospective cohort study of sexual function after rectal cancer surgery using the International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI) preoperatively and at 6 and 12 months after surgery. Predictive factors of worsening were identified by univariate and multivariate analysis. RESULTS: One hundred and one patients were included (56 men and 45 women). In men, the average IIEF showed decreased erectile function and intercourse satisfaction at 6 months (respectively 21.58 ± 7.18 to 16.60 ± 7.96, p = 0.002 and 10.87 ± 2.94, to 8.09 ± 4.45, p = 0.002) with recovery at 1 year. As a percentage, erectile dysfunction increased from the preoperative value to 6 months (64.5% vs 87.1%, p = 0.022) and was observed in 72% at 1 year. Patients with moderate to severe dysfunction increased from 22% preoperatively to 58% (p = 0.009) at 6 months and 44% at 1 year (p < 0.0001). Neoadjuvant chemoradiotherapy (OR 5.4, 95% CI 0.9-29.6; p = 0.041) and erectile worsening at 6 months (OR 20, 95% CI 1.6-238; p = 0.004) were independent factors for worse function at 6 or 12 months, respectively. No significant worsening of the FSFI was found, although there was an improvement in lubrication and orgasm. CONCLUSION: Temporary deterioration of erectile function in men is common at 6 months after surgery and chemoradiotherapy is the only predictive factor. Furthermore, patients who remain dysfunctional show an increase in the severity of symptoms in relation to the preoperative period.

Incorporating the recovered carbon black produced in an industrial-scale waste tire pyrolysis plant into a natural rubber formulation.

This paper presents the experimental results obtained after incorporating the recovered Carbon Black (rCB) produced in an industrial-scale waste tire pyrolysis plant into a Natural Rubber (NR) formulation. The purpose of this study is to increase the technical knowledge on the use of rCB as a sustainable raw material in the rubber industry. The rCB and virgin Carbon Black (vCB) (ref. N550) under study were characterized using elemental and proximate analyses, X-Ray Fluorescence (XRF), Fourier Transform Infrared (FTIR) spectroscopy, and Scanning Electron Microscopy (SEM) were used, and different measures, including the Brunauer-Emmett-Teller (BET) surface area (SBET), particle size distribution (PSD), specific gravity, and pH, were estimated. The effect of rCB incorporation on the rheological, thermal, structural, and mechanical properties of the NR composites was assessed and compared to those obtained with vCB alone. The NR composites were prepared using different loads of vCB (20, 30, 40, and 50 phr), which was also replaced with rCB at different proportions (0, 50, and 100%). According to the characterization results, rCB offers lower reinforcement properties than vCB, which is attributable to its higher volatile matter and ash contents, higher apparent PSD, lower presence of acidic functional groups, and lower SBET. Despite this, interesting performances can be achieved when rCB is partially incorporated into the formulations or by increasing its load in the composites. For instance, when 50% of vCB was replaced with rCB, the values of the aforementioned properties were found to be between those obtained with the NR composites prepared with vCB and rCB. In addition, when increasing the rCB loading, some properties matched the behavior exhibited by vCB alone, thus compensating for the low reinforcement properties of rCB. These results are expected to provide an important impetus to move towards circular economy strategies having very positive impacts from the sustainable perspective.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis.

PURPOSE: The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease. METHODS: MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation. RESULTS: Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38). CONCLUSION: Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.

Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis.

PURPOSE: Rectal advancement flap is an accepted approach for treating complex fistula-in-ano. However, a diversity of technical modifications have been described. The aim of this study was to evaluate recurrence and fecal continence rates after performing rectal advancement flaps depending upon flap thickness (full-thickness, partial-thickness, or mucosal flaps) and treatment of the fistulous tract (core-out or curettage). METHODS: Medline (PubMed, Ovid), the Cochrane Library database, and ClinicalTrials.gov were searched. Studies that involved patients with complex cryptoglandular fistulas who had been treated with rectal advancement flaps were included. The outcomes measured were recurrence and fecal continence. All of the statistical analyses were performed using Comprehensive Meta-Analysis software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random effects model was used. RESULTS: Twenty-six studies were included (1655 patients). The pooled rate of recurrence was 21%. Full-thickness flaps showed the best results concerning recurrence (7.4%), partial flaps revealed 19% and mucosal flaps 30.1%. Core-out and curettage had a similar recurrence (19 vs 21%). Regarding anal incontinence, the pooled rate was 13.3%. Mucosal- and partial-thickness flaps showed similar rates (9.3 vs 10.2%), while full-thickness flaps disturbed it in 20.4%. Most of these alterations were minor symptoms. Otherwise, core-out and curettage showed similar rates (14.3 vs 12%). CONCLUSIONS: 1. Full-thickness rectal advancement flaps offer better results regarding the recurrence than mucosal or partial flaps. 2. All flaps cause some incontinence, which increases with the thickness of the flap. 3. The results did not suggest differences in recurrence and incontinence between core-out and curettage.

"Core out" or "curettage" in rectal advancement flap for cryptoglandular anal fistula.

AIM: Transanal advancement flap is a recognized technique for complex fistula. Management of the tract is open to discussion. Excision of the tract by the "core out" technique is difficult and could increase the risk of sphincter damage. Curettage is easier but it could increase the risk of recurrence. The aim of the present study was to assess the effect of both techniques on sphincter function and to study the clinical results. METHOD: This is a retrospective analysis from a prospective database. One hundred nineteen consecutive patients with high cryptoglandular anal fistula were included. "Core out" technique was performed in 78 patients (group I) and "curettage" in 41 (group II). In both, a full-thickness rectal flap was advanced over the closed internal defect. Anorectal manometry was performed to assess sphincter function. Continence was assessed using the Wexner Scale. Recurrence was defined as the presence of an abscess or fistulization. RESULTS: Manometric results showed a significant decrease in the maximum resting pressure after surgery in both groups. The maximum squeeze pressure was significantly reduced only in group I (p < 0.001). No significant changes in Wexner score were observed. The overall recurrence rate was 5.88%, five of group I (6.4%) and two of group II (4.9%), without statistical significance (p = 0.74). CONCLUSIONS: The core-out technique causes a significant decrease in squeeze pressures, which reflects damage to the external anal sphincter. This could lead to incontinence in high-risk patients. Curettage is a simple technique that preserves the values of squeeze pressures without increasing recurrence rates.

Alopecic and Aseptic Nodules of the Scalp: A New Entity or a Minor Form of Dissecting Cellulitis?

Since the original report in 1992 and revised nomenclature in 2009, pseudocysts of the scalp and alopecic and aseptic nodules of the scalp (AANS), respectively, have been regarded as a new entity that is rare and not understood in its pathogenesis. We observed 26 cases of AANS. Except for the extent and severity of disease, we found no single feature that justifies distinguishing AANS as a nosologic entity in its own right from dissecting cellulitis of the scalp (DCS). The scarring alopecias represent a diverse group of disorders with the potential of permanent destruction of the pilosebaceous unit and hair loss. Within the maze of varied conditions leading to scarring alopecia, the most important is to keep a neat nosologic classification in mind, based both on morphology and a pathogenic understanding. We believe that AANS represents a minor form of DCS, so far predominantly observed in patients of non-African origin, and therefore, is a disease of follicular occlusion with a favorable prognosis.

Latent Microsporidia Infection Prevalence as a Risk Factor in Colon Cancer Patients.

Microsporidia are opportunistic intracellular parasites, generating serious pathology in individuals with a compromised immune system. Infection by microsporidia inhibits p53 and Caspase 3, proteins involved in apoptosis and the cell cycle, which are vital in the malignant process of epithelial cells. The presence of microsporidia in the intestinal tissues of 87 colon cancer (CC) patients and 25 healthy controls was analyzed by real-time PCR and an immunofluorescence antibody test. Anti-Encephalitozoon antibodies were analyzed in serum samples by ELISA (enzyme linked immunosorbent assay). In 36 (41.3%) CC cases, microsporidia infections were identified in their tissues vs. no cases among control subjects (p < 0.0001). An increase in IgG and IgE anti-Encephalitozoon antibodies was found in patients with CC, which would demonstrate continuous and previous contact with the parasite. The high prevalence of microsporidia in tissues and the seroprevalence in patients with CC suggest a relationship between microsporidia and the etiopathogenesis of CC.

D3-lymphadenectomy enhances oncological clearance in patients with right colon cancer. Results of a meta-analysis.

BACKGROUND: D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME + D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME + D3. MATERIAL AND METHODS: A systematic review with meta-analysis was conducted, according to PRISMA methodology. RESULTS: 29 studies were enrolled (2592 patients). No differences were accounted in morbidity variables associated with the measured techniques. CME + D3 was significantly associated with a greater distance between the tumour and the closest vascular tie, a longer colonic resection, a wider resection of mesentery and an increased number of harvested lymph nodes. Regarding to long-terms outcomes, we found a significant decrease in local recurrence in patients undergoing CME + D3 (HR:0.17) and a significant improvement in 3-year and 5-year overall survival rates (HR:0.53 vs. HR:0.57, respectively), as well as an improving survival in patients with stage II and III disease. Overall prevalence of patients with lymphatic metastases in D3-territory was of 8.6% and 2.2% of skip metastases. CONCLUSIONS: CME + D3 is a feasible surgical procedure that allows to obtain specimens with higher quality oncological resection, without greater associated morbidity, thus improving survival in patients with stage II and III right colon cancer.

Look at Your Hair the Way You Look at Your Face: Concept of Total Facial Skin and Hair Care.

With today's increasing life expectation and quality of life, the desire to look young and beautiful plays a bigger role than ever. Aging of the hair is particularly visible. And yet, cosmetic dermatology has paid comparatively little attention to the care of the aging hair. The professional market for cosmetic interventions into the face has preceded those into the hair for a number of reasons. First, the market for facial rejuvenation has been dominated by plastic surgeons, until the fillers and botulinum toxin were introduced. Second, investigative dermatology found a profound interest in the study of skin aging, particularly as it relates to ultraviolet exposure, and exposed mechanisms at the level of the DNA and repair mechanisms, opening venues for effective preventive measures and pharmacological treatments of aging-related conditions of the skin. Finally, at the level of health professionals, the care for the skin has been overrated in relation to the hair, mostly due to economic reasons. Nevertheless, the hair represents an integral part of the face and our appearance. Moreover, the discovery of pharmacological targets and the development of safe and effective drugs for treatment of hair loss indicate strategies of the drug industry for maintenance of hair growth and quantity, while the hair care industry has become capable of delivering active compounds directed toward meeting the consumer demand for maintenance of hair cosmesis and quality. To offer patients the best outcomes toward a more youthful look, we therefore should look at the whole face including the condition of the hair for a more comprehensive approach toward a total facial skin and hair care concept.

Waste tire valorization by intermediate pyrolysis using a continuous twin-auger reactor: Operational features.

Pyrolysis can be regarded as a roadmap towards a circular and sustainable economy for waste tires (WT). This work investigates the operational characteristics of a novel twin-auger reactor to transform WT by intermediate pyrolysis into tire pyrolysis oil (TPO), recovery carbon black (rCB), and tire pyrolysis gas (TPG). The influence of four operating parameters: reactor temperature (X1), WT mass flow rate (X2), solid residence time (X3) and N2 volumetric flow rate (X4), was assessed in order to maximize the TPO yield (Y1), while keeping the rCB one (Y2) as low as possible. The experimental campaign was conducted based on central composite design (CCD). The analysis of variance (ANOVA) showed that X1 and X2 exhibit the highest statistical influence. An optimization of both responses resulted in TPO, rCB, and TPG yields of 45, 40 and 15 wt%, respectively, when the pyrolyzer is operated at 475 °C, 1.16 kg/h, 3.5 min and 300 mL/min. At these conditions, the resulting TPO showed contents of C, H, S, N and O around 88.2, 9.7, 1.3, 0.7 and <0.1 wt%, respectively, along with a heating value of 42.02 MJ/kg. The rCB is comprised of moisture, volatile matter, fixed carbon, and ash around 2.5, 3.7, 75.5, and 18.3 wt%, respectively; while the TPG was mainly composed of H2 (23.7 vol%) and CH4 (28.2 vol%). Overall, these results suggest that twin-auger pyrolyzers are well suited for valorizing WT by intermediate pyrolysis.

Differences in circulating γδ T cells in patients with primary colon cancer and relation with prognostic factors.

Downregulation of the T cell system has been proposed as a mechanism to block immunity in colonic cancer (CC). However, little has been studied about circulating αß and γδ T cells and their immunological status in newly diagnosed patients. The aim of this study was to characterize the αß and γδ T cell subsets in peripheral blood of patients with CC matched with healthy volunteers. In this prospective case-control study, blood samples were obtained from 96 patients with newly diagnosed treatment-naïve infiltrating colonic adenocarcinoma and 48 healthy volunteers. Pathological report at surgery was obtained from all CC patients. A significant decrease in CD3+ γδ T cells and CD3+CD8+ γδ T cells (p<0.001) were observed in CC patients. Apoptosis was significantly increased in all conventional and both αß and γδ T cell subsets in patients with CC vs healthy subjects. γδ T cells were decreased in peripheral blood of patients with microscopic infiltration in tissues, history of cancer and synchronous colon cancer (p < 0.05). IFN-γ was significantly reduced in CC patients compared to controls. Cytotoxic effector γδ T cells TEMRA (CD8 and CD56) are the proportionally most abundant T cells in peripheral blood of CC patients. Patients with CC present a deep downregulation in the systemic T-cell immunity. These variations are evident through all tumor stages and suggest that a deficiency in γδ T cell populations could be preventing control of tumor progression. This fact prove the role of immunomodulation on CC carcinogenesis.

Carbon black recovery from waste tire pyrolysis by demineralization: Production and application in rubber compounding.

Pyrolysis offers the possibility to convert waste tires into liquid and gaseous fractions as well as a carbon-rich solid (CBp), which contains the original carbon black (CB) and the inorganic compounds used in tire manufacture. Whilst both liquid and gaseous fractions can be valorized without further processing, there is a general consensus that CBp needs to be improved before it can be considered a commercial product, seriously penalizing the pyrolysis process profitability. In this work, the CBp produced in a continuous pyrolysis process was demineralized (chemical leaching) with the aim of recovering the CB trapped into the CBp and thus, producing a standardized CB product for commercial purposes. The demineralization process was conducted by using cheap and common reagents (HCl and NaOH). In this sense, the acid treatment removed most of the mineral matter contained in the CBp and concentration was the main parameter controlling the demineralization process. An ash content of 4.9 wt% was obtained by using 60 min of soaking time, 60 °C of temperature, 10 mL/g of reagent/CBp ratio and HCl 4 M. The demineralized CBp (dCBp) showed a carbon content of 92.9 wt%, while the FRX analysis indicated that SiO2 is the major component into the ash. The BET surface area was 76.3 m2/g, and textural characterizations (SEM/EDX and TEM) revealed that dCBp is composed by primary particles lower than 100 nm. Although dCBp showed a low structure, the surface chemistry was rich in surface acidic groups. Finally, dCBp was used in Styrene Butadiene Rubber (SBR) compounding, probing its technical feasibility as substitute of commercial CB N550.

Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study. / Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico.

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.