Common pathogenesis for sirenomelia, OEIS complex, limb-body wall defect, and other malformations of caudal structures.

Decades of clinical, pathological, and epidemiological study and the recent application of advanced microarray and gene sequencing technologies have led to an understanding of the causes and pathogenesis of most recognized patterns of malformation. Still, there remain a number of patterns of malformation whose pathogenesis has not been established. Six such patterns of malformation are sirenomelia, VACTERL association, OEIS complex, limb-body wall defect (LBWD), urorectal septum malformation (URSM) sequence, and MURCS association, all of which predominantly affect caudal structures. On the basis of the overlap of the component malformations, the co-occurrence in individual fetuses, and the findings on fetal examination, a common pathogenesis is proposed for these patterns of malformation. The presence of a single artery in the umbilical cord provides a visible clue to the pathogenesis of all cases of sirenomelia and 30%-50% of cases of VACTERL association, OEIS complex, URSM sequence, and LBWD. The single artery is formed by a coalescence of arteries that supply the yolk sac, arises from the descending aorta high in the abdominal cavity, and redirects blood flow from the developing caudal structures of the embryo to the placenta. This phenomenon during embryogenesis is termed vitelline vascular steal.

A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD).

BACKGROUND: Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. METHODS: Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. RESULTS: Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. CONCLUSIONS: These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

Anal fissure management by the gastroenterologist.

PURPOSE OF REVIEW: Anal fissures are very common. They are easy to diagnose and treat in the office setting. They may coexist with hemorrhoids. In fact 20% of patients with hemorrhoids have anal fissures also. The purpose of this review is to highlight current diagnosis and treatment of anal fissures using diet, ointments and botulinum toxin to enable healing. Medical treatment relies on reducing anal sphincter spasm to allow improved blood flow and healing. RECENT FINDINGS: Many anorectal disorders can be managed in the office. Most anal fissures can be managed without the need for surgery. The need for anorectal examination, including use of anoscopy is stressed in the current literature. The use of calcium channel blockers in preference to nitroglycerin is highlighted as well as the use of botulinum toxin when ointments don't work. SUMMARY: Anal fissure can be managed nonsurgically most of the time and gastroenterologists should be able to manage them. This article should help in preventing unnecessary surgery and its complications, mainly incontinence in a small but significant number. The search for more effective drugs and options for managing this disorder continues.

[Choice of optimal treatment strategy for acute perianal thrombosis. Results of online survey]. / Vybor metoda lecheniia ostrogo perianal'nogo tromboza. Rezul'taty oprosa vrachei.

OBJECTIVE: To study the factors influencing the physicians' choice of treatment strategy in patients with acute perianal thrombosis. MATERIAL AND METHODS: A survey was conducted among 124 Russian colorectal surgeons. RESULTS: This survey showed that the choice of treatment strategy varies between private and state clinics. Conservative approach is preferred in government clinics (p=0.024). The time factor is more important for professionals. Hemorrhoidectomy is preferred in private clinicians, thrombectomy - in public clinics. The majority of physicians note that pregnancy significantly affects choice of treatment tactics. The most important factors to refuse surgery are pregnancy (r=0.796), age over 70 years (r=0.655), duration of thrombosis over 4 days (r=0.791). Large thrombosed node (2-3 cm), severe pain syndrome (r=0.858) and duration of disease less than 3 days (r=0.901) determine preferable surgical approach. CONCLUSION: The choice of treatment of acute perianal thrombosis depends on not only duration of disease, severity of pain syndrome, age and pregnancy, but also on the type of the hospital. Conservative treatment is preferable in the majority of national state hospitals. Moreover, most surgeons prefer less aggressive treatment options in the state clinics. Further research is needed to determine any important factors limiting more effective surgical treatment besides pain and patient's attitude toward the disease.

Management of rectal bleeding due to internal haemorrhoids with arterial embolisation: a single-centre experience and protocol.

AIM: To evaluate the safety and efficacy of arterial embolisation for rectal bleeding due to internal haemorrhoids. MATERIALS AND METHODS: Twenty-three patients received arterial embolisation for rectal bleeding due to internal haemorrhoids. Clinical records, technical success, and complications were analysed retrospectively. RESULTS: Good short-term outcomes were achieved with no ischaemia or pain. Regarding symptom resolution, such as irritation, discomfort, and bloody discharge, satisfaction was observed in 6/6 (100%) patients with grade II haemorrhoids and 14/17 (82.35%) patients with grade III haemorrhoids. In the study, nine of the 10 patients (10/23, 43.48%) whose superior rectal artery (SRA) had a connection with the inferior rectal artery (IRA), either unilaterally or bilaterally, had embolisation of the IRA performed. Re-bleeding was observed in two (2/23, 8.7%) patients, including one whose connection between the right SRA and right IRA was not previously noted. A reduction in the size of the haemorrhoid was observed by rectoscopy 1 month later (mean 1.91 cm versus 1.25 cm; p<0.05). The contractility of the internal and external sphincters was normal in all cases. CONCLUSION: Coil embolisation of the haemorrhoid arteries for rectal bleeding is technically feasible, safe, and well tolerated. It is proposed that embolisation of the SRA and IRA is necessary in cases where connections between the arteries are noted.

Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography.

BACKGROUND: The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC). METHODS: This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates. RESULTS: Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%. CONCLUSIONS: FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.

[The first experience of har-rar and radiofrequency ablation for hemorrhoidal disease treatment in hospitalization replacement environment]. / Pervyi opyt sochetannogo primeneniia dezarterizatsii i radiochastotnoi ablatsii gemorroidal'nykh uzlov pri III-IV stadii gemorroia v statsionarozameshchaiushchikh usloviiakh.

AIM: To analyze advisability of HAL-RAR combined with radiofrequency ablation for hemorrhoidal disease under stationary substitution conditions. MATERIAL AND METHODS: There were 152 patients. Technical features of this procedure are presented. RESULTS: RFA was not followed by prolonged hospital-stay, advanced pain syndrome. Moreover, favorable outcomes were obtained including patients with hemorrhoidal disease stage 3 and 4. CONCLUSION: HAL-RAR combined with radiofrequency ablation may be recommended for treatment of hemorrhoidal disease in stationary substitution conditions.

[Proctology for internists]. / Proktologie für Internisten.

In proctology patients can often be helped with very little effort. With knowledge of the most common disease symptoms the treating physician can in many cases correctly recognize the cause of the complaints and initiate the appropriate therapy or arrange referral to a proctological institution. This article aims to briefly and succinctly present the most common diseases in proctology (e.g. mariscae, hemorrhoids, anal fissures, perianal venous thrombosis, abscesses and fistulas, condyloma acuminatum and anal carcinoma) and to provide the treating internist, even outside of gastroenterology, assistance with the management of proctological symptoms.

Transanal hemorrhoidal dearterialization with mucopexy versus open hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials.

BACKGROUND: The aim of this study was to analyse the outcomes of transanal hemorrhoidal dearterialization with mucopexy (THDm) versus open hemorrhoidectomy (OH) in the management of hemorrhoids. METHODS: Randomized controlled trials in English were found by searching PubMed, Web of science, EMBASE, and the Cochrane Library database. Trials that compared THDm with OH were identified. Data were extracted independently for each study, and a meta-analysis was performed using fixed and random effects models. RESULTS: Four trials, including 316 patients, met the inclusion criteria. No statistically significant differences were noted in either total complications or postoperative bleeding, incontinence, recurrent prolapse, and urinary retention rate. Operative time was significantly longer for THDm with Doppler guidance than for THDm without Doppler guidance. Patients returned to normal activities faster after THDm than after OH. No statistically significant differences between THDm and OH were noted with regard to recurrence and reoperation rates. CONCLUSIONS: Our meta-analysis shows that THDm and OH are equally effective and can be attempted for the management of hemorrhoids. However, for THDm with Doppler guidance, more instruments and a longer operative time are required. Future large-scale, high-quality, multicenter trials with long-term outcomes are needed to prove these results and determine whether Doppler guidance in THD is truly necessary or not.

Doppler-guided hemorrhoidal artery ligation with hemorrhoidopexy: source and prevention of postoperative pain.

BACKGROUND: Transanal hemorrhoidal dearterialization, although it showed reliability, has not completely removed the issue of postoperative pain. OBJECTIVE: We investigated the causes of postoperative pain and proposed some changes of the technique in order to eliminate it. PATIENTS: One hundred six out of 188 operated patients were considered. Postoperative pain was investigated using a Visual Analogue Score dividing patients into three groups: 0 to 3, 4 to 6, and 7 to 10. On the basis of these results, we proposed some variations of the technique. A second group of 25 patients was therefore treated with the modified technique. Statistical analysis was conducted using the Fisher's exact test, two-tailed. MAIN OUTCOME: Pain intensity, surgical approach, and changes in the technique were analyzed, and a new proposal for a modified technique has been developed. RESULTS: The group of 106 patients, 64 males and 42 females, were divided: 71 III grade and 35 IV grade. Pain was detected in 37 cases (35%).Fifteen males (23.50%) were divided as follows: 8 mild and 7 medium or intense. Twenty-two females (52.38%) were divided as follows: 11 mild and 11 with medium or intense. For what concerns the variable grade, the pain was present in 15 III G and 22 IV G with statistic significant difference (p value 0.00333). Among the 18 patients (7 males and 11 females) who had severe pain, they all had a number of mucopexies >4, while among 19 patients (8 males and 11 females) with mild pain, only 5 had a number of mucopexies >4, resulting in a statistic significant difference (p value 0.031). In the second group, pain was drastically reduced. LIMITATIONS: We believe it is necessary to extend the sample in order to definitively adopt the proposed amendments. CONCLUSIONS: The review of the causes of postoperative pain and the changes adopted compared with those proposed in literature have allowed us to greatly reduce postoperative pain.

Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial.

AIM: This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome. METHOD: Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni- and multivariate analyses of the potential predictive factors for failure were performed. RESULTS: The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 ± 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively. Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome. CONCLUSION: THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.

Comparison of the early results of transanal hemorrhoidal dearterialization and hemorrhoidectomy using an ultrasonic scalpel.

PURPOSE: Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery) is a new approach for treating hemorrhoids. The early results of the procedure are presented and compared with those of hemorrhoidectomy using an ultrasonic scalpel (US surgery). METHODS: Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial. RESULTS: The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation. The number of analgesic tablets consumed during the first postoperative week in the THD patients was significantly lower than that in the US patients. The blood loss was significantly greater in the THD patients. The hospital stay and length of time until the first defecation after surgery were both significantly shorter in the THD patients. The postoperative complications were comparable between the two groups of patients. CONCLUSION: The THD surgery was as effective as the US surgery for the treatment of hemorrhoids in the short term. THD surgery might be a preferred treatment because it is associated with a similar complication rate and short-term results, but results in lower postoperative pain and analgesic requirements compared with the US surgery.

Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center.

BACKGROUND: Rectoanal repair (RAR), which combines doppler-guided hemorrhoidal artery ligation (HAL) and mucopexy via lifting of the hemorrhoidal prolapse, offers a minimally invasive alternative to conventional hemorrhoidectomy. METHODS: Patients with grade II hemorrhoids were treated with HAL, and patients with grade III and IV hemorrhoids were treated with the RAR procedure by two surgeons. Postoperative follow-up was performed clinically and by proctoscopy after 8 weeks routinely, and long-term follow-up was performed using a standardized postal questionnaire. RESULTS: The overall complication rate was 29% (n = 118). After short-term follow-up, 26% (n = 106) of patients reported recurrent or persistent prolapsing piles, while 21% (n = 86) of patients had recurrent bleeding. After long-term follow-up, 24% (n = 98) of patients reported prolapsing piles, 3% (n = 12) bleeding, 3% (n = 12) pruritus, and 2% (n = 8) anal pain, while 20% (n = 82) complained of persistent mixed symptoms. CONCLUSIONS: HAL and RAR provide prolonged relief for patients with hemorrhoidal disease whose main symptoms are bleeding, pruritus and pain but not for patients with prolapse as an initial indication.

Evaluation of transanal hemorrhoidal dearterialization: a single surgeon experience.

BACKGROUND: There is an increasing, though still limited, amount of evidence describing the use of the transanal hemorrhoidal dearterialization (THD) device for the treatment of hemorrhoidal disease. This study assesses postoperative outcomes from a single surgeon experience with the THD device. METHODS: From January 2009 to December 2011, 108 THD procedures were performed. With Doppler guidance, the THD device makes possible precise ligation of the branches of the superior hemorrhoidal artery. Patients were seen postoperatively at 3 weeks and 6 months. They underwent physical examination to determine whether there was recurrence of hemorrhoidal prolapse. They were asked to describe any bleeding, to rate pain using the visual analog scale, and to rate their level of satisfaction on a scale of 1-5 (with 5 = highly satisfied). A phone interview was used for follow-up at 1 year to determine the rate of recurrent prolapse. RESULTS: Of the 108 patients who underwent THD, two were lost to follow-up and excluded. All of the remaining 106 patients completed follow-up at 3 weeks and 6 months. At 3 weeks, 92% of patients had no pain and 88% were highly satisfied with the procedure at 3 weeks. This increased to 92% satisfaction at 1 year. Prolapse recurrence was 7.5% at 6 months and 10.3% at 1 year. Bleeding was the most common complication, but did not require re-intervention or transfusion. CONCLUSIONS: THD is a same-day procedure for the treatment of hemorrhoidal disease that is safe and effective, and offers the potential for immediate return to normal activity.

Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids.

AIM: Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids. METHOD: The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique. RESULTS: From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms. CONCLUSION: Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids.

THD Doppler procedure for hemorrhoids: the surgical technique.

Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease. The ligation of hemorrhoidal arteries (called "dearterialization") can provide a significant reduction of the arterial overflow to the hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called "mucopexy") can provide a repositioning of prolapsing tissue to the anatomical site. In this paper, the surgical technique and perioperative patient management are illustrated. Following adequate clinical assessment, patients undergo THD under general or spinal anesthesia, in either the lithotomy or the prone position. In all patients, distal Doppler-guided dearterialization is performed, providing the selective ligation of hemorrhoidal arteries identified by Doppler. In patients with hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a continuous suture including the redundant and prolapsing mucosa and submucosa. The description of the surgical procedure is complemented by an accompanying video (see supplementary material). In long-term follow-up, there is resolution of symptoms in the vast majority of patients. The most common complication is transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal bleeding occurs in a very limited number of patients. Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure. When accurately performed and for the correct indications, THD is a safe procedure and one of the most effective treatments for hemorrhoidal disease.

Transanal eco-Doppler evaluation after hemorrhoidal artery embolization.

BACKGROUND: Hemorrhoidal artery embolization (Emborrhoid) is a novel method for the treatment of severe hemorrhoidal bleeding. Despite having a technical success rate of 93%-100%, the clinical success ranges between 63% and 94%, with a rebleeding rate of 13.6%. AIM: To evaluate the effectiveness of this procedure in reducing hemorrhoidal flow and hemorrhoidal bleeding. METHODS: This prospective observational pilot study was conducted at Division of General Surgery 1 and Tertiary Referral Pelvic Floor Center, Treviso Regional Hospital, Italy. In a 2 months period (February-March 2022), consecutive patients with hemorrhoidal bleeding scores (HBSs) ≥ 4, Goligher scores of II or III, failure of non-operative management, and a candidate for Emborrhoid were included. Endoanal ultrasound with eco-Doppler was performed preoperatively and 1 month after the procedure. The primary endpoint was to quantify the changes in arterial hemorrhoidal flow after treatment. The secondary endpoint was to evaluate the correlation between the flow changes and the HBS. RESULTS: Eleven patients underwent Emborrhoid. The overall pretreatment mean systolic peak (MSP) was 14.66 cm/s. The highest MSP values were found in the anterior left lateral (17.82 cm/s at 1 o'clock and 15.88 cm/s at 3 o'clock) and in the posterior right lateral (14.62 cm/s at 7 o'clock and 16.71 cm/s at 9 o'clock) quadrants of the anal canal. After treatment, the overall MSP values were significantly reduced (P = 0.008) although the correlation between MSP and HBS changes was weak (P = 0.570). A statistical difference was found between distal embolization compared with proximal embolization (P = 0.047). However, the coil landing zone was not related to symptoms improvement (P = 1.000). A significant difference in MSP changes was also reported between patients with type 1 and type 2 superior rectal artery (SRA) anatomy (P = 0.040). No relationship between hemorrhoidal grades (P = 1.000), SRA anatomy (P = 1.000) and treatment outcomes was found. CONCLUSION: The preliminary findings of this pilot study confirm that Emborrhoid was effective in reducing the arterial hemorrhoidal flow in hemorrhoidal disease. However, the correlation between the post-operative MSP and HBS changes was weak. Hemorrhoidal grade, SRA anatomy and type of embolization were not related to treatment outcomes.