Assessing the suitability of video-assisted anal fistula treatment for obese patients compared to conventional surgery: a question worth investigating.

BACKGROUND AND AIMS: Video-assisted anal fistula treatment (VAAFT) is an innovative surgical approach enabling the direct visualization of the fistula tract structure. This study aims to assess the efficacy of VAAFT in comparison with that of traditional surgical methods and explore potential risk factors contributing to fistula recurrence to provide new recommendations for surgical selection. MATERIALS AND METHODS: Information was collected from 100 patients with complex anal fistula (CAF) in our hospital who underwent surgical treatment from January 2021 to January 2023. We compared the baseline information and surgical outcomes of two groups, analyzed the risk factors for fistula recurrence by using logistic regression analysis, and conducted further exploration by using the body mass index. RESULTS: Equal numbers of patients underwent VAAFT and traditional surgeries, and no significant differences in baseline information were observed. Patients who received VAAFT experienced less intraoperative bleeding (15.5 (14.0-20.0) vs. 32.0 (25.0-36.0)), shorter hospital stays (2.0 (2.0-2.5) vs. 3.0 (3.0-3.5)), reduced postoperative pain and wound discharge, but longer operative times (43.3 ± 6.9 vs. 35.0 (31.5-40.0)) compared with patients who underwent traditional surgeries. No significant differences in recurrence rates were found three and six months after operation (the p-values were 0.790 and 0.806, respectively). However, the Wexner scores of the VAAFT group were significantly low in the first follow-up (0 (0-1.0) vs. 2.0 (1.0-2.0)). Postoperative recurrence of fistulas may be associated with obesity (p-value = 0.040), especially in patients undergoing traditional surgeries (p-value = 0.036). CONCLUSION: VAAFT offers advantages, such as less pain, less trauma, and faster recovery, compared with traditional surgical treatment. Obese patients with CAF are prone to recurrence, and we recommend that they undergo VAAFT treatment rather than traditional surgeries.

4D transperineal ultrasound: feedback for good obstetric anal sphincter injuries reparation.

BACKGROUND: Obstetric anal injury is the main risk factor for traumatic anal, faecal and flatus, incontinence in women in reproductive age. Its recognition and good reparation are crucial for long term outcomes. CASE REPORT: We report a case of a nulliparous woman who reported a fourth-degree perineal tear after delivery. The obstetric anal sphincter injury was repaired and a four-dimensional transperineal ultrasound was performed after reparation and then one and three months after discharge. The woman did not experience any incontinence and no points of discontinuity were observed at tomographic ultrasound imaging reconstruction. In this case, 4D-TPUS was a tool in the obstetrician's hands to evaluate the surgical success of OASIS repair, which requires some expertise. CONCLUSIONS: 4D-TPUS ultrasound is useful and reliable during immediate puerperium and in the subsequent follow-up, giving positive feedback on the correct positioning of the stiches and on a good healing process. Further studies are needed to demonstrate this usefulness in the operators training and for improving their surgical skills.

Chemoradiotherapy versus radiotherapy alone in the management of early-stage anal squamous cell carcinoma: A comparative analysis of the French cohort FFCD-ANABASE.

INTRODUCTION: Early-stage anal squamous cell carcinomas (ASCC) are usually treated with chemoradiotherapy (CRT), with good outcomes. Radiotherapy (RT) alone might be sufficient while reducing toxicity. METHODS: Patients included in the French prospective FFCD-ANABASE and treated for T1-2N0 ASCC between 2015/01 and 2020/04 were divided into CRT and RT groups. Clinical outcomes and toxicity were reported. Propensity score matching was conducted for 105 pairs of patients. RESULTS: 440 patients were analyzed: 261 (59.3 %) in the CRT group and 179 (40.7 %) in the RT group. The median follow-up was 35.7 months. Patients receiving CRT were younger, had better Performance Status (PS) and larger tumors. No statistical difference was observed for 3-year Disease-free survival (85.3 % vs 83 %, p = 0.28), Overall survival (89.6 % vs 94.8 %, p = 0.69) and Colostomy-free survival (84.5 % vs 87.2 %, p = 0.84) between CRT and RT groups, respectively. Propensity score-matched analysis confirmed these findings. Treatment interruptions were significantly more frequent in the CRT group (36.3 % vs 21.9 %, p = 0.0013), resulting in an Overall Treatment Time (OTT) extended by 7 days. Grade 3 CTCAE v4.0 toxicities were more prevalent in the CRT group (46 % vs 19 %, p < 0.001). CONCLUSION: Adding chemotherapy to radiotherapy did not significantly improve outcomes for T1-2N0 ASCC in our study, but increased toxicity and OTT.

Efficacy of injection of autologous adipose tissue in the treatment of patients with complex and recurrent fistula-in-ano of cryptoglandular origin.

BACKGROUND: Adipose tissue injections, a rich source of mesenchymal stem cells, have been successfully used to promote anal fistula healing. This study aimed to investigate the efficacy of adipose tissue injection in treating patients with complex and recurrent fistulas of cryptoglandular origin. METHODS: We conducted a prospective, single-center, open-label, non-randomized, interventional clinical trial from January 2020 to December 2022. We enrolled nine patients, who were evaluated after at least 12 months of follow-up. All patients had seton removal, fistula tract excision or curettage, and a mucosal flap if possible or, alternatively, an internal opening suture. We used a commercially available system to collect and process adipose tissue prior to injection. This system allowed the collection, microfragmentation, and filtration of tissue. RESULTS: Selected cases included six men and three women with a median age of 42 (range 31-55) years. All patients had an extended disease course period, ranging from 3 to 13 (mean 6.6) years, and a history of multiple previous surgeries, including two to eight interventions (a mean of 4.4 per case). All fistulas were high transsphincteric, four cases horseshoe and two cases with secondary suprasphincteric or peri-elevator tract fistulas. Six cases (66%) achieved complete fistula healing at a mean follow-up of 18 (range 12-36) months. Three cases (33.3%) experienced reduced secretion and decreased anal discomfort. CONCLUSIONS: In patients with complex and recurrent fistulas, such as the ones described, many from palliative treatments with setons, the adjuvant injection of adipose tissue might help achieve complete healing or improvement in a significant percentage of cases. CLINICALTRIALS: The study protocol was prospectively registered on ClinicalTrials.gov (NCT04750499).

Case report: Spinal cord stimulation for pain relief in two patients with locally recurrent pelvic malignancy.

Introduction: Chronic cancer-related pain from locally recurrent infiltrative cancers within the bony confines of the pelvis is a devastating and hard to manage condition that can be refractory to many conventional pain management methods. Spinal cord stimulation (SCS) is an evolving and safe method of pain management and can be trialled in a quick and well-tolerated operation under local anaesthesia. To date, this has not been reported in the setting of locally recurrent inoperable pelvic cancers. Case description: In the present study, we report two cases of patients with severe back and lower limb pain resulting from recurrent anal and rectal cancers involving the right lumbar and sacral nerve roots as well as the bony sacrum, which severely affected quality of life and daily functioning. Discussion: Following successful SCS, effective pain relief was observed. Conclusion: SCS could represent an effective supplementary or alternative technique to conventional pain management in this challenging group of patients, especially if other available methods have been exhausted.

Feasibility of weekly cisplatin and radiotherapy for localized anal cancer - A Danish anal cancer group report.

BACKGROUND: Chemoradiotherapy (CRT) with flourouracil and mitomycin is the standard treatment for squamous cell carcinoma of the anus (SCCA), however the associated acute toxicity often hinders compliance. Although weekly cisplatin is a well-established treatment for other squamous cell carcinomas, it has not been explored in SCCA. PURPOSE: To investigate if radiotherapy (RT) with weekly cisplatin is a feasible option for SCCA and to report the acute toxicity. MATERIAL/METHODS: Patients were treated with RT and weekly cisplatin 40 mg/m2 between 1998-2020. Retrospective data from medical records (n = 65) and prospectively collected data from an observational study (n = 51) comprising physicianassessed toxicity (NCI-CTCAE 4.0), patient-reported outcomes (EORTC-QlQC30 + CR29) baseline, mid-therapy, end of treatment and 2-4 weeks post-treatment were included. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: We included 116 patients. T-stages were T1:4 %, T2: 71 %, T3: 17 %, T4: 8 % and 47 % has N + disease. RT doses were 53.75-64 Gy/45-51.2 Gy and the mean cumulative dose of cisplatin was 307.5 mg. The median overall treatment time was 43 days. Within 6 months after CRT 88.9 % had complete response. The median follow-up time was 4.5 years and 5-year DFS and OS were 77 % (95 %CI 68.7-84.5 %) and 86.4 % (95 %CI 78.3-91.7 %), respectively. Hospitalization occured in 20 % with 2.6 % being admitted due to febrile neutropenia. Hematological toxicty was low with 13.7 % grade 3 and 3.9 % grade 4. Anal pain, skin, gastrointestinal and urogenital toxicity were mild. CONCLUSION: RT and weekly cisplatin for SCCA showed good outcome results and an acceptable acute toxicity profile.

Anal Fissure and Its Treatments: A Historical Review.

Anal fissure is one of the most common proctological pathologies. It consists of the formation of a longitudinal tear in the anoderm, causing pain and bleeding during and after defecation. When chronic, it can significantly negatively impact the quality of life of the affected patient. Currently, multiple therapeutic options are available, both medical and surgical. The objective of this article is to highlight the historical evolution in the physiopathological understanding and treatment of this disease, underlining the key moments in this history. This is the first article to summarize the milestones in the treatment of anal fissure from ancient to current times.

Ileal Paneth Cell Phenotype is a Cellular Biomarker for Pouch Complications in Ulcerative Colitis.

BACKGROUND & AIMS: Biomarkers that integrate genetic and environmental factors and predict outcome in complex immune diseases such as inflammatory bowel disease (IBD; including Crohn's disease [CD] and ulcerative colitis [UC]) are needed. We showed that morphologic patterns of ileal Paneth cells (Paneth cell phenotype [PCP]; a surrogate for PC function) is one such cellular biomarker for CD. Given the shared features between CD and UC, we hypothesized that PCP is also associated with molecular/genetic features and outcome in UC. Because PC density is highest in the ileum, we further hypothesized that PCP predicts outcome in UC subjects who underwent total colectomy and ileal pouch-anal anastomosis (IPAA). METHODS: Uninflamed ileal resection margins from UC subjects with colectomy and IPAA were used for PCP and transcriptomic analyses. PCP was defined using defensin 5 immunofluorescence. Genotyping was performed using Immunochip. UC transcriptomic and genotype associations of PCP were incorporated with data from CD subjects to identify common IBD-related pathways and genes that regulate PCP. RESULTS: The prevalence of abnormal ileal PCP was 27%, comparable to that seen in CD. Combined analysis of UC and CD subjects showed that abnormal PCP was associated with transcriptomic pathways of secretory granule maturation and polymorphisms in innate immunity genes. Abnormal ileal PCP at the time of colectomy was also associated with pouch complications including de novo CD in the pouch and time to first episode of pouchitis. CONCLUSIONS: Ileal PCP is biologically and clinically relevant in UC and can be used as a biomarker in IBD.

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

Background: A mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle. Methods: Workshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement. Results: One hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (- 0.01 to 0.36) with a SEM of ± 12.2°. Conclusions: Knowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

A comparative study of acupuncture combined with rehabilitation gymnastics on postoperative anal function of lower rectal cancer.

BACKGROUND: From the anal function, inflammatory response and other indicators, acupuncture combined with rehabilitation gymnastics was applied to patients with cancer undergoing low resection, aiming to improve the prognosis of patients. AIM: To explore the effects of acupuncture combined with rehabilitation gymnastics on anal function after lower rectal cancer surgery. METHODS: From January 2020 to December 2022, 128 patients who underwent rectal cancer surgery in the Department of Oncology of Hebei Provincial Hospital of Traditional Chinese Medicine Hospital were selected and divided into two groups using the random number table method, with 64 patients in each group. Patients in the control group were not treated with acupuncture or rehabilitation gymnastics and served as blank controls. Patients in the study group were treated with acupuncture and rehabilitation gymnastics from the 7th postoperative day. The anal incontinence scores, changes in serum interleukin-4, interleukin-6, and interleukin-10 Levels, and serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels were compared. RESULTS: There were no significant differences in serum interleukin-4, interleukin-6, and interleukin-10 Levels between the groups before treatment (P > 0.05). After treatment, these levels were better than those of the control group (P < 0.05). There was no significant difference in the anal incontinence scores between the groups before and 7 d after surgery (P > 0.05). Anal incontinence scores in the study group were lower than those in the control group at 14 d, 21 d, and 28 d postoperatively (P < 0.05). There were no significant differences in serum motilin, 5-hydroxytryptamine, or vasoactive intestinal peptide levels between the groups before treatment (P > 0.05). After treatment, these levels were higher in the study group than in the control group, and vasoactive intestinal peptide level was lower in the study group than in the control group (P < 0.05). CONCLUSION: Acupuncture combined with rehabilitation gymnastics can promote the recovery of anal function and reduce the inflammatory response in patients with lower rectal cancer after surgery.

Evaluating the clinical application and effect of acupuncture therapy in anal function rehabilitation after low-tension rectal cancer surgery.

BACKGROUND: According to the indexes of serum and anal function, acupuncture therapy was applied to patients with low rectal cancer in order to avoid the occurrence of anal incontinence and reduce complications. AIM: To explore the clinical application and evaluate the effect of acupuncture therapy for anal function rehabilitation after low-tension rectal cancer surgery. METHODS: From the anorectal surgery cases, we selected 120 patients who underwent colorectal cancer surgery between January 2020 and December 2022 and randomly divided them into a control group (n = 60), observation group (n = 60), and control group after surgery for lifestyle intervention (including smoking cessation and exercise), dietary factor adjustment, anal movement, and oral loperamide treatment. The serum levels of motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide (VIP), Wexner score for anal incontinence, and incidence of complications were compared between groups. RESULTS: After treatment, the VIP and 5-hydroxytryptamine levels in the observation group were lower than those in the control group (P < 0.05). The motilin level was higher than that in the control group (P < 0.05). Postoperative anal incontinence was better in the observation group than in the control group (P < 0.05). The incidence of complications in the observation group was 6.67%, which was significantly lower than that in the control group (21.67%; P < 0.05). CONCLUSION: Acupuncture therapy has a positive effect on the rehabilitation of anal function after low-tension rectal cancer surgery; it can effectively help to improve the serum indices of patients, avoid the occurrence of anal incontinence, and reduce the incidence of complications. Popularizing and applying it will be valuable.

Endoscopic Balloon Dilatation of Ileal Pouch-Anal Anastomosis Strictures in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for medically refractory inflammatory bowel disease (IBD). In this systematic review and meta-analysis, we assess outcomes and safety of endoscopic balloon dilatation (EBD) for IPAA strictures. METHODS: A systematic search of numerous databases was performed through June 2023 to identify studies reporting on the outcomes of EBD in pouch-related strictures. Outcomes included technical success, clinical success at index dilation and in pouch retention, recurrence of symptoms post-EBD, and adverse events of EBD. Meta-analysis was performed using a random-effects model, and results were expressed in terms of pooled rates along with relevant 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran Q statistical test with I2 statistics. RESULTS: Seven studies with 504 patients were included. The pooled rate of technical success and clinical success of index dilatation was 98.9% (95% CI, 94.8-99.8%; I20%) and 30.2% (95% CI, 7.1-71%; I20%), respectively. The pooled rate of clinical success in pouch retention without the need for additional surgery was 81.4% (95% CI, 69.6-89.3%; I272%). The pooled failure rate of EBD was 18.6% (95% CI, 10.7-30.4%, I272%). The pooled rate of recurrence of symptoms after index dilatation was 58.9% (95% CI, 33.3-80.5%; I213%). The pooled rate of serious adverse events was 1.8% (95% CI, 1-3.5%, I20%). No deaths related to EBD were reported. CONCLUSIONS: Endoscopic balloon dilatation is safe and highly effective for management of IPAA strictures. Additional studies are needed to compare its efficacy with surgical interventions.

In this meta-analysis of 7 studies consisting of 504 inflammatory bowel disease patients with ileal pouch-anal anastomosis strictures, endoscopic balloon dilation was highly safe and effective with excellent clinical and technical success rates.

Skeletal Muscle Complex Between the Vagina and Anal Canal: Implications for Perineal Laceration.

INTRODUCTION AND HYPOTHESIS: The anatomy of the skeletal muscles located between the vagina and anus is important during complex obstetric laceration reconstructions. We aimed to clarify the composition of skeletal muscles located between the vagina and anal canal and their three-dimensional configuration relevant to perineum repair. METHODS: This observational study involved ten female cadavers. An anatomical dissection was performed to observe the muscles around the vagina and anal canal. Immunohistological analysis of the midsagittal section was performed to clarify the composition of the muscles, and dissection was performed to correspond to the cross-section. Wide-range serial sectioning and three-dimensional reconstruction were used to support these findings histologically and visualize the three-dimensional arrangement. RESULTS: The region between the vagina and anal canal included the anterior part of the external anal sphincter, superficial transverse perineal muscle approaching from the lateral side, and levator ani, located cranially. They converge three-dimensionally in the median from each direction, forming a muscle complex between the vagina and anal canal. CONCLUSIONS: The medial region between the vagina and anal canal in those giving birth includes a skeletal muscle complex formed by the confluence of the external anal sphincter, anterior bundle of the levator ani, and superficial transverse perineal muscle. In cases of severe perineal lacerations, these muscles could be injured. The anatomical knowledge that a part of the levator ani forms a muscle sling anterior to the anal canal is particularly important for obstetricians and gynecologists repairing obstetric lacerations and treating pelvic floor disorders.

To Improve Motivational Barriers to Retention in High Resolution Anoscopy, Patients and Providers Recommend Social and Environmental Changes: A Sequential Explanatory Mixed-Methods Pilot Study in a Federally Qualified Health Center.

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure's potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

RESUMEN: La pérdida de seguimiento (LTFU) en los programas de anoscopia de alta resolución (HRA) pone en peligro el potencial del procedimiento para ayudar a prevenir el cáncer anal. Exploramos factores de mejora de la calidad para comprender cómo abordar este LTFU. Utilizando el modelo COM-B transteórico (Capacidad, Oportunidad, Motivación y Comportamiento) y un diseño de métodos mixtos explicativos secuenciales, encuestamos y entrevistamos a 13 pacientes que permanecieron involucrados en la atención del VIH pero que retrasaron sus visitas de seguimiento o tratamiento de la HRA en la misma clínica comunitaria y 6 médicos y asistentes médicos de la HRA. Los análisis involucraron estadísticas descriptivas y análisis cualitativo rápido. Los pacientes eran representativos de la población LTFU en cuanto a raza, etnia, y estatus económico. En general, tenían experiencia con HRA (visitas HRA media = 4,6, DE = 2,8, mdn = 3). Los proveedores eran médicos y asistentes médicos con experiencia (promedio de años proporcionando HRA = 6,0, DE = 2,2). Los análisis revelaron dos barreras principales relacionadas: (A) barreras motivacionales como el dolor físico, la incomodidad, la vergüenza y la ansiedad; que se debieron en gran medida a (B) barreras de oportunidad, como dificultades con la programación, cuidados posteriores inconsistentes (particularmente para el dolor y el malestar), salas de examen y equipos que inducen ansiedad, y estigma internalizado y anticipado. Las barreras a la capacidad, como la limitada alfabetización sanitaria sobre la HRA, fueron menos comunes y, al igual que las barreras motivacionales, estaban vinculadas a las barreras de oportunidades. Los participantes recomendaron posibles facilitadores, incluida una programación más sencilla, la estandarización del manejo del dolor y los servicios de cuidados posteriores, y modificaciones en la sala de examen para reducir la ansiedad. Para retener a los pacientes de HRA en entornos comunitarios, las intervenciones deben abordar las barreras de oportunidades sociales y físicas que determinan fuertemente las barreras motivacionales y de capacidad. Mejorar la conveniencia, estandarizar el manejo del dolor e introducir intervenciones de estigma específicas para la HRA podría aliviar las barreras tanto motivacionales como de capacidad.

Definitive chemoradiotherapy for a patient with anal cancer after renal transplantation.

Patients after renal transplantation are susceptible to secondary malignancies, including anal squamous cell carcinoma. Chemoradiotherapy is the standard treatment for anal squamous cell carcinoma; however, typical irradiation fields for anal cancer encompass a transplanted kidney located in the right iliac fossa, which causes complete renal dysfunction. Thus, typical irradiation fields are not feasible for this population. Additionally, standard concurrent chemotherapy demonstrates nephrotoxicity. Here, we report a case of modified definitive chemoradiotherapy for a 40-year-old patient with locally advanced perianal squamous cell carcinoma after renal transplantation whose abdominoperineal resection was difficult because of a history of repeated open surgeries and long-term steroids. We modified the cranial side of the elective nodal irradiation fields in this case to spare the transplanted kidney, considering the lymph chains of the perianal tumor. We then used continuous 5-fluorouracil to avoid nephrotoxicity of mitomycin C, considering his life expectancy. Modified definitive chemoradiotherapy achieved complete remission with expected toxicities. Now, approximately five years after the procedure, the patient remains disease-free, preserving anal and renal function. Definitive chemoradiotherapy using modified irradiation fields and chemotherapy may be an option for patients with anal squamous cell carcinoma after renal transplantation.

Middle Rectal Artery Pseudoaneurysm: A Case of Massive Lower Gastrointestinal Bleeding Managed With Coil Embolization.

Pseudoaneurysms of the middle rectal artery are rare. When encountered, these have the potential for significant morbidity and mortality due to bleeding and potential rupture. Endovascular embolization is a feasible option in the management of these pseudoaneurysms. The present report describes a case of a 43-year-old male presenting with hemorrhagic shock secondary to lower gastrointestinal bleeding one day after undergoing excision of an external perineal condyloma, incision and drainage of a perirectal abscess, and biopsy of a perianal mass. Angiographic imaging revealed a right middle rectal artery pseudoaneurysm. Selective embolization of the right middle rectal artery and bilateral superior rectal arteries was successfully performed. At the two-week post-embolization follow-up, hemoglobin was stable, and the patient reported normal bowel movements with no episodes of bleeding per rectum.

Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis.

BACKGROUND: Approximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime. OBJECTIVE: To evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI. SEARCH STRATEGY: MEDLINE/PubMed, Embase 1974-2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442). SELECTION CRITERIA: All studies reporting outcomes after OASI and a subsequent birth, by any mode. DATA COLLECTION AND ANALYSIS: Eighty-six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta-analyse the primary outcome of 'adjusted AI' after OASI and subsequent birth. Subgroups: short-term AI, long-term AI, AI in asymptomatic women. SECONDARY OUTCOMES: total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre- to post- subsequent birth. MAIN RESULTS: There was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72-1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65-1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre- to post- subsequent birth (OR = 0.79 95% CI 0.51-1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31). CONCLUSIONS: Due to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision-making for asymptomatic women and to determine the effect of subsequent birth mode on long-term AI outcomes.

The use of postoperative calibrations in Hirschsprung disease: a practice to reconsider?

PURPOSE: Daily postoperative anal dilations after endorectal pull-through for Hirschsprung disease (HD) are still considered a common practice. We analyzed the potential risks of this procedure and its effectiveness compared to a new internal protocol. METHODS: All infants (< 6 months of age) who underwent transanal endorectal pull-through between January 2021 and January 2023 were prospectively enrolled in a new postoperative protocol group without daily anal dilations (Group A) and compared (1:2 fashion) to those previously treated by postoperative anal dilations (Group B). Patients were matched for age and affected colonic tract. Patients with associated syndromes, extended total intestinal aganglionosis, and presence of enterostomy were excluded. Outcomes considered were: anastomotic complications (stenosis, disruption/leakage), incidence of enterocolitis, and constipation. RESULTS: Eleven patients were included in group A and compared to 22 matched patients (group B). There were no significant differences in the occurrence of anastomotic complications between the two groups. We found a lower incidence of enterocolitis and constipation among group A (p = 0.03 and p = 0.02, respectively). CONCLUSION: A non-dilation strategy after endorectal pull-through could be a feasible alternative and does not significantly increase the risk of postoperative anastomotic complications. Moreover, some preliminary advantages such as lower enterocolitis rate and constipation should be further investigated.

Comparing the long-term follow-up anal function between robot-assisted and laparoscopic surgery for low rectal cancer: A meta-analysis and systematic review.

BACKGROUND: Robotic-assisted surgery (RAS) is increasingly used for treating low rectal cancer. Its comparative effectiveness against laparoscopic surgery (LAS) in enhancing long-term anal function remains uncertain. METHODS: A meta-analysis was conducted to compare long-term anal function outcomes between patients undergoing RAS and LAS. Meta-regression and sensitivity analyses were performed to assess available evidence. Studies published up to September 2023 in English or Chinese were included. RESULTS: Seven studies were identified. RAS patients exhibited lower low anterior resection syndrome (LARS) scores (standardised mean difference [SMD] = -1.39; 95% confidence interval [CI]: -2.64 to -0.15) and Wexner scores (SMD = -0.74; 95% CI: -1.20 to -0.27) compared with LAS patients. However, RAS did not significantly reduce major LARS risk (odds ratio = 0.85; 95% CI: 0.68-1.04). CONCLUSIONS: RAS slightly improved postoperative anal function compared with LAS. Further studies with large samples are warranted to confirm or update our findings.