Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Ferguson Hemorrhoidectomy for Prolapsed Internal Hemorrhoids: A Multicenter Prospective Study.

OBJECTIVE: To compare transanal hemorrhoidal dearterialization (THD) with mucopexy to Ferguson hemorrhoidectomy in terms of recurrence rates and quality of life. BACKGROUND: There is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared with Ferguson hemorrhoidectomy in terms of recurrence rates. METHODS: This was a multicenter prospective study. Participating surgeons performed the operation they knew best enrolling 10 patients each. Surgeons' unedited videos were reviewed by an independent expert. Patients with prolapsed internal hemorrhoids in at least 3 columns were eligible. The primary endpoint was recurrence rates defined as prolapsing internal hemorrhoids. Patient-reported outcomes and satisfaction were evaluated with Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, Short-Form 12 scores, and Patient satisfaction (4-point Likert) scale. RESULTS: Twenty surgeons enrolled 197 patients. THD patients had lower Visual pain scores at postoperative day (POD) 1 (6.2 vs 8.3, P =0.047), POD7 (4.5 vs 7.7, P =0.021), POD14 (2.8 vs 5.3, P <0.001), and medication use at POD14 (23% vs 58%, P <0.001). Median follow-up was 3.1 (1.0-5.5) years. Recurrence rates did not differ between the study arms (5.9% vs 2.4%, P =0.253). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, P =0.031) and 3 months (95.1% vs 63.3%, P =0.029), but did not differ at 6 months (91.7% vs 88%, P =0.228) and 1 year (94.2% vs 88%, P =0.836). CONCLUSION: THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared with Ferguson hemorrhoidectomy with nonsignificantly different recurrence rates.

Perfecting the venerable SSC.

Stainless steel crowns (SSCs) are the preferred restoration of pediatric dentists for children requiring a pediatric dental rehabilitation due to their low cost and durability. Despite low technique sensitivity SSC placement can be challenging in some clinical situations including when placed on primary canines. Primary canines restored with SSCs often result in premature contacts and posterior open bite making acquiring an "as the patient presented" (ATPP) occlusion difficult when providing a pediatric dental rehabilitation. Opening of the posterior occlusion due to premature canine contact in a dental rehabilitation is often viewed as unavoidable. This technique article describes a simple method to address this clinical situation and reviews basic principles and techniques for placing SSCs.

Molecular-based Alternatives for Colorectal Cancer Screening during the COVID-19 Pandemic.

Due to the COVID-19 pandemic, important elective procedures, such as screening colonoscopy, have been delayed or cancelled, and there may be a very long waitlist for rescheduling once the moratorium is lifted. However, DNA-based stool sample tests may be useful for colorectal cancer screening when colonoscopy is not available. The aim of this review is to demonstrate the potential utility of enhanced DNA-based stool testing for colorectal cancer screening and diagnosis during crises that strain available healthcare resources, such as the current COVID-19 pandemic. This review shows that DNA-based stool sample tests have the potential to enable colorectal cancer screening to prioritize patients to elective colonoscopy procedures, the continued delay of which during the COVID-19 pandemic has already placed a burden on future elective procedures.

A Multicenter Prospective Non-Randomized Study Comparing Ferguson Hemorrhoidectomy and Transanal Hemorrhoidal Dearterialization for Prolapsed, Nonincarcerated, Reducible Hemorrhoids: A Study Protocol.

INTRODUCTION: Current evidence suggests that transanal hemorrhoidal dearterialization (THD) is associated with less postoperative pain and faster recovery than Ferguson hemorrhoidectomy. However, there is some uncertainty regarding the durability of the therapeutic effect in terms of recurrent disease. Objective and significance: The aim of this study will be to evaluate the outcome of THD compared to Ferguson hemorrhoidectomy in terms of recurrence rate at 1-year follow-up. METHODS: This is a multicenter, parallel-arm, non-randomized prospective study comparing Ferguson hemorrhoidectomy and THD in terms of recurrence rate at one year. The primary endpoint is recurrence rate at one year defined as prolapsing internal hemorrhoids at physical examination. Secondary endpoints include the following postoperative complications: urinary retention, constipation (requiring laxative or emergency room visit), dysuria, pruritis ani, anal pain, anal stenosis, unhealed wound, fissure, fecal urgency, and flatus or stool incontinence. Adults older than 18 years with prolapsed, non-incarcerated, reducible hemorrhoids in at least 3 columns at physical examination will be included in one of the study arms: Ferguson hemorrhoidectomy and THD. Surgeons with proven expertise in hemorrhoids surgery will enroll patients undergoing Ferguson hemorrhoidectomy and THD (not both). Each participating surgeon will enroll a maximum of 10 patients. Ethics and Dissemination: This study was approved by the Institutional Review Boards of Stony Brook University (previously) and New York Medical College (currently), and registered in ClinicalTrials.gov (NCT03245086). The findings of the study will be published in a peer-reviewed journal.

Emergency Colorectal Surgery in a COVID-19 Pandemic Epicenter.

Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a considerable risk during emergency colorectal surgery in a pandemic epicenter. It is well known that the primary route of SARS-CoV-2 transmission is through respiratory droplets. However, little is known about shedding of the virus in bodily fluids and associated risks. Although the current moratorium on elective surgery addresses multiple ongoing concerns, including the management of precious resources as well as unknown exposure risks, surgeons undeniably must face and mitigate risks related to exposure to patient airway management-related aerosols, bodily fluids, surgical smoke, contaminated insufflation, and specimen handling in emergency colorectal surgery. Given the significant concern of airborne transmission, the authors recommend conventional, in lieu of laparoscopic, access in emergency colorectal surgery in a COVID-19 pandemic epicenter.

THD Doppler: A Reliable Surgical Procedure to Treat Hemorrhoids.

The search for alternatives to excisional surgery for internal hemorrhoids has been motivated by a desire to reduce postoperative pain and its associated disability as well as chronic sequelae. Among several non-excisional procedures, Doppler-guided transanal hemorrhoidal dearterialization (THD Doppler) has emerged as an alternative that offers minimal postoperative pain. However, there is some skepticism regarding the ligation of hemorrhoidal arteries, the usefulness of Doppler guidance, and the recurrence rates after THD Doppler. The aim of this narrative review is to compare THD to both non-excisional alternatives, such as rubber band ligation and stapled hemorrhoidopexy, and excisional alternatives, such as Ferguson hemorrhoidectomy. The authors seek to give readers concise insight into the evidence available in the English literature. This report does not offer a quantitative synthesis of the data, but rather highlights the role of THD Doppler in the treatment of internal hemorrhoids.

Tying and Tearing in Robotic and Laparoscopic Intracorporeally Hand-Sewn Ileocolic Anastomoses. A Propensity Score-Matched Prospective Study.

AIM: The aim of this study was to evaluate the impact of the ergonomics of laparoscopy as well as the lack of tactile feedback in robotic surgery on intracorporeal suturing. METHODS: This was a prospective cohort study that compared the first 12 consecutive robotic hand-sewn ileocolic anastomoses to matched laparoscopic cases performed by the same surgeon. The endpoints were interrupted suturing and tying time, and the numbers of interrupted sutures placed and torn. Propensity score matching was based on age, body mass index, previous abdominal surgery, and diagnosis. Ileocolic anastomoses were hand-sewn in two layers: running 3-0 polyglycolic acid and interrupted 3-0 silk. Continuous variables were compared using the Student t test, whereas a Chi-square test was used to compare categorical variables. Linear regression and a cumulative sum analysis (CUSUM) were used for quality control. RESULTS: Median time for robotic suturing and tying was significantly shorter than that in matched laparoscopic cases (89.5 sec (IQR 76-103.5) vs. 160 sec (IQR 146-210), p<0.0001). There were fewer torn sutures in laparoscopic suturing (1 (IQR 1-2.5) vs. 0 (IQR 0-0.5), p<0.0026). No differences were found in complication rates (6 vs. 2 p=0.19). CUSUM analysis did not show a significant improvement in the number of torn sutures over time. CONCLUSION: Although there were more torn sutures with robotic suturing and tying, significantly less time was required than for laparoscopic intracorporeal suturing. This study suggests that torn sutures may be the result of a lack of tactile feedback rather than the presence of a learning curve.

Repair of Parastomal Hernia with Component Separation at Reversal of Loop Ileostomy. A technical note.

AIM: The aim of this technical note is to describe a surgical technique to repair parastomal hernias with component separation and mesh at reversal of loop ileostomy. BACKGROUND: Stage III rectal cancer patients who have completed neoadjuvant chemoradiation will undergo low anterior resection with loop ileostomy. Following completion of adjuvant chemotherapy, the ileostomy will be reversed after an average of five to six months. A minority of patients presenting with an obstructed rectal cancer may undergo laparoscopic loop ileostomy prior to commencing neoadjuvant chemoradiation, resulting in a longer ileostomy time. TECHNIQUE: Loop ileostomy reversal consists of five steps: mobilization of the stoma, side-to-side anastomosis, component separation, placement of biologic mesh, and purse-string skin closure. CONCLUSION: The surgical technique described here, consisting of component separation and mesh at loop ileostomy reversal, is effective for repairing parastomal hernia.

Evaluation of the Educational Environment of a Cadaver Course in Robotic Colorectal Surgery: A Cross-sectional Study.

BACKGROUND: The educational environment is a crucial metric of medical education that affects the course participants' motivation, achievement, happiness and success. The aim of this study was to evaluate the educational environment of a cadaver course in robotic colorectal surgery by comparing the perceptions of the participating residents to those of the participating surgeons. METHODS: This was a cross-sectional study carried out in 2017. Participants from the U.S. and Europe attended a course using eight fresh frozen cadaver torsos with no prior abdominal surgery. After course completion, participants anonymously completed 50-item Dundee Ready Educational Environment Measure (DREEM) questionnaires to evaluate five components of the educational environment: perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception. Internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient. Mean scores were compared using an independent samples t-test. RESULTS: Twenty of 24 participants completed the DREEM questionnaire, consisting of 9 residents and 11 surgeons (12 from the U.S., 8 from Europe). The internal consistency of the questionnaire was excellent (alpha=0.97). The mean total score was excellent for both residents and surgeons, and the difference between the groups was not significant (154.1±25.8 vs. 168.1±18.9, p=0.197). Perception of learning was significantly better among surgeons ("teaching highly thought of") than among residents ("a more positive perception") (40.5±3.6 vs. 35.7±5.6, p=0.04). CONCLUSIONS: This study suggests that the residents' perception of learning may have been negatively influenced by the participation of surgeons in the same cadaver station.

Diet rich in saturated fat decreases the ratio of thromboxane/prostacyclin in healthy men.

OBJECTIVE: To investigate the effect of dietary saturated fat (SFA) from animal sources on the urine excretion 11-dehydro thromboxane B2 (TXB2) and 6-keto prostaglandin F 1alpha (PGF 1alpha) in 27 healthy free-living male subjects aged 30 to 55 years. METHODS: It was a randomized crossover design. Each volunteer was randomly assigned to one of the two diets (high fat and low fat) for a period of 4 weeks, after which each subject resumed his usual diet for 2 weeks as a 'wash-out period', before being assigned to the other diet for an additional 4 weeks. RESULTS: Serum proportion of 20:4n-6 was 5% lower in the high fat (6.2% of total fatty acid) than in the low fat diet (6.5% of total fatty acid), which was associated with a significantly decreased ratio of the urinary excretion 11-dehydro TXB2 to 6-keto PGF 1alpha (P < 0.05). However, there was no significant fall in the absolute urinary excretion of 11-dehydro TXB2. CONCLUSIONS: Diet rich in SFA from animal sources may influence TXA2 formation via effect on tissue proportion of 20:4n-6.

Fertility and pregnancy outcomes following resectoscopic septum division with and without intrauterine balloon stenting: a randomized pilot study.

BACKGROUND AND OBJECTIVES: Although uterine stenting is performed routinely following hysteroscopic metroplasty, we were unable to find any evidence documenting its value with regards to septum reformation and/or obstetrical performance. To evaluate the benefits of intrauterine Foley catheter/balloon splinting after resectoscopic septum division on septum reformation, fertility, and pregnancy outcomes. DESIGN AND SETTING: Prospective, randomized controlled pilot study (Canadian Task Force Classification I) conducted in university affiliated teaching hospital. PATIENTS AND METHODS: Twenty-eight women with infertility and/or adverse pregnancy outcomes diagnosed with intrauterine septum were randomized into having a No. 14 pediatric Foley catheter/balloon for 5 days (n=13) vs. no balloon (n=15) following resectoscopic septum division. None of the patients received preoperative endometrial thinning, antibiotic prophylaxis or adjuvant postoperative hormone therapy. All uterine septa were divided under general anaesthesia using a 26 F (9 mm) resectoscope with a monopolar electrical knife using glycine irrigant solution (1.5%) and 120 watts of power of low voltage (cut) waveform. RESULTS: The median age (range) was 29 years (23-38) and 32 years (22-40), respectively (P=.59). The groups were comparable by age, past obstetrical performance and comorbidities including endometriosis stage I-IV in 3 and 4 women, in the catheter/balloon and balloon group, respectively, and one in each group of polycystic ovarian syndrome and Crohn disease and one case of tubal obstruction in the balloon group. There were no intra- or postoperative complications. At 3 months, a hysterosalpingogram was done in 10 (77%) and 13 (87%) women, respectively, the results of which were normal. At 12-18 months, 1 woman in the balloon and 3 in the control group were not trying to conceive and 1 in each group had not conceived. Of the remaining women, 11 (92%) in each group had conceived and pregnancy outcomes included spontaneous abortion 3 (25%) and 4 (33.3%), ectopic pregnancy 0 and 1, second trimester loss 1 (8.3%) and 0 and term pregnancy 8 (66.6%) in both groups. Conception through assisted reproductive technology occurred in 2 and 1 woman, respectively. CONCLUSIONS: Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes.