A morphometric analysis of pathological alterations in hemorrhoidal disease versus normal controls: a controlled trial

Objective: Until today, the true pathophysiology of hemorrhoidal disease (HD) has not yet been unraveled. More and more evidence guides us towards the hypothesis that reduced connective tissue stability is associated with a higher incidence of hemorrhoids. The present study aimed to compare the quantity and quality of collagen, and vessel morphometrics, in patients with symptomatic HD compared with normal controls. Methods: Twenty-two samples of grade III and grade IV HD tissue from patients undergoing a hemorrhoidectomy between January 2004 and June 2015 were included in the study group. Samples of 15 individuals without symptomatic HD who donated their body to science and died a natural death served as controls. The quantity and quality of anal collagen, and anal vessel morphometrics were objectified. The quality of collagen was subdivided in young (immature) and old (mature) collagen. Results: Patients with HD had an increased percentage of total anal collagen (62.1 ± 13.8 versus 18.7 ± 14.5%; p = 0.0001), a decreased percentage of young collagen (0.00009 ± 0.00008 versus 0.0008 ± 0.0008%; p = 0.001), and a smaller surface area of the anal vessels (795.1 ± 1215.9 micrometre2 versus 1219.0 ± 1976.1; p = 0.003) compared with controls. The percentage of old collagen did not differ between the control and study groups (0.588 ± 0.286% versus 0.389 ± 0.242%; p = 0.06). Conclusion: The outcomes of the present study suggest that alterations in anal collagen composition may play a role in the formation of hemorrhoids. (AU)

Haemorrhoidal haemodynamic changes in patients with haemorrhoids treated using Doppler-guided dearterialization.

BACKGROUND: Arterial hyperflow to haemorrhoids has been implicated as a possible pathophysiological co-factor in haemorrhoidal disease. The purpose of this study was to investigate how transanal haemorrhoidal dearterialization (THD) can influence haemodynamic parameters at the level of the haemorrhoidal piles. METHODS: Patients with grade III haemorrhoids selected for THD between July and December 2018 were evaluated using endoanal ultrasonography and colour Doppler imaging at the level of internal haemorrhoids before and 1 year after the surgical procedure. Peak systolic velocity, pulsatility index, resistivity index, acceleration time, and end-diastolic velocity were measured, and preoperative and postoperative values compared. Symptom severity was measured using a symptom-based questionnaire (score range 0-20). RESULTS: Of 21 patients treated, 17 completed the study. Compared with preoperative values, postoperative peak systolic velocity (mean(s.d.) 18.7(1.1) versus 10.3(0.4) cm/s; P < 0.05), pulsatility index (5.5(0.3) versus 2.8(0.4); P < 0.050), and resistivity index (1.0(0.2) versus 0.8(0.5); P < 0.050) decreased significantly, whereas acceleration time increased significantly (65.6(3.6) versus 83.3(4.7) cm/s2; P < 0.050); end-diastolic velocity did not change (1.9(0.2) versus 2.0(0.4); P = 0.753). Symptoms disappeared or had improved significantly in all patients by 1 year after surgery. The mean(s.d.) total symptom severity score decreased from 15.8(1.1) to 1.2(1.6) (P < 0.001). CONCLUSION: THD affects the main haemodynamic parameters at the level of internal haemorrhoids and is associated with a decrease in arterial hyperflow.

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.

Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far?

Haemorrhoids are abnormally enlarged anal cushions within the lower rectum. They are common, and have potential to significantly impact patients' quality of life. Superior rectal artery embolisation is a technique which has been discussed in the literature as far back as 40 years ago. More recently, there has been interest in the role of embolisation in the treatment for haemorrhoids, as an alternative to established minimally invasive and conventional surgical techniques. In this review, we discuss the current literature on the topic, with particular focus on technique, clinical outcomes and complications. Emerging procedural and technical considerations are discussed, with further review of the role of coil vs. particle embolisation.

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.

Laparoscopic fluorescence navigation for left-sided colon and rectal cancer: Blood flow evaluation, vessel and ureteral navigation, clip marking and trans-anal tube insertion.

BACKGROUND: Recently, the indocyanine green (ICG) fluorescence navigation method has attracted much attention as a means of intraoperative navigation, especially during laparoscopic surgery. The newly developed near-infrared (NIR) fluorescent resin also emits NIR fluorescence, as does ICG. Presently, new devices made with this resin are being developed. The purpose of this study was to present our fluorescence navigation techniques for left-sided colon and rectal cancer. METHOD: Fifty-nine patients with left-sided colon and rectal cancer underwent laparoscopic surgery with fluorescence navigation between July 2019 and April 2020. The surgeries included 54 intestinal blood flow (IBF) evaluations using ICG, 16 preoperative fluorescence clip marking (FCM) procedures, 7 fluorescence ureteral navigation procedures, 4 fluorescence vessel navigation (FVN) procedures during lateral lymph node dissection, and 3 fluorescence-guided trans-anal tube insertion procedures. Laparoscopic surgery and fluorescence observation were performed using a VISERA ELITE 2. In FCM, the Zeoclip FS device was used. In ureteral navigation and trans-anal tube insertion, the Near-Infrared Ray Catheter (NIRC™) fluorescent ureteral catheter (NIRFUC) was used. RESULTS: No complications related to the fluorescence navigation techniques, including those involving ICG, the Zeoclip FS and the NIRFUC, occurred. In 5 cases, the surgical plan was changed according to the IBF evaluation with ICG, and no anastomotic leakage occurred in those cases. These fluorescence navigation techniques provide previously unavailable visual information regarding the IBF, vessel and ureter routes and accurate endoscopic clip and drainage tube locations in the intestinal tract. CONCLUSIONS: Technology to visualize blood flow dynamics and structures using fluorescence can be considered innovative, especially when applied in laparoscopic surgery, which relies on vision. The popularity of fluorescence navigation has also appeared to increase the safety of colorectal surgery. CLINICAL TRIAL REGISTRATION: Examination of fluorescence navigation for laparoscopic colorectal cancer surgery. Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY.

BACKGROUND: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. AIM: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. METHOD: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). RESULTS: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. CONCLUSION: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

From nutrition to medicine: Assessing hemorrhoid healing activity of Solanum melongena L. via in vivo experimental models and its major chemicals.

ETHNOPHARMACOLOGICAL RELEVANCE: Solanum melongena L. (eggplant) is used for treatment of rheumatism, beriberi, itching, toothache, bleeding, asthma, bronchitis, cholera, neuralgia and hemorrhoids in traditional medicine (Turkish, Chinese, and Indian). Hemorrhoids from these diseases, are common illness in all over the world, which are treated with various approaches including ethnobotanicals. AIM OF THE STUDY: This study aimed to evaluate the anti-hemorrhoidal activity of eggplant, an edible plant, which is commonly utilized around the world. MATERIALS & METHODS: In vivo anti-hemorrhoidal activity of the methanolic extract prepared from eggplant was evaluated by experimental hemorrhoid model, subsequently histological and biochemical analysis. Hemorrhoid, which was induced by applying croton oil to the anal area of the rats. Furthermore, the extract was screened for anti-inflammatory activity which is based on the inhibition of acetic acid-induced increase in capillary permeability. The healing potential was comparatively assessed with a reference Pilex® tablet and cream. Phytochemical analysis performed by HPLC. The amount of the major phenolic compound (chlorogenic acid) in extract was found by using HPLC method. RESULTS: Histological and biochemical analysis demonstrated that eggplant extract is highly effective against hemorrhoid in comparison to the controls and the commercial preparation. In addition, the methanolic extract demonstrated significant inhibitory effect on acetic acid-induced increase in capillary permeability. The phytochemical studies identified major compound as chlorogenic acid (2.86%) by liquid chromatography. CONCLUSION: The eggplant calyxes, not edible, are easy to reach, by products/vast from the food sources. This is the first scientific evidence revealing that the eggplant extract has significant anti-hemorrhoidal and anti-inflammatory activity.

[Surgical key points of precision functional sphincter-preserving surgery].

The principle of sphincter-preserving surgery is to preserve the anal sphincter function under the premise of radical resection. Due to low position of rectal tumor, conventional laparoscopic surgery has difficulties in operating in the deep and narrow pelvis, which may lead to inaccurate tissue dissociation, imprecise positioning of tumor edge, excessive stretch of the anal sphincter complex, and excessive removal of distal rectal mucosa. Moreover, pain from abdominal auxiliary incision has an unavoidable side effect for postoperative recovery. With the help of the Liu's transanal microsurgery system, precision functional sphincter-preserving surgery (PPS) can be successfully performed. PPS tries to preserve left colonic artery and pelvic autonomic nerve in the transabdominal operation. In the part of transanal surgery, measurement, localization and resection of the lower edge of the tumor are conducted under a clear and open visual field with the transparent screw anal dilator. After the rectum is cut off, the specimen is taken out through the anus to avoid abdominal incision. Inserting the intestinal supporter to support the bowel stump, full thickness of bowel stump is then sutured with anal canal by vertical mattress suture. Special transanal tube is placed afterwards without routine prophylactic stoma. PPS can achieve precise tumor resection and sphincter preservation simultaneously.

[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.

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.

Transanal haemorrhoidal dearterialization with mucopexy (thd-m) for treatment of hemorrhoids: is it applicable in all grades? brazilian multicenter study / A técnica de desarterialização hemorroidária transanal associada à mucopexia (thd-m) é aplicável em todos os graus? estudo multicêntrico brasileiro

ABSTRACT Background: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. Aim: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. Method: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). Results: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. Conclusion: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

RESUMO Racional: A desarterialização hemorroidária transanal associada à mucopexia (THD-M) tem sido indicada como alternativa à hemorroidectomia convencional para o tratamento da doença hemorroidária nos seus variados graus. No entanto, ainda hoje existe controvérsia com relação a sua eficácia para os graus mais avançados. Objetivo: Avaliar a eficácia da técnica THD-M para tratamento doença hemorroidária e comparar os resultados imediatos e tardios nos diferentes graus. Método: Entre julho de 2010 e setembro de 2015, 705 pacientes consecutivos com hemorroidas sintomáticas de graus II, III e IV foram submetidos ao tratamento cirúrgico pelo método THD-M e acompanhados por um período médio de 21 meses (12-48). As operações foram realizadas por seis cirurgiões com experiência em cirurgia colorretal, em três estados brasileiros. Resultados: Complicações intraoperatórias foram observadas em 1,1% dos casos, incluindo quatro casos de hematoma, dois de laceração da mucosa e dois de sangramento. Todos foram controlados com sutura hemostática. As complicações pós-operatórias mais comuns foram: tenesmo transitório (21,4%); dor (7,2%); prolapso mucoso ou hemorroidário (6,4%); plicoma residual (5,6%); impactação fecal (3,2%); trombose hemorroidária (2,8%); sangramento (2,1%); fissura anal (0,7%) e abscesso anal (0,3%). Não houve casos de complicações severas ou mortalidade perioperatória. A recorrência do prolapso e sangramento foi maior na doença hemorroidária grau IV do que nos graus III e II (26.54% e 7.96% vs. 2.31% e 0.92% vs. 2.5% e 1.25%; p<0,001), respectivamente. Conclusão: O método THD-M é seguro e efetivo no tratamento da doença hemorroidária nos graus II e III com baixo índice de complicações. No entanto, para a doença hemorroidária de grau IV essa técnica está relacionada com maior índice de recorrência e complicações tardias, não devendo ser considerada opção eficiente neste estágio de doença.

Angiosarcoma de margen anal asociado a prolapso rectal completo / Angiosarcoma of the anal margin associated with complete rectal prolapse

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Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications.

BACKGROUND: Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. METHODS: All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. RESULTS: A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). CONCLUSIONS: The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

Stapled Hemorrhoidectomy Versus Transanal Hemorrhoidal Dearterialization in the Treatment of Hemorrhoids: An Updated Meta-Analysis.

This meta-analysis aimed to compare the clinical outcomes of stapled hemorrhoidectomy (SH) and transanal hemorrhoidal dearterialization (THD) for treating hemorrhoidal disease. Randomized control trials (RCTs) comparing SH with THD were searched in databases, including MEDLINE, PubMed, Web of Science, EMBASE, and the Cochrane Library database. Nine RCTs, with 1077 patients, were included in this meta-analysis. Nine RCTs, with 1077 patients, were included in this meta-analysis. The bleeding rate in the SH patient group was higher than that in the THD group. No significant difference was detected between SH and THD in terms of operating time, postoperative pain, hospital time, and return-to-work time. The total recurrence rate was higher in the THD group than in the SH group. In conclusion, SH and THD are effective for treating hemorrhoids. SH produces better outcomes in terms of a relatively lower recurrence rate. Future studies with long follow-up periods are needed to confirm these results.