Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient?

BACKGROUND: Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation. METHODS: During a 53-month period (February 2009-July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery. RESULTS: During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455-3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study's 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049). CONCLUSIONS: These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.

Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients.

AIM: Minimally invasive approaches to proctectomy for rectal cancer have not been widely adopted due to inherent technical challenges. A modification of traditional transabdominal mobilization, termed transanal total mesorectal excision (TaTME), has the potential to improve access to the distal rectum. The aim of the current study is to assess outcomes following TaTME for rectal cancer. METHOD: This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent TaTME for rectal cancer at a single institution. The study period was from 1 March 2012 to 31 July 2015. RESULTS: During the study period 50 patients underwent TaTME. The median tumour distance from the anal verge was 4.4 (3.0-5.5) cm. The rate of conversion from a planned minimally invasive approach was 2.2%. The median operative time was 267.0 (227.0-331.0) min. The median lymph node yield was 18.0 (12.0-23.8), the macroscopic quality assessment of the resected specimen was incomplete in 2% and the circumferential resection margin positivity rate was 4%. Intra-operative morbidity occurred in 6% and the 30 day morbidity rate was 36%. The median length of stay was 4.5 (4.0-8.0) days. The median follow-up was 15.1 (7.0-23.2) months; two patients have developed a local recurrence and eight patients have developed distant recurrence. CONCLUSION: These data suggest that TaTME for rectal cancer is feasible with an acceptable pathological outcome and morbidity profile. Further data on functional and long-term survival outcomes are required.

COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™).

AIM: Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis. METHOD: The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained. RESULTS: Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses. CONCLUSION: Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.

Robotic TransAnal Minimally Invasive Surgery in a cadaveric model.

The technique of TransAnal Minimally Invasive Surgery (TAMIS) was pioneered in 2009 as a hybrid approach to endoluminal resections of appropriately selected rectal lesions. There are, however, limitations to performing this type of resection. Robotic TAMIS is a novel, experimental technique and in this study was performed in a cadaveric model at a surgical education center. Various tasks were carried out using robotic TAMIS, including full-thickness sharp and cautery excision of rectal wall, as well as intra-luminal suturing of the surgical defect. It was found that for the da Vinci-trained surgeon, these tasks were simple to perform and accomplished with greater precision when compared to standard TAMIS. Our initial results indicate that robotic TAMIS overcomes the limitations of standard TAMIS and that it is a feasible platform for transanal surgery. The cost, however, of performing robotic TAMIS may limit its application to special cases in which standard TAMIS or transanal endoscopic microsurgery resections may prove difficult. Further study is necessary to validate these preliminary findings before robotic TAMIS is performed on live patients.

Murine epidermal label-retaining cells isolated by flow cytometry do not express the stem cell markers CD34, Sca-1, or Flk-1.

Keratinocyte stem cells are present in the murine epidermis, based on both in vitro and in vivo evidence, and better characterization of these cells remains an active goal. Because keratinocyte stem cells are believed to cycle slowly, a good method for identification is based on their ability to retain nucleoside analog, such as bromodeoxyuridine. Adult stem cells have been identified in other tissues, including hematopoietic, neural, and skeletal muscle, and stem cell surface markers have been characterized. We wanted to determine if cell-surface markers present on both hematopoietic and skeletal muscle stem cells (CD34, Sca-1, and Flk-1) were also present on keratinocyte stem cells, and could be used to identify them. The cell-surface expression of cells that retained bromodeoxyuridine label for at least 21 d was compared with that of nonlabel-retaining cells. Double-labeling for flow cytometric analysis was employed, and label-retaining cells were found to lack expression of the tested markers. Beta1 integrin levels were also evaluated, and although high expression was found on label-retaining cells, it was not specific for these cells.

Concomitant positive reactions to allergens in a patch testing standard series from 1988-1997.

BACKGROUND: Patch testing is a useful diagnostic technique in patients with suspected allergic contact dermatitis (ACD). Concomitant reactions may reflect associations between tested allergens. OBJECTIVE: This study was performed to identify positive correlations between reactions to test substances in a standard screening series. The results of patch testing in patients seen from 1988 to 1997 are described. METHODS: Data were collected from chart review for patients who underwent patch testing to the full standard screening series at the Massachusetts General Hospital Contact Dermatitis Clinic. The Fisher exact test was used to evaluate associations between allergens. RESULTS: A total of 927 patients were patch tested to 22 allergens included in a screening tray. The mean age was 43.9 years, and 68.6% were women. Two or more positive reactions occurred in 36.5% of patients. Reactions to 13 pairs of allergens were found to be significantly correlated: balsam of Peru/fragrance mix, carba mix/thiuram mix, carba mix/paraben mix, cobalt chloride/potassium dichromate, cobalt chloride/nickel sulfate, ethylenediamine/neomycin sulfate, formaldehyde/imidazolidinyl urea, formaldehyde/paraben mix, formaldehyde/quaternium-15, imidazolidinyl urea/quaternium-15, neomycin sulfate/potassium dichromate, paraben mix/quaternium-15, and potassium dichromate/thimerosal. CONCLUSION: Concomitant reactions to 13 pairs of allergens in a standard series occurred at a rate greater than would be predicted by chance. Such associations may reflect cross-sensitization or cosensitization.

Lichen planus localized to the nails.

BACKGROUND: Lichen planus may rarely be localized to the nails. OBJECTIVE: A case of ungual lichen planus is reported that was misdiagnosed as onychomycosis. METHODS: A 52-year-old woman had progressive nail dystrophy for 13 months that was unresponsive to oral terbinafine. A nail biopsy was performed. RESULTS: Histopathologic findings were consistent with lichen planus. CONCLUSION: Onychomycosis may be confused clinically with other causes of nail dystrophy. It is important to confirm the diagnosis of onychomycosis with appropriate laboratory or histologic analysis.

Patch testing reactions to a standard series in 608 patients tested from 1990 to 1997 at Massachusetts General Hospital.

BACKGROUND: Patch testing is a useful diagnostic tool when allergic contact dermatitis is suspected clinically. OBJECTIVE: This study describes the results of patch testing performed from January 1, 1990 to June 1, 1997 at the Massachusetts General Hospital Contact Dermatitis Clinic. The findings are compared with those previously reported by the North American Contact Dermatitis Group (NACDG). METHODS: Data were collected from chart review and analyzed. Patients included in the study underwent patch testing to the full European standard series of allergens. A standardized patch testing technique was used, and readings were performed by a single observer. RESULTS: A total of 608 patients were patch tested to a screening tray of 24 allergens; 69.9% were women. At least one positive patch test reaction was observed in 60.0% of patients. The most common sensitizers were nickel sulfate, fragrance mix, potassium dichromate, cobalt chloride, balsam of Peru, quaternium-15, and neomycin sulfate. The sensitization rate to potassium dichromate (9.4%) was higher than has been reported by the NACDG. A statistically significant difference in the sensitization rate in men and women was observed for nickel, quinoline mix, epoxy resin, and formaldehyde. The prevalence of positive patch test reactions was not found to be influenced by testing during the summer months. CONCLUSIONS: In the authors' opinion, the prevalence of contact sensitization is generally comparable with the findings of the NACDG, with the exception of reactions to potassium dichromate. This difference in results probably reflects, in part, differences in methodology. The test concentration of potassium dichromate was 0.5%, commonly used in Europe, instead of the 0.25% concentration used by the NACDG. Further investigation is necessary to determine the optimal testing concentration of potassium dichromate.

Novelty shop 'itching powder'.

To evaluate causes of itch, commercial 'itching powders' were sought for evaluation. Only one product, produced in Germany and consisting of ground rose hips, is currently sold in novelty shops in the Boston area. These plant fibres appear to provoke itch and prickle sensations by non-allergic mechanical stimulation, similar to the action of wool fibres.