The management of cryptoglandular fistula-in-ano.

Idiopathic cryptoglandular fistula-in-ano is a common pathological condition. Fistula-in-ano has been managed by a number of surgical techniques, and there is still no consensus regarding the management of this condition. Surgical techniques aim to treat and cure the fistula-in-ano with minimal risk of recurrence or complications, and to maintain patient continence. This article discusses the evidence available to inform the management of idiopathic cryptoglandular fistula-in-ano, and problems that surgeons face because of the lack of high-quality evidence.

72 h Is the Time Critical Point to Operate in Acute Appendicitis.

BACKGROUND AND AIMS: Delay of operative management of acute appendicitis may adversely affect post-operative outcomes and increase the likelihood of post-operative complications occurring. We aim to correlate the duration of symptoms with intra-operative findings to create a timeline of the pathological change in appendicitis. METHODS: Appendicectomies performed at a large teaching hospital between June 2015 and July 2016 were prospectively analysed. Time of onset of pain, operative findings, pre-operative C-reactive protein (CRP) and white cell count (WCC) were recorded. Intra-operative findings were categorised by the macroscopic appearance of the appendix, which was subdivided into erythematous, purulent, necrotic and perforated. These results were correlated with the symptom duration. Statistical analysis was completed using Mann-Whitney U and Chi-squared tests. RESULTS: One hundred and ninety patients had histologically confirmed appendicitis during the study period. Median time to operation from symptom onset was 49 h. Median time for the appearances of erythematous, purulent, necrotic and perforated appendicitis to develop was 36.5, 41, 55.5 and 86 h, respectively (p value < 0.0001). Median CRP of the non-perforated and perforated appendicitis groups was 22 and 161 mg/L, respectively (p value < 0.0001). Our data demonstrated that after 72 h of symptoms, the likelihood of a perforated appendicitis increased significantly (p value < 0.0001) when compared to 60-72 h. CONCLUSIONS: A significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptoms, when compared to 60-72 h. We can therefore argue that it may be reasonable to prioritise patients approaching 72 h of symptoms for operative management.

Two Interesting Cases of Meralgia Paraesthetica.

Meralgia paraesthetica (MP) is a condition originally described by Bernhardt in 1878 and was eventually named by Roth in 1895. It is caused by compression of the lateral femoral cutaneous nerve (LFCN) resulting in varying types of discomfort. Severity of the symptoms can range from mildly uncomfortable to painfully disabling. In this article we discuss 2 patients with a LFCN injury occurring as a result of laparoscopic ventral rectopexy (LVR). The first patient is a 46-year-old female who reported pain and dysesthesia in the left groin and the anterolateral thigh, 2 days post LCR. A conservative approach was taken and at the 6-month follow-up the symptoms had resolved. The second patient is a 51-year-old female who reported increased sensitivity to bed sheets over the anterolateral aspect of her left thigh, in the immediate post-operative period following LVR. She was similarly managed conservatively but her symptoms persisted. The LFCN arises from the dorsal branches of the second and third lumbar roots. It crosses the iliacus muscle deep to the fascia. Injury or entrapment to surrounding neural structures including the LFCN, commonly results following common laparoscopic procedures. In some cases, additional surgical intervention is required for successful management of the symptoms. In our patients, the MP syndrome was clearly related to the operation because symptoms appeared in the immediate post-operative period and were not present beforehand. LVR is a relatively new and evolving procedure with few reports of associated peri-operative complications.Key words: Meralgia paraesthetica, laparoscopy, rectopexy, lateral femoral cutaneous nerve.

The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation.

BACKGROUND: Optimal surgical intervention for low-grade haemorrhoids is unknown. Rubber band ligation (RBL) is probably the most common intervention. Haemorrhoidal artery ligation (HAL) is a novel alternative that may be more efficacious. OBJECTIVE: The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids. DESIGN: A multicentre, parallel-group randomised controlled trial. PERSPECTIVE: UK NHS and Personal Social Services. SETTING: 17 NHS Trusts. PARTICIPANTS: Patients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL. INTERVENTIONS: HAL with Doppler probe compared with RBL. OUTCOMES: Primary outcome - recurrence at 1 year post procedure; secondary outcomes - recurrence at 6 weeks; haemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness. RESULTS: A total of 370 participants entered the trial. At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [adjusted odds ratio (OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51; p = 0.0005]. The main reason for the difference was the number of extra procedures required to achieve improvement/cure. If a single HAL is compared with multiple RBLs then only 37.5% recurred in the RBL arm (adjusted OR 1.35, 95% CI 0.85 to 2.15; p = 0.20). Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL), suggesting significant deterioration in both groups over the year. Symptom score, EQ-5D-5L and Vaizey score improved in both groups compared with baseline, but there was no difference between interventions. Pain was less severe and of shorter duration in the RBL group; most of the HAL group who had pain had mild to moderate pain, resolving by 3 weeks. Complications were low frequency and not significantly different between groups. It appeared that HAL was not cost-effective compared with RBL. In the base-case analysis, the difference in mean total costs was £1027 higher for HAL. Quality-adjusted life-years (QALYs) were higher for HAL; however, the difference was very small (0.01) resulting in an incremental cost-effectiveness ratio of £104,427 per additional QALY. CONCLUSIONS: At 1 year, although HAL resulted in fewer recurrences, recurrence was similar to repeat RBL. Symptom scores, complications, EQ-5D-5L and continence score were no different, and patients had more pain in the early postoperative period after HAL. HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY. LIMITATIONS: Blinding of participants and site staff was not possible. FUTURE WORK: The incidence of recurrence may continue to increase with time. Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness. The polysymptomatic nature of haemorrhoidal disease requires a validated scoring system, and the data from this trial will allow further assessment of validity of such a system. These data add to the literature regarding treatment of grade II/III haemorrhoids. The results dovetail with results from the eTHoS study [Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 2016, in press.] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy. Combined results will allow expansion of analysis, allowing surgeons to tailor their treatment options to individual patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN41394716. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 88. See the NIHR Journals Library website for further project information.

Is modern management of fistula-in-ano acceptable?

Fistula-in-ano has been managed by a number of techniques and there remains no consensus on the most appropriate management for all patients. The mainstay of any treatment balances the need to control sepsis vs the risk of potential incontinence post-intervention. Management should focus on the primary source of sepsis.

An unusual presentation of sclerosing mesenteritis as pneumoperitoneum: case report with a review of the literature.

Sclerosing mesenteritis is a rare condition that involves the small or large bowel mesentery. An unusual presentation of this condition, which led to difficult preoperative assessment and diagnosis, is described. This report is followed by a comprehensive review of the literature.