Dentate Line Research Articles

Psoas Minor: Major Confusion

Introduction & ObjectiveThe psoas minor muscle is found in the retroperitoneum with close association to the psoas major and iliacus muscles. Major anatomical textbooks fail to offer a clear consensus on psoas minor, providing conflicting information on the insertion site, function, and relationship to the iliopsoas complex. Reported prevalence of the psoas minor muscle ranges from 40‐65% in each individual hip, but available research is limited by sample size or is not representative of U.S. demographics. Accurate descriptions of the structure of the psoas minor muscle would allow for improved hypotheses regarding muscle function and repercussions of muscle dysfunction. This study aims to document the presence and insertion of the psoas minor muscle in a U.S. donor population, suggest an alternative source to lumbar back pain, and discuss ramifications of muscle dysfunction and applicable osteopathic intervention.Materials & MethodsAt this time, eleven donors were evaluated in the Sam Houston State University College of Osteopathic Medicine’s Human Anatomy Lab. The presence or absence of the psoas minor muscle was determined bilaterally. Muscles were manually traced from origin to the tendon and then the point of insertion. If needed, the inguinal ligament and anterior pelvic structures were dissected for better visualization. Findings were recorded in a secure database and photographed.ResultsThe psoas minor muscle was present bilaterally in seven donors, present unilaterally in one donor, and bilaterally absent in three donors. On all donors evaluated, the insertion site was the pectin pubis with distal blending of the tendon with iliac fascia.Significance & ConclusionAnatomical texts have a variety of descriptions for the documented insertion, such as the pectin pubis, iliopubic eminence, arcuate line, pectineal line or iliopubic ramus. In this study, donors with a psoas minor muscle were determined to have a common insertion site: the pectin pubis. Muscle origin (lateral surface of T12‐L1 vertebral bodies and discs) and bilateral presence (n=7/11; 63%) in the study aligned with current literature.Findings of this study support hypotheses of alternative sources of dysfunction that may contribute to lumbar back pain and hip snapping syndrome rather than more commonly reported sources, such as lumbar back musculature or the iliacus and psoas major muscles. Proximal dysfunction of a psoas minor muscle may contribute to lumbar back pain by abnormally rotating the originating vertebrae in the direction of the hypertrophic muscle. Distal dysfunction may contribute to hip snapping syndrome, in which the iliopsoas tendon “snaps” over the iliopectineal eminence when returning the leg from a position of flexion, abduction, or external rotation. From an osteopathic manipulative approach, the psoas minor may be treated with counterstrain techniques or muscle energy to the lumbar spine to restore normal tone and function. We will continue to collect data in an ongoing study in order to provide an evidence‐based recommendation for the reporting of psoas minor insertion and function, as well as the presentation and potential treatment of psoas minor dysfunction.

A comparative study of bilateral lsias verses conservative management in acute anal fissure

Background: Anal fissure is a tear in anal canal just below dentate line. It can be acute or chronic. In most patients, it is located in posterior midline. Its treatment is both conservative and surgical. In conservative management, there are no clear guidelines and its goal is to break the cycle of anal sphincter spasm allowing improved blood flow to fissured area for healing. Surgery is considered for patients not responding to conservative measures and its gold standard is lateral internal sphincterotomy.Methods: This prospective study was conducted among 60 patients with acute anal fissure. Patients were randomly divided into two study groups based on treatment protocols conservative management and Bilateral LSIAS. Prior informed written consent was obtained. Demographic profile, history, investigations, diagnosis, treatment and follow-up data was recorded and analyzed.Results: Patients with Bilateral LSIAS got pain relief immediately after surgery. 57% patients with conservative management reported head-ache and perianal itching. Over 86% of patients with Bilateral LSIAS got relief from pain and discomfort after treatment; around over 46% patients with conservative approach, had pain and discomfort after 6 weeks of treatment.Conclusions: Results show that Bilateral LSIAS surgery is a better approach than conservative management of anal fissure. Further, the Bilateral LSIAS surgery has maximum chances of early recovery and pain relief and reduced chances of progression to chronic anal fissure. Hence, we can conclude that for anal acute fissure, Bilateral LSIAS surgery procedure is the treatment of choice.

Comparative study between closed vs open lateral internal sphincterotomy in treatment of chronic anal fissure

Background: Anal fissure is a benign yet highly prevalent condition that can cause considerable pain and discomfort. It is a longitudinal Split or tear of the anal canal extending proximally from the anal verge towards the dentate line. Objectives: To compares the open and closed techniques of lateral internal sphincterotomy and study which method is better among open vs closed lateral sphincterotomy. Material & Methods: Patients admitted in Bowring and Lady Curzon hospital and Victoria hospital attached to Bangalore Medical College and Research Institute from November 2015 to May 2017 were studied (n=60). Thirty patients underwent closed and thirty underwent open lateral internal sphincterotomy out of 60 after informed written consent. Results: Post operative pain after 48, 60, 72 and 96 hours was less in closed group along with seroma, hematoma and abscess. Conclusion: we observed that closed lateral internal anal sphincterotomy is better than open technique.

Long-term prognosis of familial adenomatous polyposis with or without mucosectomy.

This study primarily aimed to compare the long-term prognosis of patients who underwent total colectomy/proctocolectomy with or without mucosectomy to the dentate line for the diagnosis of familial adenomatous polyposis (FAP). Patients who underwent total colectomy/proctocolectomy for FAP between January 1979 and December 2020 and were followed up at Hamamatsu University Hospital were included in this study. Those who underwent total proctocolectomy with hand-sewn ileal pouch-anal anastomosis were defined as the mucosectomy group. Those who underwent total colectomy or total proctocolectomy using the stapled ileal pouch-anal anastomosis approach were defined as the no mucosectomy group. A total of 61 individuals (37 families) were diagnosed during the surveillance period (median, 191months). Between the mucosectomy (n = 24) and no mucosectomy groups (n = 34), metachronous rectal cancer was significantly more common in the no mucosectomy group (21% in no mucosectomy vs. 0% in mucosectomy, P = 0.02). Overall survival in the no mucosectomy group was worse than that in the mucosectomy group (84.5% in no mucosectomy vs. 100% in mucosectomy at 120months, 81.1% vs. 90.0% at 240months, 50.6% vs. 75.0% at 360months, P = 0.09). Cox regression analysis revealed an independent effect of not performing mucosectomy on overall survival (P = 0.03). Long-term surveillance revealed that colectomy or total proctocolectomy without mucosectomy had a negative impact on the overall survival of patients with FAP. Therefore, we recommend total proctocolectomy with mucosectomy, i.e., hand-sewn ileal pouch-anal anastomosis, for FAP.

Can transrectal ultrasonography distinguish anorectal malignant melanoma from low rectal adenocarcinoma? A retrospective paired study for ten years

BackgroundAnorectal malignant melanoma (ARMM) and low rectal adenocarcinoma (LRAC) have some similarities in clinical behaviors, histopathological characteristics and ultrasonographic findings, diagnostic errors are common. By comparing the transrectally ultrasonographic features between the two tumors, we propose to provide more possibilities in differentiating them.MethodsThe data of 9 ARMMs and 27 age- and gender-matched LRACs (the lower margin below the peritoneal reflection) in West China Hospital Sichuan University between April 2008 and July 2019 were retrospectively reviewed. The ultrasonic features between the two groups were compared.ResultsTransrectal ultrasonography (TRUS) showed that the length of ARMM was shorter than that of LRAC (28.22 ± 12.29 mm vs. 40.22 ± 15.16 mm), and ARMM had a lower position than that of LRAC (the distance to anal verge was 50.78 ± 11.70 vs. 63.81 ± 18.73 mm). Unlike LRAC, the majority of ARMM in our study was confined to the intestinal mucosa/submucosa (66.67/25.93%) (P < 0.05).ConclusionsBased on the data of our study, several ultrasonographic findings (length, invasion depth, and position) of ARMM were significantly different from LRAC. Accordingly, more attention should be paid to masses at anorectal junction with lower position, shorter length, and shallower infiltration depth. Instead of the most common tumor, LRAC, ARMM should be taken into account to avoid a misdiagnosis, which will result in a poorer prognosis.

Efficacy and Safety of Endoscopic Submucosal Dissection for Rectal Tumors Extending Versus Not to the Dentate Line: A Systematic Review and Meta-Analysis.

To evaluate the outcomes of endoscopic submucosal dissection (ESD) for rectal tumors extending to the dentate line (RTDLs) compared with rectal tumors not extending to the dentate line (non-RTDLs). There is limited composite data on the outcomes of ESD for RTDLs versus non-RTDLs. We performed a systematic review and meta-analysis of studies that reported the clinical outcomes of ESD for RTDLs and non-RTDLs. Main outcomes were pooled estimated rates of en bloc/complete/curative resection, local recurrence, and incidence of bleeding, perforation, stricture, anal pain, and fever. Six studies were enrolled, including 265 cases of RTDLs and 788 cases of non-RTDLs. The en bloc resection rate was comparable for RTDLs and non-RTDLs [odds ratio (OR), 1.04; 95% confidence interval (CI), 0.55-1.95; P=0.90]. The complete resection rate was significantly lower for RTDLs (OR, 0.59; 95% CI, 0.41-0.83; P=0.003), as well as the curative resection rate (OR, 0.57; 95% CI, 0.38-0.87; P=0.010). The rates of stricture, postoperative anal pain and local recurrence were significantly higher for RTDLs than non-RTDLs (OR, 3.07; 95% CI, 1.01-9.31; P=0.05) (OR, 42.10; 95% CI, 4.73-374.97; P=0.0008) (OR, 3.00; 95% CI, 1.13-7.96; P=0.03), but the higher rates of postoperative bleeding and fever for RTDLs were not significantly (OR, 1.33; 95% CI, 0.53-3.30; P=0.54) (OR, 2.23; 95% CI, 0.55-9.07; P=0.26), as well as its lower perforation rate (OR, 0.85; 95% CI, 0.27-2.63; P=0.78). Despite its inferior outcomes than non-RTDLs, ESD is still a feasible and safe treatment for RTDLs if appropriate lesions are treated by experienced operators.

The Deployment of a Newly Developed Proximal Release-Type Colonic Stent Is Feasible for Malignant Colorectal Obstruction near the Anal Verge: A Single-Center Preliminary Study.

Introduction: Colonic self-expandable metallic stents are widely used to treat malignant colorectal obstructions. Stent placement in lesions near the dentate line causes problems, including severe pain due to difficulty in positioning the stent accurately. Therefore, a proximal release-type stent was developed to overcome this issue, and this preliminary study aimed to investigate its efficacy and safety. Patients and Methods: This research enrolled eight patients with malignant colorectal obstructions up to 10 cm from the anal verge who required placement of the newly developed proximal release-type colonic stent. The primary outcome was the clinical success rate, and the secondary outcomes were the technical success and adverse events rates. Results: The technical and clinical success rates were 87.5% each, and the mean procedure time was 25.5 ± 22.0 min. The mean procedure time in the rectosigmoid colon was significantly longer than that in the rectum. Only one (12.5%) patient had stent migration, and neither anal pain nor tenesmus was observed. Discussion: The stent was highly effective in treating lesions near the anal verge, and it might contribute to the expansion of indications for colorectal stents for lesions near the dentate line. However, the indications for rectosigmoid colon lesions should be cautiously considered.

A new technique for surgical haemorrhoidectomy without post-operative complication: A case series

IntroductionHemorrhoids are a common coloproctology problem and among 10% of cases need surgical intervention. However, the established surgical interventions still have many complications. Case presentationWe reported three female patients, who presented with circular 3rd degree internal hemorrhoids. The surgical treatment was performed with pre-operative anal dilatation using a 33 mm dilator for 20 minutes, followed by triangle incision above the dentate line. The hemorrhoid excision was performed, and the wound was sutured with simple interrupted radial sutures using a multifilament absorbable 3-0 thread. There were neither complaints of pain, bleeding, anal incontinence, anal stenosis, wound dehiscence, nor recurrence at the first, second, and fourth weeks of follow-ups in all patients. DiscussionPost-operative bleeding, pain, and anal incontinence are common after an open hemorrhoidectomy, while suture breakage and anal stenosis were reported after the old technique of closed hemorrhoidectomy. Stapled hemorrhoidectomy had less complications but requires a relatively more expensive cost for the device itself. We performed a combination of preoperative anal dilatation, above dentate line triangle incision, and simple interrupted radial sutures to treat the patients with 3rd degree internal hemorrhoids, which resulted in no post-operative complications within the first month of follow-up. ConclusionA combination of preoperative anal dilatation, above dentate line triangle incision, and radial suture technique is a simple and effective surgical option for treating a 3rd degree hemorrhoid.

Gastrointestinal: Endoscopic ultrasound of rectal subepithelial lesion mimicking gastrointestinal stromal tumor.

A 60-year-old man presented with anorexia, weight loss, and constipation for 3 months. On peri-rectal examination, a bulge was palpated in the rectum. He underwent colonoscopy, which showed large subepithelial lesion (SEL) starting from anorectal junction extending proximally till rectosigmoid junction obliterating the lumen without complete obstruction (Fig. 1a). Contrast-enhanced computed tomography of the pelvis showed a large lobulated heterogeneous enhancing soft tissue lesion within the rectum (Fig. 1b). Endoscopic ultrasound (EUS) was performed, which showed a large well defined lobulated hetero-echoic lesion (70 × 63 mm) with multiple cystic spaces in peri-rectal area (Fig. 1c). Possibility of rectal malignant gastrointestinal stromal tumor (GIST) was considered looking at CT and EUS image. To confirm our diagnosis, EUS-guided fine needle aspiration (FNA) was performed. During FNA, dark brownish fluid was aspirated (Fig. 2a). Possibility of bleed within tumor was considered because of dark brownish fluid aspiration; however, black pigments were noticed on slide preparation (Fig. 2b). Histopathological examination showed pleomorphic cells with abundant brownish pigment with multinucleation suggestive of malignant melanoma (Fig. 2c). Patient was advised for surgery and referred to the surgeons. Malignant melanoma is an extremely rare and aggressive tumor of the rectum. It accounts for 0.5–4% of all anorectal malignancies and < 1% of all melanomas. It is most common site of primary gastrointestinal melanoma followed by stomach, small intestine, and colon. Patients usually present in the fifth or sixth decade, and it is more common in female patients. Anorectal melanomas usually appear as ulcerated polypoidal lesions rather than SEL. EUS is an important diagnostic tool in diagnosis and differentiation of SEL. There is lack of characterization of anorectal melanoma on EUS because of rarity of tumor. Yonal et al. described the EUS morphological features of esophageal melanoma as iso to hypoechoic solid tumor mass with variable areas of internal hyper-echogenicity and anechoic cystic spaces, similar to the findings from our case. Morphological features of some SELs are confusing; therefore, EUS FNA plays an important role in differentiation of SELs. Therapy in anorectal melanomas is dictated by the local staging of disease and also the presence of lymph node and distant metastases. Multidisciplinary approach is required depending on the stage of tumor. Surgery has been the mainstay of treatment for anorectal melanoma. Although these tumors are usually radio-resistant and chemo-resistant, combination of chemotherapy and immunotherapy remains a therapeutic option for advanced metastatic disease. Overall, 5-year survival is only 3–22%, and survival in recurrent or metastatic disease is less than 10 months. Although a rare entity, anorectal melanoma can mimic GIST and may be a differential during the evaluation of rectal SEL. Early diagnosis of tumor is of paramount importance for favorable prognosis.

Transitional Anal Cells Mediate Colonic Re-epithelialization in Colitis

Epithelial wound healing is compromised and represents an unleveraged therapeutic target in inflammatory bowel disease (IBD). Intestinal epithelial cells exhibit plasticity that facilitates dedifferentiation and repair during the response to injury. However, it is not known whether epithelial cells of a neighboring organ can be activated to mediate re-epithelialization in acute colitis. Histological findings of a permanent squamous tissue structure in the distal colon in human IBD could suggest diverse cellular origins of repair-associated epithelium. Here, we tested whether skin-like cells from the anus mediate colonic re-epithelialization in murinecolitis. We studied dextran sulfate sodium-induced colitis and interleukin 10-deficient colitis in transgenic mice. We performed lineage tracing, 3-dimensional (3D) imaging, single-cell transcriptomics, and biophysical modeling to map squamous cell fates and to identify squamous cell types involved in colonic repair. In acute and chronic colitis, we found a large squamous epithelium, called squamous neo-epithelium of the colon (SNEC), near the anorectal junction. Neighboring squamous cells of the anus rapidly migrate into the ulcerated colon and establish this permanent epithelium of crypt-like morphology. These squamous cells derive from a small unique transition zone, distal to the border of colonic and anal epithelium, that resists colitic injury. The cells of this zone have a pre-loaded program of colonic differentiation and further upregulate key aspects of colonic epithelium during repair. Transitional anal cells represent unique reserve cells capable of rebuilding epithelial structures in the colon after colitis. Further study of these cells could reveal novel approaches to direct mucosal healing in inflammation and disease.

A Rare Hidden Mole, an Incidental Finding in Colonoscopy

Question: An 82-year-old man with hypertension, auricular fibrillation, with a pacemaker and mitral/aortic biological protheses was referred to our hospital for total colonoscopy owing to a positive fecal occult blood test. Two small tubular adenomas were found. In addition, a dark 3-mm-diameter macule in the anal canal closely below the pectinate line in the right anal wall was detected (Figure A). An endoscopic biopsy was performed under local anesthesia with mepivacaine and epinephrine. Histopathological images are shown in Figures B to D.

Inflammatory cloacogenic polyps in children: diagnostic yield of rectal retroflexion during colonoscopy

Background and aimsInflammatory cloacogenic polyps (ICPs) are inflammatory lesions occurring around the anal transitional zone. These are rare in the pediatric population, and most reported cases are found in adults. Therefore, this study aimed to evaluate the usefulness of rectal retroflexion (RR) during colonoscopy in detecting ICPs in children.MethodsA total of 1837 colonoscopies were performed in 1278 children between September 2003 and August 2020 at the Seoul National University Bundang Hospital. The laboratory test results and colonoscopic and histopathological findings were retrospectively reviewed. ICP was detected using the RR and was diagnosed based on the histologic findings of the polyp.ResultsA total of 69 patients were diagnosed with juvenile polyps (n = 62) or ICP (n = 7), with the latter being detected through RR. All children with ICP were diagnosed from 2013 onwards when RR during colonoscopy came to be routinely performed in our medical center. The patients with ICP were older at diagnosis and more associated with a family history of colorectal polyps than JP. Stool occult blood and the polyps’ endoscopic characteristics, such as number, location, volume, and shape, significantly varied between the two groups. Additionally, there was a statistically significant difference in the polypectomy method. During the long-term follow-up, there was no recurrence of ICP.ConclusionsDue to their location at the anorectal junction, ICPs may be overlooked during colonoscopy, leading to misdiagnosis. Therefore, a retroflexion view during colonoscopy may help detect ICPs in pediatric patients, especially those presenting with hematochezia.

Are parturition scars truly signs of birth? The estimation of parity in a well‐documented modern sample

AbstractParturition scars have been frequently studied in the last decades, but their association with pregnancy and birth is still controversial. Other biomechanical, biometric, and lifestyle factors are also likely to influence the development of pelvic features. Most previous studies of pelvic features were based on skeletal collections with no reliable information on parity or even sex and thus were unable to disentangle these factors. Here, we study the association of pelvic features with birth and other body variables (age, stature, weight, osteoarthritis, and centrum–collum–diaphyseal angle) using multiple regression and path modeling in a modern sample of female individuals from New Mexico (USA) with detailed background information (n = 150). We also explored the utility of pelvic features to predict the number of births. To this end, we scored the expression of the preauricular sulcus, sacral preauricular extension, extended pubic tubercle, exostosis at the pectineal line, dorsal, and ventral pubic pitting using CT scans from the New Mexico Decedent Image Database. Quantitative measurements of pelvic features were then used as predictors of parity. Overall, the regression models accounted only for relatively small fractions of variance in pelvic feature expression. The only feature significantly associated with the number of births was dorsal pubic pitting (R2 = 0.2372), whereas the expression of most pelvic features increased with age, independent of parity. Presumably, the development of dorsal pubic pitting is affected both by biomechanical stress and the increased hormonal secretion during pregnancy and birth. The individual prediction of parity based on pelvic features is too imprecise for forensic or archeological applications. However, using a size score of dorsal pubic pitting allowed us to estimate the mean parity in groups of individuals relatively well. Hence, pelvic features may still be used to compare average parity across recent or historic populations.

Transanal versus laparoscopic total mesorectal excision: a comparative study of long-term oncological outcomes.

Transanal total mesorectal excision (TaTME) is the most recent approach developed to improve pelvic dissection in surgery for mid and low rectal tumors. There are still inconsistencies regarding the technique's oncological results. The aim of this study was to analyze clinical and oncological outcomes of the learning curve of TaTME in comparison to laparoscopic TME (lapTME). Rectal cancer patients who had TaTME and lapTME in two Portuguese colorectal units between March 2016 and December 2018 were eligible. Primary endpoints were 5-year overall survival, disease-free survival, and local recurrence. Secondary endpoints were clinical and pathological outcomes. Forty-four patients underwent TaTME (29 men) and 39 lapTME (27 men) with a median age of 69 and 66 (p = 0.093), respectively. No differences were observed concerning baseline characteristics, emphasizing their comparability. In the TaTME group, there were more hand-sewn anastomosis (0 lapTME versus 7 TaTME, p = 0.018) with significantly less distance to the dentate line (40mm lapTME versus 20mm TaTME, p = 0.005) and significantly more loop ileostomies performed (28 lapTME versus 41 TaTME, p = 0.001). There were no differences in post-operative mortality, morbidity, readmissions, and stoma closure. Groups were similar in relation to specimen quality, margins, and resectability; however, TaTME had a significantly higher node yield (14 lapTME versus 20 TaTME, p = 0.002). Finally, no disparities were noted in oncological outcomes, namely local and distant recurrence, 5-year overall survival, and disease-free survival. Even with the disadvantage of the learning curve of a new technique, TaTME appears to be comparable to lapTME, with similar long-term oncological outcomes. It has, however, a demanding learning curve, significant risk for morbidity and should be used only for selected patients.

Complications after Stapled Hemorrhoidectomy: A Single Center Experience

Background: A circumferential strip of mucosa about 1.5 to 2 centimetres above the dentate line is removed in stapled hemorrhoidectomy, a new technique for haemorrhoids treatments. Objective: The aim of the study was to evaluate complications after stapled hemorrhoidectomy.Methods:A total of 101 patients between the age group 20 to 70 years were diagnosed with grade 3 and grade 4 haemorrhoids. Patients are included in stapled haemorrhoidectomy. The questionnaire focused on stapled hemorrhoidectomy procedures performed in the period July 2018 to June 2020. Descriptive analysis was done based on the student’s T-test using SPSS 24 software version. The level of significance was set at 5% (p &lt; 0.05).Results:In the 2-years timeframe, out of 101 patients in the Immediate (within 1 week) complications of stapled hemorrhoidectomy, 84.16% were in None, 5.94% were severe pain, 3.96% were bleeding, 1.98% were Thrombosis, 0.99% were urinary retention, 1.98% were Anastomotic dehiscence 0.99% were Fissure, 0.99% were perineal intramural hematoma and 0.99% were submucosal abscess. Out of 90.09% were in none, 1.98% were Recurrent hemorrhoids, 0.99% were Severe pain, Stenosis, Fissure, Skin tag, Thrombosis, Staples problems, Intramural abscess and Intussusception.Conclusion:Although stapled hemorrhoidectomy appears to be promising, we believe that a multicenter randomized controlled trial with a long-term follow-up comparing stapled hemorrhoidectomy and banding is required before the treatment can be recommended. The majority of difficulties can be avoided by following the rectal wall anatomy during the surgery.

Robotic versus laparoscopic low anterior resection following neoadjuvant chemoradiation therapy for stage II-III locally advanced rectal cancer: a single-centre cohort study.

Neoadjuvant chemo-radiotherapy (nCRT) of locally advanced rectal cancer is associated with challenging surgical treatment and increased postoperative morbidity. Robotic technology overcomes laparoscopy limitations by enlarged 3D view, improved anatomical transection accuracy, and physiologic tremor reduction. Patients with UICC stage II-III rectal cancer, consecutively referred to our institution between March 2015 and June 2020 (n = 102) were treated with robotic (Rob-G, n = 38) or laparoscopic (Lap-G, n = 64) low anterior resection (LAR) for total meso-rectal excision (TME) following highly standardized and successful nCRT treatment. Feasibility, conversion rates, stoma creation, morbidity and clinical/pathological outcome were comparatively analysed. Sex, age, BMI, ASA scores, cTN stages and tumour distance from dentate line were comparable in the two groups. Robotic resection was always feasible without conversion to open surgery, which was necessary in 11/64 (17%) Lap-G operations (p = 0.006). Primary or secondary stomata were created in 17/38 (45%) Rob-G and 52/64 (81%) Lap-G patients (p < 0.001). Major morbidity occurred in 7/38 (18.4%) Rob-G and 6/64 (9.3%) Lap-G patients (p = 0.225). Although median operation time was longer in Rob-G compared with Lap-G (376; IQR: 330-417min vs. 300; IQR: 270-358min; p < 0.001), the difference was not significant in patients (Rob-G, n = 6; Lap-G, n = 10) with ≥30 BMI (p = 0.106). Number of resected lymph nodes, ypTN staging and circumferential resection margins (CRM) were comparable. Resection was complete in 87% of Rob-G and 89% of Lap-G patients (p = 0.750). Robotic LAR is not inferior to laparoscopic LAR following nCRT. Larger, randomized studies are needed to confirm lower conversion in robotic, compared to laparoscopic resection.

Long-term Outcome of Triple Stapling Resection and J Pouch Anal Stapling Anastomosis for Ulcerative Colitis.

We previously reported laparoscopic total proctocolectomy with J pouch anal anastomosis, which was created at the dentate line by our original procedure using staplers, Triple Stapling Resection and J pouch Anal Stapling Anastomosis (TSRJASA), for ulcerative colitis (UC) patients. UC patients have undergone TSRJASA since it was introduced in our institution. However, the long-term outcome of TSRJASA for UC patients has not been elucidated. From January 2014 to December 2018, fourteen patients with ulcerative colitis, including three cases of concomitant cancer, who underwent TSRJASA were enrolled in this study. Anal manometry was performed using the Pock Monitor GMMS-100 system (STAR MEDICAL, INC., Tokyo, Japan) one and two years after surgery. Maximum resting pressure, maximum squeeze pressure, and the length of the high-pressure zone were measured. Fecal incontinence was evaluated using the Wexner incontinence questionnaire. J pouch anal anastomosis was created at the dentate line in all patients. In a manometric examination two years after surgery, maximum resting pressure was 75.3 (54-88) mm Hg, maximum squeeze pressure was 125.0 (90-160) mm Hg, and the length of the high-pressure zone was 39.6 (35-42) mm. Wexner score was 2.8 (1-4). TSRJASA is a useful procedure for UC patients given its acceptable defecation function.

Effect Of Leech Therapy On TEP (Thrombosed External Pile): A Case Study

The Thrombosed external pile is the one which is located distal to the dentate line and develop as a result of tortuosity and distension of External Hemorrhoidal venous system. The engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and subsequently clot; this leads to the Acute Thrombosed External Pile mass, a bluish purplish discolored swelling with severe pain and tenderness. The present case is of TEP (Thrombosed external pile) and the effect of Leech application is evaluated on this. The main objective is to assess the effective role of Leech on essential parameters of the patient,that are troublesome sign and symptoms - Pain, edema, tenderness and discoloration. The case is successfully managed with Leech therapy. Hirudin, calin, Factor Xa present in the saliva of Leech helps in oppressing the process of blood clot in an External pile mass and provides a symptomatic relief to the patient.

Inadequate Rectal Pressure and Insufficient Relaxation and Abdominopelvic Coordination in Defecatory Disorders

Diagnostic tests for defecatory disorders (DDs) asynchronously measure anorectal pressures and evacuation and show limited agreement; thus, abdominopelvic-rectoanal coordination in normal defecation and DDs is poorly characterized. We aimed to investigate anorectal pressures, anorectal and abdominal motion, and evacuation simultaneously in healthy and constipated women. Abdominal wall and anorectal motion, anorectal pressures, and rectal evacuation were measured simultaneously with supine magnetic resonance defecography and anorectal manometry. Evacuators were defined as thosewho attained at least 25% rectal evacuation. Supervised (logistic regression and random forest algorithm) and unsupervised (k-means cluster) analyses identified abdominal and anorectal variables that predicted evacuation. We evaluated 28 healthy and 26 constipated women (evacuators comprised 19 healthy participants and 8 patients). Defecation was initiated by abdominal wall expansion that was coordinated with anorectal descent, increased rectal and anal pressure, and then anal relaxation and rectal evacuation. Compared with evacuators, nonevacuators had lower anal diameters during simulated defecation, rectal pressure, anorectal junction descent, and abdominopelvic-rectoanal coordination (P < .05). Unsupervised cluster analysis identified 3 clusters that were associated with evacuator status (P < .01), that is, 10 evacuators (83%), 16 evacuators (73%), and 1 evacuator (5%) in clusters 1, 2, and 3, respectively. Each cluster had distinct characteristics (eg, maximum abdominosacral distance, rectal pressure, anorectal junction descent, anal diameter) and correlates that were more (clusters 1-2) or less (cluster 3) conducive to evacuation. Cluster 2 had 16 evacuators (73%) and intermediate characteristics (eg, lower anal resting pressure and relaxation during evacuation; P < .05). Women with DDs and a modest proportion ofhealthy women had specific patterns of anorectal dysfunction, including inadequate rectal pressurization, anal relaxation, and abdominopelvic-rectoanal coordination. These observations may guide individualized therapy for DDs in the future.

Hirschsprung Disease.

Hirschsprung Disease.