Pile Research Articles

Fournier's gangrene in Patients Operated for Hemorrhoidal Prolapse in the Surgical Emergency Department.

Fournier's gangrene (FG) is a well known often fatal fasziitis of the pelvic floor following ano-rectal, urologic and gynecologic infections. Although rarely it is described as a complication of operative anal procedures and predisposing factors such as diabetes, alcoholism, immune-defects and consumptive diseases.
 Current literature only briefly mentions the potential risk of FG after such a common surgical procedure. However, devastating complications occur more often than expected. This catastrophic complication without a predisposing factor is discussed along with a review of the literature.
 The objective of this article is to provide updated and relevant information regarding the recognition, diagnosis and management of FG, from the general surgeon to the emergency department.
 This article refers to two complicated cases of Fournier's gangrene. The patients underwent emergency surgical intervention with the diagnosis of hemorrhoidal prolapse with rectal bleeding and accompanying anemia…
 Conclusion; The gold standard for treatment was found to be a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids. Further, patient survival was found to be directly related to the time from diagnosis to treatment when they underwent surgical debridement. 
 The General surgeon must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management.

English translation and cross-cultural validation of the patient-reported outcome measurement-haemorrhoidal impact and satisfaction score (PROM-HISS).

The aim of this study was to translate the Dutch patient-reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS) to English and perform a cross-cultural validation. The ISPOR good practice guidelines for the cross-cultural validation of PROMs were followed and included two steps: (1) Two forward and two backward translations. The forward translation concerned the translation from the source language (Dutch) to the target language (English), performed by two independent English speakers, one medical doctor and one nonmedical. Subsequently, a discussion about discrepancies in the reconciled version was performed by a stakeholder group. (2) Cognitive interviews were held with patients with haemorrhoidal disease (HD), probing the comprehensibility and comprehensiveness of the PROM-HISS. Discrepancies in the reconciled forward translation concerned the terminology of HD symptoms. Furthermore, special attention was paid to the response options, ranging from "not at all", indicating minor symptoms, to "a lot", implying many symptoms. Consensus among the stakeholder group about the final version of the translated PROM-HISS was reached. Interviews were conducted with 10 native English-speaking HD patients (30% female), with a mean age of 44 years (24-83) and primarily diagnosed with grade II HD (80%). The mean time to complete the PROM-HISS was 1 min 43 s. Patients showed a good understanding of the questions and response options, found all items relevant and did not miss important symptoms or topics. The translated English language PROM-HISS is a valid tool to assess symptoms of HD, its impact on daily activities and patient satisfaction with HD treatment.

Occlusion of rectal arteries in the treatment of recurrent hemorrhoidal disease after transanal surgical interventions

The article presents data on variant X-ray anatomy of the superior rectal artery and types of arterial architectonics of the rectum. The causes of recurrent hemorrhoidal disease after traditional transanal surgical interventions are highlighted. The possibilities of endovascular occlusion of rectal arteries in the treatment of relapses of chronic hemorrhoids are shown. Its technical variants are given depending on the number of hemorrhoidal arteries and types of arterial architectonics of the rectum.Over a 2-year period, clinical results of endovascular occlusion of hemorrhoidal arteries were evaluated in 11 patients with relapse of the disease after various transanal interventions: after latex ligation of internal hemorrhoids – in 5, transanal desarterization of internal hemorrhoids with mucopexia – in 4, hemorrhoidectomy – in 2. The average age of patients was 44.2 ± 12.5 years. Men – 5, women – 6. Superselective occlusion of the target hemorrhoidal branches of the upper rectal artery was performed with EmboGold (Merit Medical) microparticles, 500–700/300–500 mkm in size. Immediate results: cessation of bleeding on the first day – in 4 patients, after 3 days – in 5, after 7 days – in 2. Terms of hospitalization – 1 day, disability – 4.3 ± 0.7 days. Long-term results (from 1 to 2 years) were observed in all 11 patients. The course is relapse-free.As an illustration, a clinical case is presented – successful treatment of a patient with recurrent hemorrhoidal disease by endovascular occlusion of hemorrhoidal arteries after five traditional transanal surgical interventions: sclerosing, ligation, dearterization of internal hemorrhoids, dearterization of internal hemorrhoids with mucopexia, removal of external hemorrhoids. Within 3 months after endovascular occlusion – complete regression of all symptoms of hemorrhoidal disease. According to the questionnaire (after 1 and 2 years) there is no relapse of the disease, the patient is subjectively satisfied with the endovascular treatment.

Prevention and Treatment of Anastomotic Strictures After Procedure for Prolapse and Hemorrhoids.

Procedure for Prolapse and Hemorrhoids (PPH), also known as circular stapled hemorrhoidectomy, is a common method of treating hemorrhoids due to its low risk of complications and minimal postoperative pain. Several complications have appeared alongside the rise of treated cases, however, and this has led to a progressive slowing of the clinical use of PPH in recent years. Anastomotic stenosis is one of the most common complications of PPH, but the greater amount of tissue removed and the speed with which it can heal make it the best choice for patients with severe prolapsed annular hemorrhoids or rectal mucosal prolapse. Therefore, academics continue to comprehensively study PPH to take advantage of annular resection and reduce complications. In this paper, we analyzed the causes, intraoperative warnings, and postoperative therapy of anastomotic stenosis induced by PPH, with an eye toward scientific application in the anorectal field, based on the experience of clinical applications.

Outcomes of diode laser haemorrhoidoplasty in treatment of second, third and fourth grades of haemorrhoids. a retrospective study

Introduction Management of hemorrhoidal disease had been always a challenge for colorectal surgeons. Recently, the use of diode laser in proctology has emerged as an alternative to conventional surgical treatment. The laser beam causes shrinkage and degeneration that depend on the power and the duration of laser light application. It is also associated with minimal postoperative pain, bleeding, discharge and short hospital stay. Patients and methods This prospective study was carried out on 104 patients with second, third and fourth grades of hemorrhoids in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospitals, during the study period (18 months, from February 2021 to August 2022). All patients underwent laser hemorrhoidoplasty lasotronix device, bare fibers, wavelength 1470 nm and 8 watts of power. Mucopexy was added in 28 patients with grade 4 hemorrhoids. Results Postoperative pain was evaluated using VAS score, in the first 6 h VAS ranged from 4-9 with mean of 5.81±1.23 SD, after 12 h ranged from 1 to 7 with mean of 4.19±1.70 SD. There was significant relation between the grade of hemorrhoid and postoperative edema (P value was less than 0.001) as all of the 24 patients who developed edema, they were grade 4 hemorrhoids. Also, there was relation between grade 4 hemorrhoid and the development of other postoperative complications but P value was not significant (0.066 in infection and 0.260 in recurrence). There was no incontinence or stenosis in all of the 104 patients and recurrence occurred only in 4 cases (3.8%) and underwent conventional hemorrhoidectomy after six months of follow up. Conclusion Diode laser is a safe minimally invasive procedure for the treatment of second, third and fourth grades of hemorrhoids with less postoperative pain and early return to normal activities but high cost remains the only limitation.

A prospective randomized comparative study between Stapler hemorrhoidopexy and laser hemorrhoidoplasty in the management of third-degree piles

Background Hemorrhoidectomies are considered one of the most commonly performed procedures worldwide. Advances in techniques and technology have emerged new modalities in the management of piles with different grades. Aim The aim of this study is to weigh the advantages and disadvantages of laser hemorrhoidoplasty (LH) versus Stapler hemorrhoidopexy (SH). Methods A prospective randomized trial with 120 patients with symptomatic third degree hemorrhoidal disease who presented with pain and bleeding was undertaken in March 2020 and followed patients for two years in Ain Shams University Hospitals until March 2022. The remaining 60 patients (group B) had SH, while the first 60 patients (group A) got LH. The following factors were evaluated: preoperative complaints (bleeding Per rectum, rectal/perianal pain, mass coming out of anus), operative and postoperative outcomes, operative time, postoperative pain, bleeding, urinary retention, fecal/flatus incontinence, thrombosis of external haemorrhoids, anal/rectal stenosis, wound issues, and recurrence. The visual analog scale (VAS), which is based on a numeric pain rating scale with 0 denoting no pain and 10 denoting severe pain, was used to record postoperative discomfort. Results Operative time and blood loss were significantly better in LH than SH with Operative time 23.04±3.42 min in LH compared with SH 33.72±4.48 min (P < 0.001) and Operative blood loss in LH 5.61±1.06 ml compared with SH 11.67±1.92 ml (P < 0.001). There was less postoperative hospital stay in LH group. Postoperative pain was significantly higher in SH verses LH in the first 12 h (5.83±0.86 in stapler vs 5.02±0.6 in laser in the first 12 h) (P < 0.001). Postoperative VAS score at 24 h and 1 week the VAS score was higher for LH in comparison with SH (3.86±0.48 in laser vs 3.39±0.56 in SH at 24 h), (1.59±0.37 in laser vs 1.01±0.43 at 1 week). As regard Returning to activities SH was significantly better than LH. Regarding early postoperative complications like early Postoperative bleeding and urinary retention we found no statistically significant difference between SH and LH in our study. As regard Late Postoperative complications SH was significantly better regarding recurrence after 2 years with only one case of recorded recurrence verses 7 cases in LH group Also, SH was significantly better regarding postoperative flatus incontinence and late anal stenosis with only one patient of Flatus incontinence and late anal stenosis in SH group verses 6 patients of Flatus incontinence and 4 patients of anal stenosis in LH group. While other late postoperative complications were better in SH Group but were not statistically Significant. Conclusions Both SH and LH are probably equally valuable techniques in modern haemorrhoid surgery. However, SH has an advantage because of lower pain after 24 h better, faster recovery and Return to activities and less postoperative complications so SH is a better technique with overall better outcomes. Results of LH showed be revised, liberal use of LH in third degree hemorrhoidal disease according to patient preference should be regulated. LH should be evaluated in depth in a large-volume studies.

Long-term results of dearterialization and mucopexy for stage II–III hemorrhoids

BACKGROUND:Nowadays, minimally invasive procedures are mainly performed in the treatment of hemorrhoidal diseases. However, the feasibility of using ultrasound navigation for hemorrhoidal artery ligation-rectoanal repair (HAL-RAR) is still discussed because digital palpation of hemorrhoidal arteries for ligation is safe and easy to perform. AIM:To evaluate the long-term results of HAL with mucopexy by digital examination in comparison with traditional HAL-RAR in the surgical treatment stage II–III hemorrhoidal disease. MATERIALS AND METHODS:The controlled randomized trial included 150 patients with stage II–III hemorrhoidal disease. The study group (n=75) included patients who underwent surgery using digital palpation with mucopexy, and in the control group (n=75), the HAL-RAR was used. The primary endpoint was a recurrence of the main symptoms. Secondary endpoints included patient satisfaction and discomfort, pain intensity, prolapse of hemorrhoidal piles, and rectal bleeding. RESULTS:The groups did not differ in sex, age, body mass index, and stage, and symptoms of hemorrhoidal disease. During the 12-month follow-up, no difference in the prolapse of hemorrhoidal piles (p=0.49), patient satisfaction (p=0.95), and discomfort (p=0.67) was found. Periodic bleeding occurred in 5.3% and 17.3% of the patients in the study and control groups, respectively (p=0.037). After 2 months of follow-up, pain recurred in 8 (10.6%) patients in the study group and 22 (29.3%) in the control group (p=0.037). At 18 months follow-up, no difference in patient satisfaction (p=0.95) and discomfort (p=0.89) was noted; however, the rate of hemorrhoidal prolapse was significantly higher in the study group (16.3%) than in the control group (13.5%) (p=0.045), and bleeding was reported in 10.2% and 15.4% of the patients in these groups, respectively (p=0.86). Open hemorrhoidectomy for relapse of hemorrhoidal prolapse was performed in 2 (2.6%) patients in the study group and 4 (5.3%) patients in the control group (p=0.68). CONCLUSION:Ligation of hemorrhoidal arteries in combination with mucopexy without ultrasound guidance is a safe, easy, and reproducible technique, with comparable effectiveness, and long-term results to HAL-RAR. This procedure can be recommended for the surgical treatment of stage II–III hemorrhoids.

Minimally invasive laser technologies in the surgical treatment of hemorrhoidal disease: problems and prospects (literature review)

Based on the literature data, the article reviews the latest advances in the surgical treatment of patients with hemorrhoids. The methods of historical significance, as well as current surgeries are analyzed.The literature review focuses on laser technologies, in particular, laser hemorrhoidoplasty. The paper considers the historical aspects of the development of this approach in proctology, the main surgical techniques, indications and contraindications, possible intra- and postoperative complications, among which the most common are intraoperative bleeding, delayed bleeding, and pain syndrome. The analysis of clinical efficacy and the structure of recurrences and adverse outcomes are presented. Different regimes of laser exposure are analyzed as well. According to the literature data, laser hemorrhoidoplasty is a relatively clinically effective and safe minimally invasive surgical intervention, characterized by short postoperative rehabilitation and a low number of complications. Laser hemorrhoidoplasty is characterized by a low severity of pain syndrome both during the intervention and in the postoperative period. The high economic efficiency of the considered surgical intervention was noted. Meanwhile, the question of the optimal dosing and parameters of the laser energy used in the course of laser hemorrhoidoplasty remains open and should be answered in the upcoming clinical and experimental studies.

Comparing outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in grade II-III hemorrhoidal disease: a retrospective analysis.

Hemorrhoidal disease is a common ailment that presents a challenge in terms of standard treatment methods. Although surgical hemorrhoidectomy is often considered the gold standard, new surgical techniques have emerged, such as laser hemorrhoidoplasty and LigaSure hemorrhoidectomy, to address postoperative pain, bleeding, and extended return-to-work times. This study aims to compare the outcomes of laser hemorrhoidoplasty and LigaSure hemorrhoidectomy in patients with grade II-III hemorrhoidal disease. A retrospective analysis was conducted on a cohort of patients who underwent laser hemorrhoidoplasty or LigaSure hemorrhoidectomy. Data were collected on postoperative pain, complications, recurrence rates, and return-to-work times. The primary outcome was the difference in postoperative pain between the two groups, as assessed using the Visual Analog Scale (VAS). Patients in the laser hemorrhoidoplasty group experienced significantly lower postoperative pain compared to those in the LigaSure hemorrhoidectomy group. Bleeding amounts during the operation were also significantly lower in the laser group. However, the recurrence rate was higher in the laser group compared to the LigaSure group (9.4% versus 2.5%). Return to work and normal activities time after laser hemorrhoidoplasty was shorter than after LigaSure hemorrhoidectomy. Laser hemorrhoidoplasty is a minimally invasive technique that can be safely applied in suitable grade II-III patients, offering lower postoperative pain rates, fewer complications, and shorter return to work and normal activity times compared to LigaSure hemorrhoidectomy. However, recurrence rates are still higher for laser hemorrhoidoplasty. Future studies should explore the potential of combining laser hemorrhoidoplasty with other surgical treatments.

Proctological disorders: psychometrics assessment of personality features and clinical evaluation.

Patients with gastrointestinal diseases have been shown to report greater stress, anxiety, depression and obsessive-compulsive characteristics. The aim of our study is to investigate personality characteristics and general distress of adult patients suffering from common coloproctological conditions. We conducted a retrospective observational study including patients aged 18years or older, with diagnosis of haemorrhoidal disease (HD group) or anal fissure (AF group). The final sample was composed of 64 participants, who were asked to complete a battery of questionnaires. They were compared with a control group of healthy volunteers. In terms of general distress, HD group scored higher than both the CG and AF groups. The two proctological groups had higher scores in neuroticism/emotional lability compared to the CG group. In the MOCQ-R scale (obsessive-compulsive tendency), HD group had significantly higher scores compared to the CG group in the total score (p < 0.01,) and also scored higher in the doubting/ruminating subscale compared to the AF group. We support the importance of taking a multidisciplinary perspective and incorporating psychometric tools to assess the psychological and personality dimensions of patients into proctological clinical practice. The correct early evaluation and management of these conditions may result in an improvement in patients' quality of life and better response to treatment.

Evaluation of the Farsi-translated Hemorrhoidal Disease Symptom Score and Short Health Scale questionnaires in patients with hemorrhoid disease: A cross-sectional study.

The Hemorrhoidal Disease Symptom Score (HDSS) is a tool that is scored based on five main symptoms: pain, bleeding, itching, soiling, and prolapse. Furthermore, the Short Health Scale (SHS) is a measurement tool of subjective health and health-related quality of life. This study was performed to validate the Farsi-translated Hemorrhoidal Disease Symptom Score (HDSS), and Scale Short Health Scale adapted for hemorrhoidal disease (SHS-HD) as a measure of symptom severity in patients with hemorrhoid disease. In this study, HDSS and SHS-HD were translated into Farsi. Participants with confirmed hemorrhoid disease completed the questionnaire. Subsequently, the questionnaire's discriminative validity, convergent validity, reliability, sensitivity, and specificity were evaluated. Data from 31 patients were analyzed (mean age 39.68; 71% male). The results of the analysis showed good internal consistency as Cronbach's α for HDSS and SHS were 0.994 and 0.995 respectively. Spearman's correlation coefficient for the test-retest comparison was 0.986 (p < 0.01). The responses demonstrated good convergent validity. Moreover, the comprehension and suitability of each question were rated as excellent (Pearson's correlation coefficient = 0.3). Our findings revealed that the Farsi translation of the HDSS and SHS-HD can be a valuable tool for evaluating the symptom severity in patients with hemorrhoid disease.

Hemorrhoidal Artery Ligation for the Treatment of Grade II-III Hemorrhoids: Is it Worth the Use of Doppler Guide in Long-Term Follow-Up?: A Single-Center Cohort Study.

Hemorrhoidal artery ligation (HAL) may reduce postoperative pain and complications and shorten patients' recovery when compared to standard hemorrhoidectomy. It is unclear if the Doppler guide (DG) is useful in reducing recurrence risk. To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade. Between January 1, 2014 and January 31, 2021, 122 patients affected by grade II-III hemorrhoidal prolapse underwent DG-HAL or HAL at Chivasso Hospital, Italy. Mucopexy was routinely performed. After discharge, patients were subjected to 1-week, 1-, 3-, 6-, and 12-month clinical assessment. Thereafter, they were interviewed by telephone annually. Seventy-six (62.3%) DG-HAL and 46 (37.7%) HAL procedures were performed. Median surgical time was 30 (15-45) minutes for DG-HAL versus 25 (15-40) minutes for HAL (P = 0.005). No intraoperative complications occurred. Postoperative bleeding needing surgery occurred in 2 (1.6%) patients in the DG-HAL group. During a median follow-up of 46 months (6-86), we registered 18 (23.7%) recurrences in the DG-HAL group and 13 (28.3%) in the HAL one (P = 0.574). No cases of incontinence or anal stenosis occurred. No significant difference was observed between the two groups in terms of patients' satisfaction. At multivariate analysis, age ≥ 65 years resulted a protective factor for recurrence (odds ratio 0.31; 95% confidence interval 0.09-0.98; P = 0.047). In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.

Hemorroids Therapy: a Tailored Approch

One of the most common reasons to consult a coloproctologist is symptomatic haemorrhoids. Typical signs and symptoms as well as a specialised examination, including proctoscopy, are essential for the correct diagnosis. The vast majority of patients can be treated conservatively with excellent results in terms of quality of life. Sclerotherapy provides good control of symptoms at any stage of haemorrhoidal disease. If conservative treatment fails, there are various surgical options. A tailored approach is mandatory. Besides well-known procedures such as Fergusson, Milligan-Morgan procedure or haemorrhoidopexy (Longo) there are less invasive options such as HAL-RAR, IRT, LT and RFA. Postoperative bleeding, pain and faecal incontinence are rare complications after surgery.

Anal carcinoma: A retrospective analysis in a Mexican cohort.

e15502 Background: Anal carcinoma is a rare neoplasm, representing &lt; 1% of all neoplasms with rising incidence and mortality. More than 90% of cases are linked with high-risk human papillomavirus (HPV). Other factors such as HIV status, smoking and socioeconomic disparity may have important roles. Few data are available on the Mexican population. Methods: Retrospective analysis of patients with pathology-confirmed anal carcinoma treated at an Oncology Reference Center in North-East Mexico from 2010 to 2020. Using descriptive statistics, we report clinical and pathological features, time from symptom onset to diagnosis and treatment, as well as response and recurrence rate. Results: Forty-one patients were included in the final analysis. The mean age at diagnosis was 61.4 +/- 13.8 years and 58.5% were women. Smoking history was identified in 17 patients (41.5%). 9.8% were HIV-positive, however 63.4% of all patients had unknown status at cancer diagnosis. Mean duration of symptoms to diagnosis was 344 days (range 4-1435 days) and the median interval from symptom onset to registration for oncology consultation was 424 days (range 28-1695 days). Patients attended a median of 3 (range 1 to 7) previous clinical consultations before being referred to our center. It is noteworthy that 44% of patients had hemorrhoidal disease history. Squamous cell carcinoma was the most common histological subtype with 93% of all cases, arising from the anal canal in 78% of cases, while 22% corresponded to perianal cancer. Regarding the clinical stage at presentation, 2.4% of patients had localized disease, while 95% had regional spread and 2.4% presented with distant metastases at diagnosis. Treatment intent was curative in 85.4%. Treatment modalities included radiotherapy (97%), surgery (7%), chemotherapy (88%). Concurrent chemoradiotherapy was received by 85%. Most patients were treated with a total dose between 45 and 60 Gy to the tumor volume. Radiotherapy delays due to toxicity occurred in 31.7% of cases, these unplanned treatment interruptions correlated negatively with response rate (p &lt; 0.001). The chemotherapy regimen used was 5-fluorouracil (5-FU) with mitomycin C (MMC) in 29%, capecitabine monotherapy in 31.7%, 5-FU with cisplatin in 12.5%, capecitabine with MMC in 5%, and capecitabine with cisplatin in 5%. Among patients treated with curative-intent, 46% had a complete response and 37% had a partial response. Relapse occurred in 10 cases (24%), the majority being local relapses (54%). Distant relapse occurred in 15% of all cases. The median disease-free interval (DFI) was 32.5 months (range 0-252 mo). Colostomy rate was 29%, the median colostomy-free survival (CFS) was 10 months (range 3-15 mo). The comparative analysis between MMC-based chemotherapy and chemo without MMC did not show difference in response rate, recurrence, DFS and CFS. Conclusions: Due to its rarity and complex management patients with anal carcinoma should be treated at experienced centers.

The use of sodium thiosulfate in the treatment of hemorrhoids

Hemorrhoidal disease is one ofthe most common pathologies ofthe anorectal region, its specific weight in the structure of diseases ofthe colon is about 40%. Hemorrhoids are a socially significant disease, most often found in the able-bodied population. The reason for the development of hemorrhoids, on the one hand, is a violation of blood circulation in the cavernous corpuscles, due to which they increase and nodes form, and on the other hand, dystrophic changes in the ligamentous apparatus of hemorrhoids, in connection with which they gradually shift down and begin to fall out of the anal canal. One of the factors provoking the development of hemorrhoidal disease may be the presence of dissinergia of the pelvic floor muscles, which, in accordance with the Roman criteria IV, is part of the functional constipation syndrome. Not only dissinergia, but also high basal pressure in the anal canal (increased tone of the internal anal sphincter) can lead to stool retention. High rates of basal anal pressure can occur as a result of damage to the mucous membrane of the anal canal during straining, which leads to reflex spasm of the anal sphincter (anal continuity reflex). Thus, a vicious circle can form and thereby exacerbate constipation and the course of hemorrhoidal disease. Also, the relationship between dysenergic defecation and hemorrhoidal disease can be justified by the fact that physiotherapy aimed at correcting the work of the pelvic floor muscles contributes to better control over the manifestations of hemorrhoidal disease in complex therapy. The return of symptoms or, in other words, the recurrence of the disease in patients after surgery for hemorrhoids more often occurs with concomitant constipation. In accordance with clinical recommendations for the treatment of hemorrhoids, the use of an adequate amount of fluid and the intake of dietary fiber (fiber preparations) is indicated to normalize the activity of the gastrointestinal tract and eliminate constipation as part of complex therapy. If it is impossible to take dietary fiber, laxatives come to the fore of constipation therapy. This article presents clinical examples of the efficacy and safety of using sodium picosulfate.

Phlebotonics for conservative treatment of haemorrhoids: when, to whom, how?

Hemorrhoidal disease (HD) is a pathological enlargement of the external and/or internal hemorrhoidal piles, which may be accompanied by the bleeding and prolapse of haemorrhoids outside the anal canal. The incidence of HD among the population of the Russian Federation is 130–145 patients per 1000 people, occurring mainly in patients 45–65 years old. Among all coloproctological diseases in Russia, haemorrhoids became the reason for visiting a coloproctologist in 35–41.9% of cases. In outpatient department, the disease occurs with a frequency of 694 per 100,000 population. The treatment of hemorrhoids often begins at the coloproctologist’s office during outpatient visits. Typical clinical presentations of hemorrhoids include a complex of symptoms: periodic rectal bleeding during defecation, prolapsed hemorrhoids requiring manual reduction. Pain and itching are much less common symptoms. The treatment of hemorrhoidal disease consists of a complex of conservative measures, minimally invasive and surgical treatments, or a combination of above methods. Systemic phlebotropic drugs that affect various pathogenesis links of hemorrhoidal disease hold one of the first rightful places at the very core of modern conservative therapy regimens. Phlebotropic drugs are a large group of biologically active substances that are products of chemical synthesis or plant processing. The venotonic drugs containing flavonoids diosmin and hesperidin are the most studied ones. Various effects of diosmin and hesperidin from anti-ulcerogenic and antitumor to antioxidant and anti-inflammatory ones have been studied in clinical and experimental studies. Its venotonic and angioprotective effects are the most important actions for the treatment of hemorrhoidal disease. This review of literature is aimed determining the place of phlebotonics in outpatient practice for the treatment of haemorrhoidal disease.

The system of anesthesiological support for coloproctological operations

Introduction. The prevalence of hemorrhoidal disease is 200 people per 1000 adult population, of which 75% are professionally active people. The choice of anesthetic support affects not only the effectiveness of the operation, but also the course of the early postoperative period. At the same time, regardless of the use of various variants of neuroaxial blockades, most authors indicate the development of complications such as acute urinary retention and severe postoperative pain syndrome in the postoperative period.Aim. To substantiate and evaluate the effectiveness of the proposed system of anesthesiological support for proctological operations.Material and methods. The study was conducted in 100 patients who were divided into two groups of 50 people. The operations were performed under conditions of combined anesthesia (spinal anesthesia + medical sedation). Spinal anesthesia was achieved with 0.5% isobaric bupivacaine solution, the average dose was 8.5 ± 0.12 mg. For drug sedation, a continuous infusion of propofol was used at a target concentration of 5–4–3 mg/kg per hour. The criterion for including patients in the main group was the appointment in the early postoperative period of the alpha 1 adrenoblocker tamsulosin hydrochloride at a dose of 0.4 mg/day.Results and discussion. The system of anesthetic support, including a combination of spinal anesthesia using an isobaric solution of bupivacaine at a dose of 7.5 to 10.0 mg and intravenous sedation with propofol at a target concentration of 5–4–3 mg/kg per hour, program of postoperative anesthesia based on a combination of multidirectional drug action and the appointment of alpha 1 adrenoblocker tamsulosin hydrochloride at a dose of 0.4 mg/day allows for high-quality and safe surgical treatment.Conclusion. The administration oftamsulosin hydrochloride at a dose of 0.4 mg prevented the development of acute urinary retention of patients.

The role of laser technologies in coloproctology

Laser (Light Amplification by the Stimulated Emission of Radiation) is a technical device that emits electromagnetic radiation focused in the form of a beam in the range from infrared to ultraviolet, with high energy and biological effect. In the first quarter of the 20th century, A. Einstein laid the foundation for its creation, believing that when atoms are excited from an external radiation source, a multiple increase in the released photons occurs, and the result of this process is recorded as light energy. Back in the late twentieth century, lasers in coloproctology were used as a scalpel, in fact, they performed traditional surgical interventions, but using energy tools, however, this did not deprive patients of extensive wounds and, as a result, pronounced pain sensations. The modern use of laser in proctology is really minimally invasive. An optical fiber is carried through small punctures on the skin or fistula, through which the laser energy flows directly to the target and acts aiming. In coloproctology, lasers are used to treat hemorrhoidal disease, rectal fistulas and pilonidal sinus this isrecorded in clinical guidelines. The use of laser treatment with these nosologies can reduce the severity of pain after surgery, significantly reduce the healing time of wounds, shorten the period of disability, without reducing the quality of life of patients. At the same time, these interventions are almost as effective as classical operations, in some cases even superior. But despite these encouraging data, it is necessary to conduct further research in order to develop clear technical regulations for the use of laser techniques and tracking long-term results.

O132 Preliminary results of radiofrequency ablation for haemorrhoidal disease at a district general hospital

Abstract Introduction Haemorrhoidal disease (HD) is a common perianal condition. There is still limited data on the role of minimally invasive surgery for HD. The aim of our study was to report the outcome of radiofrequency ablation of haemorrhoids under local anaesthetic (RAFAELO) at our institution. Methods 23 patients who had a day-case RAFAELO procedure under local anaesthesia without sedation by a single surgeon from March to October 2022 were retrospectively reviewed. We analysed patients’ demographics, haemorrhoid severity score (HSS), the health's condition scale in EQ-5D-5L questionnaire, and recurrence rate. Results The mean age of patients was 50 years (SD 14). 65% were male whereas 35% were female. Majority of haemorrhoids (48%) were Grade 3A. Most of the cases had previous procedures such as rubber band ligation (57%) and hemorrhoidal dearterialization (9%). Only 34% had no prior hemorrhoidal surgery. The mean HSS score significantly improved from 13.2 (SD 4.9) to 4 (SD 2.2) with p &amp;lt; 0.001 postoperatively. The health's condition scale became significantly lower from 64 (SD 23.6) to 23.9 (SD 14.6) with p &amp;lt; 0.001. The median length of follow up was 2 months (range 1-5 months). There was no acute postprocedural complication but there was a recurrence rate of 13% requiring further procedures. Conclusion This study supports previous findings that RAFAELO is a safe and effective procedure for HD. It also highlights that it can be performed in the out-patient setting safely. However, further studies with larger samples, longer follow-up and comparison with other procedures are suggested.

Ilaser Submucous Destruction in the Treatment of Hemorrhoids

Aim: to improve the results of treatment in patients with hemorrhoids of the 2nd and 3rd stages.Materials and methods. The prospective study included 60 patients with hemorrhoids of the 2nd and 3rd stages. All patients underwent destruction of internal hemorrhoids with a fiber laser with a diode pump with a wavelength of 1940 nm. The technique is based on the effect of laser energy on the cavernous tissue of the internal hemorrhoidal node and on the terminal branches of the upper rectal artery. The efficiency of the destruction of internal hemorrhoids and the frequency of relapses of the disease were evaluated. The effectiveness of the proposed method was evaluated using anoscopy, measurement of the size of internal hemorrhoidal nodes, transrectal ultrasound with dopplerography. The analysis of the intensity of the pain syndrome, the consumption of nonsteroidal anti-inflammatory drugs and the assessment of the quality of life on the SF-36 scale was carried out. Sphincterometry was performed in all patients to determine the possible effect of laser radiation on the rectal locking apparatus. To assess the possible causes of complications, a single-factor analysis of the amount of energy transferred to each hemorrhoidal node and the total amount of energy spent on the operation was conducted.Results. In all patients, by day 7 after surgery, the pain syndrome in 43 patients (75.4 %) corresponded to 0 points according to VAS. In 3 patients (5 %) intraoperative hemorrhage developed. In the early postoperative period, 5 patients (8.3 %) had 7 complications: 5 cases of thrombosis of the external hemorrhoidal node and 2 — of acute urinary retention. The conducted single-factor analysis showed the dependence of the development of complications on the energy transferred to each hemorrhoidal node and its total amount for the entire operation. In terms of up to 6 months, there were no signs of a return of the disease in any case (hemorrhoidal prolapse and blood discharge). The detected hemorrhoids before the operation, a month after the operation, were not visualized, which persisted after 6 months. The performed transrectal ultrasound examination with spectral-wave dopplerography for up to 6 months allowed to diagnose a persistent decrease in blood flow along the terminal branches of the upper rectal artery compared with preoperative values. When performed sphincterometry, there was no change in the parameters of the anal sphincter function compared to preoperative parameters.Conclusion. The proposed method applying a fiber laser with a diode pump with a wavelength of 1940 nm makes it possible to affect transdermally the internal hemorrhoidal node without damaging the mucosa of the anal canal. The absence of postoperative wounds in the anal canal leads to a decrease in pain syndrome, and by day 7 there are no clinical manifestations of hemorrhoids. The method of laser destruction of internal hemorrhoids can be used in outpatient conditions and can improve the quality of life of patients in the early postoperative period.