Mucosal Prolapse Research Articles

PRIMARY PROCEDURE FOR ANORECTAL MALFORMATIONS IN CHILDREN; A SINGLE CENTER EXPERIENCE

Tariq Waheed , Sajjad Ali , Muhammad Uzair ,Inayat Ur Rehman
 Objective: To share our experience with outcome of primary procedure for anorectal malformation (ARM) in children.
 METHODOLOGY: Retrospective study included 40 patients from both sexes operated between January 2018 and January 2019 for high and intermediate ARM in the department of paediatric surgery Khyber teaching hospital Peshawar. Patients with common cloaca and associated life threatening anomalies were excluded. Demographic and clinical data was tabulated and analyzed. Cost of the procedure was recorded in Pakistani Rupees and hospital stay in days. Continence was evaluated by Kelly’s score and parents’ satisfaction graded by Likert scale.
 RESULTS: Male to female ratio was 1.6:1. Mean hospital stay was 5.91±1.01 days and mean cost of 22950 ± 3234 PKR. Wound dehiscence was recorded in 3 (7.5%), 2 (5.0%) patients developed surgical site infection and 11 (35.48%) patients had perianal excoriation. Adhesive obstruction and mucosal prolapse were seen in 1 (2.5%) patient each while anal stenosis in 2(5.0%) Patients. After 6 months 28 (70%) patients had formed stools while 12 (30%) had loose stools. Stool frequency was 0-1 time/day in majority i.e. 20 (50 %) patients. Continence was fair in 24 (60%) patients. Parents of 20 (50%) patients were very satisfied, 17(42.5%) satisfied only. Continence for age and sex revealed insignificant P values of 0.213 and 0.07 respectively.
 CONCLUSION: Primary procedure for anorectal malformations may be a good alternative to traditional three stage procedure in selected patients with intermediate and high variety of ARM.
 KEY WORDS: Anorectal malformation (MeSH); Abdominoperineal pull through (Non-MeSH); Kelly’s score (Non-MeSH).

POSTERIOR SAGITTAL ANORECTOPEXY FOR PAEDIATRIC RECTAL PROLAPSE

Introduction: Rectal prolapse is a very common and self limiting condition amongst the paediatric age group in India. Majority of the cases respond to conservative management. The various modalities of management of the same include surgical as well as medical modalities. Surgical namely Thierschs anal circlage, laparoscopic suture rectopexy, and posterior sagittal rectopexy Aim - To evaluate the safety and efcacy of posterior sagittal rectopexy in children with rectal prolapse. Patients and Methods: Twenty patients aged between 1 and 7 years presented with rectal prolapse. These patients underwent posterior sagittal anorectopexy after pre anaesthetic check up. These patients were followed up at 1week, 15days and 1month for 3 months. Results: Constipation improved in 18 out of 20 patients, who had a history of constipation before surgery. Partial mucosal prolapse recurrence occurred in two patients. Conclusion: Posterior Sagittal Rectopexy is a good option in cases of rectal prolapse in children once all the conservative methods have failed. The technique is safe and effective. It has satisfactory functional results.

Laparoscopic Ventral Mesh Rectopexy (LVMR) for Internal and External Rectal Prolapse: An Analysis of 122 Consecutive Patients.

Even though several reports have been published on the results of laparoscopic ventral mesh rectopexy (LVMR) in Asia, there are few mid-term or long-term results of LVMR. The authors aimed to evaluate the results of LVMR in patients with internal rectal prolapse (IRP) external rectal prolapse (ERP). From September 2013 to January 2019, 122 patients with IRP (n=48) or ERP (n=74) underwent LVMR. Constipation and fecal incontinence (FI) scores were evaluated using the Cleveland Clinic Florida score preoperatively and postoperatively. The questionnaire for the change of obstructed defecation or FI symptoms after surgery was also administered to grade the results as cured, improved, unchanged, or worsened for each survey. The mean age of the patients was 61.9 years. The mean operation time was 116.5 minutes, and the mean hospital stay was 5.1 days. The mean follow-up was 42.1 months. There were no mesh-related complications. Eight patients (10.7%) among the ERP group required additional surgery for recurrent full-thickness prolapse. Eleven patients (14.7%) who had mucosal prolapse within 2 cm underwent stapled hemorrhoidopexy after LVMR. In the postoperative 6-month period, the overall constipation score (7.12) significantly improved compared with the preoperative score (13.03) (P<0.001), whereas the FI score significantly improved after surgery (12.16 to 8.92; P<0.001). LVMR is a feasible and safe technique and favorable recurrence for ERP. Functional outcomes of obstructed defecation and FI were improved and the satisfaction of LVMR was high after the surgery. LVMR can be considered a recommended surgical option to treat ERP and IRP.

PELVIC FLOOR MUSCLE TRAINING USING BIOFEEDBACK THERAPY VERSUS BILATERAL POSTERIOR TIBIAL NERVE STIMULATION FOR TREATMENT OF OBSTRUCTED DEFECATION A RANDOMISED CONTROLLED TRIAL

Obstructed defecation syndrome (ODS) is a type of constipation characterized by two or more of the following symptoms in more than 25 percent of defecation trials: straining, lumpy or hard stools, urgency, sense of incomplete evacuation, pelvic heaviness and manual maneuvers to promote defecation.obstructed defecation is of two basic types: functional and mechanical. The functional type involves idiopathic megarectum, anismus (pelvic floor dys-synergy), and descending perineal syndrome, while the mechanical type includes rectocele, enterocele, internal rectal intussusception and overt rectal prolapse.An excessive straining is likely to be the “primummovens”, causing tissue weakness and organ descent, and often is due to longterm anxiety, muscle tension and resulting in non-relaxing puborectalis muscle. The increased straining causes pudendal nerve stretch which may lead to a pudendal neuropathy which affects the rectal sensations.ODS has been also defined as an “iceberg syndrome”, as the two most frequent lesions, i.e., rectocele and rectal internal mucosal prolapse, present in more than 90% of patients with ODS, are easily detectable and may be considered “emerging rocks”, whereas the “surgical ship” is likely to “sink” due to the “underwater rocks”, i.e., the occult lesions.

Rectal mucosal prolapse with an emphasis on endoscopic ultrasound appearance

AimThe diagnosis of mucosal prolapse syndrome (MPS) continues to be a challenge. Endoscopic ultrasound (EUS) is of clinical value in anorectal diseases. This study seeks to investigate the use of EUS in the diagnosis of MPS. MethodsA total of 39 patients diagnosed with MPS between June 2015 to December 2019 were included in this study. Their clinical histories, endoscopic images, EUS images, and pathological data were retrospectively collected, and the EUS images were reviewed to summarize the characteristics of MPS. ResultsIn total, 39 MPS patients were enrolled. The main presenting symptoms were bleeding (61.5%) and constipation (53.8%). Gross appearance of the rectal lesions was mainly classified into three types: 51.3% of the lesions were polypoidal/nodular, 33.3% were ulcerative and 15.4% were flat with erythematous mucosa only. A total of 10 patients underwent EUS operation. With regard to the EUS appearance of MPS, four patients with polypoidal/nodular lesions showed thickening of the mucosa on EUS. The diffuse thickening of the mucosa-submucosa layer and disappearance of the architectural structure was observed in four patients with ulcerative lesions. Finally, the thickening of the muscularis propria was observed in two flat lesions. The serosal layers were intact in all the MPS patients. Neither blood flow signals nor regional lymph nodes were observed on EUS. ConclusionThe EUS characteristics for MPS corresponding to different gross appearance can be classified into three types. These findings suggest that EUS is useful in the diagnosis of MPS.

Delayed presentation of anorectal malformations in a tertiary care hospital in India.

To study delayed presentation of ARMs, management and its effect on surgical and functional complications. It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6months. Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis.

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

A case of mucosal prolapse syndrome complicated by well-differentiated tubular adenocarcinoma and high-grade adenoma after long-term follow-up by colonoscopy

This study included a 45-year-old woman. In 20XX, we performed colonoscopy (CS) on fresh bloody stools, and a diagnosis of rectal mucosal prolapse syndrome (MPS) was made. In 20XX+14 years, CS was reexamined because of fresh bloody stools, and a biopsy of the same site revealed well-differentiated tubular adenocarcinoma. The lesion was resected via endoscopic submucosal dissection (ESD) and histopathologically diagnosed as MPS with high-grade adenoma and well-differentiated tubular adenocarcinoma. The symptoms improved after ESD, and no recurrence was observed during the 18-month follow-up. We experienced a case of a well-differentiated tubular adenocarcinoma in MPS during the long-term follow-up of MPS. In this case, performing ESD was useful not only for cancer treatment but also in terms of therapeutic effects on symptoms. Although MPS is a chronic benign inflammatory disorder, characterized by rectal mucosal prolapse with fibromuscular obliteration, it is necessary to consider the possibility of the appearance of cancer during the follow-up of MPS.

Delorme surgery for colonic mucosal prolapse after intersphincteric resection.

Mucosal prolapse at the site of anastomosis is a long-term complication unique to ISR. It reduces the QOL of patients due to a worsened anal function and local symptoms around the anus. We herein sought to assess the surgical outcomes after Delorme surgery for these patients. ISR was performed in 720 patients with low rectal cancer between January 2001 and March 2019 at the National Cancer Center Hospital East. Among these patients, the 33 (4.5%) who underwent initial Delorme surgery for postoperative colonic mucosal prolapse were identified from the medical records and then were analyzed retrospectively. We estimated the anal function using Wexner's incontinence score and assessed whether local anal symptoms due to the prolapse improved postoperatively. Stoma closure was performed before Delorme surgery in 15 (45.5%) patients, and we compared the preoperative and postoperative anal function in these patients. The average Wexner's incontinence score changed from 15.1 before to 12.9 after Delorme surgery. Local symptoms around the anus improved in all 33 (100%) patients. Recurrence of colonic mucosal prolapse occurred in 5 patients (15%), and Delorme surgery was reperformed in these cases. Delorme surgery for colonic mucosal prolapse following ISR has clinical benefits for both improving anal local symptoms and slightly improving the anal function.

S3380 Mucosal Prolapse Syndrome: Case Report and Literature Review

INTRODUCTION: Mucosal prolapse is a rare condition that consists of protrusion of the rectal mucosa through the anal sphincter. This condition comprises, solitary rectal ulcer syndrome, adenocarcinoma, hamartomas, inflammatory cloacogenic polyp, inflammatory myoglandular polyp, and proctitis cystica. It is prevalent among males (3:1) and typically found in the 4-6 decades of life, the patient presents with hematochezia, tenesmus, partial incontinence, constipation, or can be asymptomatic. Surface erosion of the mucosa can occur as well as inflammation, hemorrhage, and fibrosis. Histologic features are disruption of the muscular mucosal and fibromuscular repair on the lamina propia. CASE DESCRIPTION/METHODS: The patient is a 23 year old female with a medical history of sickle cell trait and family history of gastrointestinal cancer and polyps who presented to the outpatient clinic complaining of rectal bleeding accompanied by anemia. Skin tags and large external hemorrhoids were noted on digital rectal exam (DRE). A colonoscopy was then scheduled. This was later done revealing, but was limited due to the inability to advance the scope beyond 20 cm, with evidence of a large, indurated and ulcerated mass in the rectal area measuring approximately 4 cm. Additionally a circumferential, indurated lesion 8-10 cm from anal verge was found with multiple biopsies performed to rule out malignancy (Figure 1). The biopsy results showed fragmented hyperplastic colonic mucosa showing fibrosis and smooth muscle strands in the lamina propia, consistent with mucosal prolapse syndrome (Figure 2). The patient was then referred to colorectal surgery due to hemorrhoids and prolapsed polyps near the anal verge. A hemorrhoidectomy was performed shortly thereafter for symptomatic relief. DISCUSSION: Mucosal prolapse syndrome is the presenting sign of a variety of conditions, as the differential diagnosis is broad. Among almost all cases colonoscopy will allow for direct visualization and treatment of polyps and ulcerations. Biopsies will confirm the etiology in most of the cases. These conditions present with constipation, leading to spastic contraction, which ultimately leads to congestion. Histologically, there is an overlap with the findings seen among all the mentioned etiologies. Findings such as fibromuscular obliteration, glandular crypt abnormalities, and gland dilation are reported and mimicking of adenomas and adenocarcinomas. The primary purpose is to rule out malignancy and then establish surveillance.Figure 1.: Colonoscopy showing an indurated mass in the rectal area.Figure 2.: Fragmented hyperplastic colonic mucosa showing fibrosis and smooth muscle strands in the lamina propria.

Large prolapse-related lesions of the sigmoid colon.

Large prolapse-related lesions (LPRL) of the sigmoid colon have been documented histologically but may not be readily recognized endoscopically. Colonic lesions referred for endoscopic mucosal resection (EMR) were enrolled prospectively. Endoscopic features were carefully documented prior to resection. Final diagnosis was made based on established histologic criteria, including vascular congestion, hemosiderin deposition, fibromuscular hyperplasia, and crypt distortion. Of 134 large ( ≥ 20 mm) sigmoid lesions, 12 (9.0 %) had histologic features consistent with mucosal prolapse. Distinct endoscopic features were: broad-based morphology; vascular pattern obscured by dusky hyperemia; blurred crypts of varying size and shape; and irregular spacing of sparse crypts. Focal histologic dysplasia was identified in 6 of 12 lesions (50.0 %). LPRL of the sigmoid colon exhibit a distinct endoscopic profile. Although generally non-neoplastic, dysplasia may be present, warranting consideration of EMR.

The outcome of two stage repair in anorectal malformations with rectovestibular fistula.

Wound infection and dehiscence after recto vestibular fistula repair may affect the fecal continent mechanisms. A significant number of children with anorectal malformations have long term social, economic and psychological problems due to fecal incontinence. The role of protective colostomy should not be under estimated especially when you are treating the children from poor socioeconomic settings with compromised nutritional status. Objectives: The aim of this study was to evaluate the outcome of two stage limited posterior sagittal anorectoplasty with protective colostomy in female patients of congenital recto vestibular fistula. Study Design: Prospective study. Settings: Department of Pediatric Surgery, DHQ Teaching Hospital Sahiwal. Period: January 2016 to December 2018. Material &amp; Methods: Thirty four girls with anorectal malformation and recto vestibular fistula underwent two stage anorectoplasty. Divided sigmoid colostomy and limited posterior sagittal anorectoplasty was performed in first stage. Six to eight weeks later stoma was closed in second stage. All the patients were evaluated for fecal continence, constipation, bowel function and complications of stoma formation, definite procedure and stoma closure. Results: The age distribution of patients at the time of surgery ranged from 9 months to 5 years (mean 27.32 months). During the first stage of repair, three patients (8.82 %) developed wound infection. Mucosal prolapse was seen in two patients (5.88%). Anal stenosis was noticed in one patient (2.94%). Seven patients (20.58%) developed peri stoma skin excoriation. Stoma prolapse was observed in three patients (8.82%). Four patients (11.76%) developed wound infection after colostomy closure. During the follow up period, constipation was reported in five patients (14.70%) and soiling in one patient (2.94%). Conclusion: Two stage correction of congenital recto vestibular fistula under the cover of colostomy is safe strategy. It is strongly recommended in a setup with limited resources and weak infrastructure. It is also useful for patients from poor socioeconomic settings.

Examination of rectal mucosal prolapse syndrome requiring differentiation from rectal tumor

Examination of rectal mucosal prolapse syndrome requiring differentiation from rectal tumor

Outcomes of laparoscopic continent catheterizable conduit procedures in children with neurogenic bladder: An 8-year experience in a single center

The continent catheterizeable conduit (CCC) procedure plays an important role in the treatment of children with neurogenic bladder. Laparoscopic procedures offer significant benefits; however, the potential complications should not be ignored. By comparing the complications of CCC in laparoscopic and open neurogenic bladder operations in our center, we aimed to explore the advantages of laparoscopic CCC construction in children. All the cases of neurogenic bladder who had undergone laparoscopic or open lower urinary tract reconstruction at our hospital from June 2009 to December 2016 were retrospectively reviewed. We compared the rates of various complications in the laparoscopic and open groups as well as the appendix and Yang-Monti groups. 61 patients were included in this study. Laparoscopic CCC procedure was performed in 45 cases, 9 were converted to open owing to other combined procedures. Open CCC construction was performed in 16 cases. The mean follow-up time was 4.5 years. Catheterization was safe and uneventful in 72.1% of patients. Complications occurred in 17 cases, including stoma stenosis (n=5), leakage (n=5), mucosal prolapse (n=3), conduit atresia (n=3), and angulation of the conduit (n=1). Eleven cases received surgical revision. There were no statistically significant differences in complication type or rate in the laparoscopic and open group, or in the appendix and Yang-Monti group. Although our study showed a notable complication rate associated with CCC, this did not differ for open and laparoscopic procedures, and laparoscopic procedures can achieve satisfactory results comparable to open procedures. From our single center's experience of lower urinary tract reconstruction, laparoscopic CCC surgery has a shorter hospital stay and no more complications than the open procedure. It is a safe and feasible procedure in children.

Comperative Study of Laser Haemorrhoidoplasty and Miligan-Morgan Haemorrhoidectomy in 2nd and 3rd Degree Haemorrhoid

Background: Arterial overflow in the superior hemorrhoidal arteries would lead to dilatation of the hemorrhoidal venous plexus, according to the ‘‘vascular’’ theory. Hemorrhoid laser procedure (LHP) is a new laser procedure for outpatient treatment of hemorrhoids in which hemorrhoidal arterial flow feeding the hemorrhoidal plexus is stopped by laser coagulation. Compare the hemorrhoid laser procedure with Miligan-Morgan open surgical procedure for outpatient treatment of symptomatic hemorrhoids. &#x0D; Material and methods: This study was conducted at Chittagong Medical College Hospital (CMCH) and Private Hospital in Chittagong. Patients with symptomatic grade II or grade III hemorrhoids with minimal mucosal prolapse were eligible for the study: 30 patients treated with the laser hemorrhoidoplasty, and 30 patients–with Miligan-Morganhemorrhoidectomy. Operative time and postoperative pain with visual analog scale, were evaluated.&#x0D; Results: A total number of 60 patients (33 men and 27 women, mean age 45 years) entered the trial. Significant differences between laser hemorrhoidoplasty and Miligan-Morgan surgical procedure were observed – i) Operative time ii) Early postoperative pain. There was a statistically significant difference between the two groups regarding peri-operative and the early postoperative period: 1 week, 2 weeks, 3 weeks and 1 month after respective procedure.&#x0D; Conclusions: Laser hemorrhoidoplasty procedure is more preferred in comparison with conventional open surgical hemorrhoidectomy. Postoperative pain is significantly lesser in laser procedure compared with surgical procedure&#x0D; JCMCTA 2020 ; 31 (1) : 86-89

Gastrointestinal Polyps and Polyposis in Children: Experience of Endoscopic and Surgical Outcomes

Introduction: There are gaps in the literature regarding outcome of multiple polyps and dilemmas in the management issues in polyposis syndromes in children. Objective: We aimed to study the clinical behaviour of gastrointestinal (GI) polyps with emphasis on therapeutic outcomes of polyposis syndrome. Methods: Proven cases of GI polyp(s) on endoscopy were classified as single polyp, multiple polyps, and polyposis syndrome. Complex presentation was defined as 1 or more of the following: severe anaemia, anasarca, intussusception, rectal mucosal prolapse, and diarrhoea. A clinico-endoscopic criterion was applied in polyposis syndrome patients for the decision of surgery versus endoscopic therapy with surveillance. Results: Of total 240 patients, there were no significant differences between single (52.5%, n = 126) versus multiple polyps (27.5%, n = 66) with respect to age, symptoms, histology, and recurrence. Polyposis syndrome (20%, n = 48) presented with complex symptoms (50%), higher family history, significantly lower haemoglobin, total protein, and albumin as compared to single and multiple polyps (p < 0.01). Nineteen polyposis patients with favourable clinico-endoscopic criteria were endoscopically eradicated for polyps in 3 (1–4) sessions with sustenance of laboratory parameters at 1 year and 30% symptomatic recurrence at follow-up of 23.5 (7–40) months. There were no major endoscopic complications. Nineteen patients required proctocolectomy with improvement in laboratory parameters 6 months post-surgery. Conclusions: Multiple polyps behave similar to single polyps in children. A clinico-endoscopic criterion may guide for optimal management of polyposis syndrome. Colectomy may be effectively deferred in a large proportion of polyposis syndrome patients if maintained on an endoscopic protocol.

Mucosal prolapse in capsule endoscopy. What does it make us think of?

Mucosal prolapse in capsule endoscopy. What does it make us think of?

Evaluation of Mucopexy-Recto Anal Lifting (MuRAL): A New Method for Treating Hemorrhoids.

Objectives: Ligation and excision remain the commonly recognized standard surgical modality for treating hemorrhoids. Further, impediments to surgical treatment owing to social factors and the need for minimally invasive procedures and other confounders have resulted in the adoption of the mucopexy-recto anal lifting (MuRAL) method which is associated with favorable outcomes. The objective of this study was to describe the procedure and report the outcomes in patients who underwent MuRAL. Methods: Between March 2016 and February 2018, 55 patients (26 males and 29 females) underwent MuRAL for hemorrhoids and rectal mucosal prolapse. The duration of the surgical procedure and hospitalization, postoperative complications, and satisfaction were evaluated. Results: The mean age of the male patients (n = 26) was 61.5 ± 4.9 years and that of the female patients (n = 29) was 61.5 ± 3.2 years. The mean duration of surgery was 46 ± 23 minutes for males and 53 ± 28 minutes for females, and the mean observation duration was 317 ± 186 days. Intraoperative hemorrhage was low for males and females. The mean hospitalization period was 3.2 ± 1.5 days for males and 4.3 ± 2.1 days for females. Differences in several postoperative complications were observed between male and female patients. Postoperative satisfaction was rated high by the patients. Conclusions: Risks of hemorrhage and pain associated with the MuRAL method were low because the procedure does not involve incision or excision. Other than ligation and excision, recurrence is favorable compared with that of other surgical modalities for the treatment of hemorrhoids.

Hemorrhoidal Laser Procedure (HeLP) and Hemorrhoidal Laser Procedure + Mucopexy (HeLPexx) and Other Emerging Technologies.

Minimally-invasive treatments for hemorrhoids should be encouraged as they cause low morbidity, reasonable discomfort and quicker return to work. According to the "vascular theory", hemorrhoidal disease is mainly caused by blood overflow into hemorrhoidal plexus deriving from the superior hemorrhoidal arteries. Many different procedures have been described in the literature with the common goal of reducing the blood flow into the hemorrhoidal piles. 'HeLP' (Hemorrhoids Laser Procedure) is a novel form of dearterialization to treat patients suffering from symptomatic hemorrhoids. The procedure consists of the closure of the terminal branches of the superior rectal artery approximately 2-3 cm above the dentate line by means of laser shots originated by a diode laser platform. The arteries, at that level, have variable location and distribution. Therefore, a doppler probe set at the frequency of 20MHz helps identifying the arteries that would be missed otherwise. The laser beam is well tolerated by patients. For this reason, anesthesia is not required in most cases and the procedure allows a quick return to daily activities. In the case of concomitant severe mucosal prolapse, laser treatment can be combined with suture mucopexy. Three to six running sutures allow a complete lifting of hemorrhoidal piles, securing a long-term resolution of symptoms. 'HeLP' is indicated in patients with symptomatic hemorrhoids where conservative treatment failed and when mucosal prolapse is scarce or not symptomatic. The addition of mucopexy to laser treatment (HeLPexx) contributes to the overall resolution of symptoms when mucosal prolapse is an issue. Emborrhoid is another novel, 'hi-tech' form of selective dearterialization used in selected cases of hemorrhoids where the main symptom is bleeding. It is generally used in cases where surgery is contraindicated due to severe concomitant diseases.

A Rare Case of Rectal Prolapse Complicated by Maggot Infestation

Rectal prolapse defined as mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice (Gourgiotis and Baratsis Int J Colorectal Dis. 22 (3):231-43, 2007). It can present with various symptoms including pain, incomplete evacuation, bloody or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent and have risk of strangulation. Mucosal prolapse, in contrast, is defined as protrusion of only the rectal mucosa from the anus. Here we are describing a case of complete rectal prolapse with extensive maggot infestation treated by perineal proctosigmoidectomy and proximal transverse colostomy. The patient doing well after 1-month follow-up planned for colostomy closure now.