Rectal Stricture Research Articles

A Case of Diffuse Large B-cell Lymphoma of Colon in a Patient with Ulcerative Colitis

INTRODUCTION: Adalimumab is an anti-TNF agent approved for the treatment of severe active Ulcerative Colitis (UC). Use of anti-TNF agents along with thiopurines increases the risk of lymphoma compared to thiopurines alone. Limited data is available regarding the risk of lymphoma in UC patients treated with anti-TNF agents alone. CASE: A 66 y/o old male with Left sided UC maintained on azathioprine (5 years) and adalimumab (3 years), presented with increasing abdominal cramping and bloody diarrhea with mucus for 3 weeks. Hemodynamically stable and physical exam significant for diffuse abdominal tenderness. Labs: Hgb 12.2 g/dL, normal WBC, negative Stool studies and C. difficile toxin. CT Abdomen showed distal sigmoid and rectal wall thickening with pericolonic fat stranding consistent with active inflammation and lymphadenopathy. Flexible sigmoidoscopy showed near complete obstruction due to rectal stricture with inability to pass scope beyond 10 cm. Biopsy revealed Diffuse large B-cell lymphoma. Azathioprine and Adalimumab were stopped and the patient received chemotherapy (with R-CHOP), followed by radiation and subsequent colectomy. DISCUSSION: Patients with Inflammatory Bowel Disease (IBD) have a slightly increased risk of lymphoma compared to the general population. The absolute risk is nearly twice as high in Crohn's Disease (CD) compared to UC. Incidence of lymphoma is approximately 4 times higher in IBD patients treated with thiopurines compared to patients not on these drugs. Among patients treated with anti-TNF agents (with and without thiopurines), the SIRR was 5.5 for past use (95% CI: 4.5-6.6) and 4.4 for current use (95% CI: 3.4-5.4). However studying the association between lymphoma and anti-TNF drugs is complicated because most patients treated with anti-TNF agents have been previously treated with Thiopurines or are receiving both medications concurrently. Reactivation of latent EBV infection is the best-studied mechanism for development of lymphoma in IBD patients on immunosuppressant therapy. When the patient develops lymphoma, therapy should be discontinued until the lymphoma has been treated and is in remission. If the patient has UC, surgical therapy is a better option when there is concern for lymphoma. Anti-TNF agents are effective in the treatment of IBD and can significantly improve quality of life. Decision to start these agents should be made by considering the potential risk of lymphoma against benefits.Figure 1Figure 2Figure 3

Successful treatment of rectovaginal fistula and rectal stenosis due to perianal Crohn's disease by dual-port laparoscopic abdominoperineal resection: a report of two cases.

BackgroundThe incidence of rectovaginal fistula in women with Crohn’s disease has been reported to be 3–10 %. Although rectovaginal fistulas can be managed medically and surgically, they have high rates of recurrence and complications. Rectal stenosis is another condition that occurs due to perianal Crohn’s disease. A novel, minimally invasive procedure, dual-port laparoscopic abdominoperineal resection using a multichannel port, has been shown effective in patients with lower rectal cancer and patients with medically uncontrolled ulcerative colitis. This report describes the use of the same method for two patients with Crohn’s disease-related rectovaginal fistula and rectal stenosis.Case presentationThe first patient, a 22-year-old woman, was diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn’s disease 2 years earlier. Induction therapy with infliximab and endoscopic balloon dilatation did not improve her symptoms. The second patient, a 33-year-old woman, was also diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn’s disease, and medical treatment was also unsuccessful. Both patients underwent dual-port laparoscopic abdominoperineal resection using a multichannel port, with no perioperative and postoperative complications.ConclusionThese findings show that this reduced port method can be used to successfully treat patients with Crohn’s disease-associated rectovaginal fistula and rectal stenosis.

Pouch Salvage Surgery for Treatment of Colitis and Familial Adenomatous Polyposis: Report of Five Cases

Introduction: The restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is currently the preferred surgicalmethod for most patients with ulcerative colitis and familial adenomatous polyposis and sometimes, functional bowel diseases.Infection around the pouch, remaining rectal stump, stricture at anastomosis site, pouch dysfunction and refractory pouchitis canlead to pouch failure. Pouch salvage surgery could prevent pouch failure in some cases.Case Presentation: In this report, five patients were introduced, who underwent pouch salvage surgery after RPC/IPAA surgeryfailure. Two of the patients were male and three were female and the relevant age range was 16 to 41. Initially, RPC/IPAA surgerywas performed on these five patients. Four of the patients underwent RPC/IPAA surgery as a result of ulcerative colitis and, one ofthe patients as a result of familial adenomatous polyposis. However, due to pouch failure from the RPC/IPAA surgery, pouch-salvagesurgery was performed on each of these five patients. Two of the patients underwent pouch-salvage surgery due to infection andpouch fistula, and the other three underwent this surgery due to the remaining rectal stump, anastomosis stenosis and pouchdysfunction. The average time for when pouch-salvage surgery was performed was 3.5 years (three months to five years) after theinitial operation and the patients were under follow-up care for two to seven years.Conclusions: After performing pouch salvage operation, pouch function was acceptable in all patients and we could closeileostomies of all of them.

Complication and remission rates after endoscopic argon plasma coagulation in the treatment of haemorrhagic radiation proctitis.

The management of haemorrhagic radiation proctitis is challenging because of the necessity for repeated intervention. The efficacy of argon plasma coagulation has been described before but the optimum treatment strategy remains debatable. This is a review of our experience over a decade treating patients with haemorrhagic radiation proctitis and their follow-up. This is a retrospective review of consecutive patients who underwent argon plasma coagulation for haemorrhagic radiation proctitis between January 2003 and December 2013. The patients were followed up using a prospectively maintained database. Ninety-one patients were included with a mean follow-up of 13.1months. Majoity (n=85, 93.4%) of the patients were female. Mean age at the time of treatment was 58.2 (range 23-87) years old. Majority of the patients (n=73, 80.2%) received radiotherapy for gynaecological malignancies followed by colorectal (n=13, 14.3%) and urological (n=5, 5.5%) malignancies. Mean interval between radiation and proctitis was 13.8 (range 3-40) months. Seventy-nine percent of patients were successfully treated after 1-2 sessions. Seventeen (18.7%) patients experienced self-limiting early complications, and three (3.3%) had late complications of rectal stenosis which was managed conservatively. Severity of bleeding during the initial presentation is an independent factor that predicts the number of sessions required for successful haemostasis (p=0.002). Argon plasma coagulation is a reasonable treatment option in patients with haemorrhagic radiation proctitis with good safety profile. Our study suggests that the number of APC sessions required to arrest bleeding correlates with the severity of bleeding on initial presentation.

PTU-016 The Endoscopic Submucosal Dissection Learning Curve: The Experience of a Large Volume Italian Colorectal (CRC) Screening Centre

Introduction Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique. In Eastern countries the learning curve is begun with gastric GI lesions carried out under expert supervision and then goes on to address esophageal and colon lesions. As Early Gastric Cancer (EGC) is a rare disease in Western countries, expert guidance is not commonly available. Methods All the ESD performed in our Endoscopy Unit in Padua from February 2012 to December 2015 including 12,552 colonoscopies were recruited retrospectively in this study. We considered the learning curve of a single endoscopist who performed 10 ESD on in vivo animal models under expert supervision before starting on human subjects. All the dissections were performed using a Hybridknife needle and ERBEJET2 (ERBE®). ESD was performed if the neoplastic lesion was considered susceptible to ESD regardless to the size. T tests for unpaired data and Pearson’s chi-test were used for statistical analysis. Results 49 ESD were performed, 28 M(57%), mean age 63 yr. The breadown was: 29 rectum (59%), 12 sigmoid tract (24%), 2 trasverse colon (4%), 4 ascending colon (8%), 2 stomach (4%). The neoplastic lesions were: 36 laterally spreading tumours (73%), 5 polypoid lesions 0 Is (10%), 4 recurrent ton scars (8%), 4 polypoid lesions 0 Isp(10%). Mean polyp area was 17.6 cm 2 (range 1–70). Mean intervention time was 98 min (range 20–240). En-bloc dissection was successful in 34/49 (69%) and R0 was reached in 24/33 (72%). The histological features of the polyps were: 10 LGD (20%), 27 HGD (55%), 9 pT1 (18%), 3 pT2 (6%). The procedural complications that took place (14/49 = 28%) included: perforation during the procedure in 10/49 (20%), delayed bleeding in 3/49 (6%), rectal stenosis in 3/49 (6%). No deaths or surgical interventions followed the periprocedural complications. From the 12 th procedure onwards the surgical performance became acceptable 22/27 (81%) vs 3/12 (25%) (p th procedure onwards the surgical performance became good 17/19 (90%, p 2 (p=ns). Only 3 complications occurred after the 30 th procedure (p=ns). Conclusion Our findings demonstrate than an endoscopist can reach a satisfactory level of competence in ESD procedures by beginning training with in vivo animal models (at least 10 procedures) and then should go on to colo-rectal neoplasms (without size limits and no less than 12 procedures). Trainees have probably still not reached a learning curve plateau even after 40 procedures. Disclosure of Interest None Declared

Surgical Correction of Anastomotic Rectal Stricture in a Dog

Surgical Correction of Anastomotic Rectal Stricture in a Dog

Stenosis rates after endoscopic submucosal dissection of large rectal tumors involving greater than three quarters of the luminal circumference.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for large rectal tumors. There are limited data available on stenosis rates following ESD of large rectal lesions. We aimed to evaluate the stenosis rate following ESD of large rectal tumors with rectal mucosal defectsgreater than three quarters of the circumference. We retrospectively identified patients who underwent rectal ESD between January 1998 and July 2014. Patientswith rectal mucosal defects greater than three quarters the luminal circumference were included for analysis. Clinicopathologic characteristics, treatment outcomes and adverse events were assessed. Stenosis was defined as an inability to pass a pediatric colonoscope into the sigmoid colon. None of the patients underwent prophylactic balloon dilation. A total of 363 patients with 370 rectal lesions were treated by ESD. Among these, 26 patients had 26 lesions with rectal mucosal defects greater than three quarters of the luminal circumference. Median tumor size (range) was 80 (47-150) mm. Four lesions (15%) required between 90 and <100% circumferential dissection, while complete circumferential ESD was performed in two lesions (8%). Dissection extended to the anal canal in six patients. The median procedure time was 220min. En bloc resection and curative resection were achieved in 88.5 and 65.4%, respectively. Delayed bleeding rates and perforation rates were 7.7 and 0%, respectively. During a median follow-up period of 9.8 (0-59) months, there were no patients with complaints of constipation or fecal incontinence. One patient (4.2%) was noted to have rectal stenosis, but was clinically asymptomatic. Endoscopic balloon dilation was not required in any patients. Stenosis may rarely occur after ESD of large rectal lesions with rectal mucosal defectsgreater than three quarters of the circumference, even without prophylactic endoscopic balloon dilation.

Gastric carcinoma presenting with severe rectal stenosis: ‘Schnitzler’s metastasis’: case report and review of the literature

Distant metastasis of primary gastric carcinoma may occur via venous, lymphatic spread and/or peritoneal seeding. Herein we report on an atypical presentation of clinical, endoscopic, and radiologic features of metastatic gastric adenocarcinoma with symptoms mainly due to rectal carcinomatous involvement. Case report and review of the literature We presented the case of 39-year-old-woman with a clinical history of 6 months of dyspepsia, abdominal discomfort, and constipation, who was admitted to hospital with a full-blown picture of mechanical bowel obstruction. These symptoms occurred owing to secondary linitis plastica of the rectum. An extended Hartmann procedure was performed, and the patient was referred to systemic chemotherapy. The overall survival was 5.5 months. The symptoms, findings, preoperative management, and treatment choices are discussed with a review of published cases of Schintzler’s metastasis. Gastric linitis plastica is the most common cause of secondary neoplastic infiltration of the colon. An unusual case of Schnitzler’s metastasis to the rectum, synchronously or metachronously, should occur from diffuse type signet-ring cell gastric carcinoma. The clinical findings of severe rectal stenosis with a poorly differentiated gastric adenocarcinoma must call attention to the entity of rectal Schnitzler’s metastasis.

Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients

Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series. A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014. Demographic, perioperative, short-term outcomes, and recurrence data were analyzed. There were 75 patients with 76 lesions analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m(2) (SD 4.7 kg/m(2)). Median American Society of Anesthesiologists (ASA) score was 2 (range 1 to 4). There were 59 benign (77.3%) and 17 malignant (22.7%) lesions: 6 pT0, 6 pT1, 4 pT2, and 1 pT3. Median lesion distance from the anal verge was 10 cm (range 6 to 16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intraperitoneal entry; all were closed transanally, but 2 had temporary diverting ileostomies fashioned to ensure healing. Median length of stay was 1 day (range 0 to 6). One patient had a fragmented lesion (1.3%). Five patients had positive margins: 2 in palliative pT2 resections, and 3 in pT1, pT2, and gastrointestinal stromal tumor (GIST) patients. They were managed with radical resection (pT1 and pT2 lesions) and surveillance/medical oncology (GIST). Postoperatively, 3 patients had complications (bleeding, rectal stricture, and recto-vaginal fistula), and all were managed nonoperatively. After median follow-up of 39.5 months (range 10.5 to 65.3 months), 1 pT1 patient with negative margins developed a local recurrence and underwent salvage APR. Transanal minimally invasive surgery is a viable option for excision of benign or early stage rectal masses, with mid-term oncologic outcomes comparable to those of radical resection. Further, TAMIS minimizes the morbidity and can allow more patients to benefit from the minimally invasive approach.

Coloperineal Fistula with Complete Rectal Stricture Complicated After Posterior Sagittal Anorectoplasty

Abstract Introduction: This video presents a case of coloperineal fistula complicated after posterior sagittal anorectoplasty (PSARP), treated with laparoscopic surgery. Methods and Materials: This...

Transanal anorectal stricturoplasty using the Heineke-Mikulicz principle: a novel technique.

Current surgical options for the treatment of rectal stricture are either technically difficult or result in a high rate of recurrence. We describe the results of a simple and potentially effective technique of transanal stricturoplasty using the Heineke-Mikulicz principle. The medical records and a prospectively maintained database of patients with rectal stricture were searched. Those who underwent transanal stricturoplasty for an anorectal stricture from 2007 to 2013 were studied retrospectively. Morbidity, length of hospital stay and the rates of success and recurrence were recorded. Fifteen patients with a symptomatic rectal stricture who failed dilatation underwent transanal stricturoplasty. The types of stricture included strictures in Crohn's disease (n = 7) and anastomotic stricture after stapled ileoanal anastomosis for ulcerative colitis (n = 4), after stapled hemorrhoidopexy (n = 3) and after low anterior resection for rectal cancer (n =1). The median (range) distance of the stricture from the dentate line was 4 (0-6) cm. Recurrence of symptoms after anal dilatation occurred at a median of 3 (1-4)weeks. The median follow up after transanal stricturoplasty was 21 (6-88) months. Two patients had symptomatic recurrence at 12months and both underwent a repeat transanal stricturoplasty, resulting in persistent patency of the strictured area at the time of the last follow up, 10 and 26months, respectively, after repeat transanal stricturoplasty. The remaining 13 had a satisfactory result. Despite the retrospective nature of this report and the small sample size and short follow up, the results strongly suggest that transanal Heineke-Mikulicz-type stricturoplasty is a promising treatment for this important condition. This operation is easy to perform and may result in success.

A Case of Ischemic Proctitis with a Rectal Stricture Causing Sigmoid Colon Perforation

A Case of Ischemic Proctitis with a Rectal Stricture Causing Sigmoid Colon Perforation

Buried Adenocarcinoma Masquerading as a Refractory Rectal Stricture

45 year old African American female with a long standing history of Crohn's colitis (involving the descending and sigmoid colon with perianal fistulas) and medication non-compliance presented with worsening constipation for months. Patient was not on medications at the time of presentation, but has a history of treatment with asacol, azathioprine and infliximab. Patient denied fevers, nausea, vomiting or rectal bleeding. Colonoscopy revealed a 5 cm long tight rectal stricture about 10 cm from the anal verge along with extensive pan colitis and normal small bowel. Biopsy of the stricture revealed inflammatory infiltrate. MR enterogram revealed a tight rectal stricture with enhancement indicating inflammation. Patient was treated with high doses of prednisone followed by infliximab infusions along with endoscopic dilations to which she had minimal response. This was followed by injection to infliximab directly into the rectal stricture with limited response. Patient was referred for surgery where she underwent abdominal perineal resection of rectum with end-colostomy. The stricture appeared benign on macroscopic examination but pathology reports revealed intra-strictural adenocarcinoma and normal overlying mucosa. She had to undergo repeat surgery for complete resection followed by radiation and chemotherapy. Discussion: The association between inflammatory bowel disease (IBD) and colorectal cancer (CRC) is well-known and has been widely described in literature. The risk of malgnancy is directly related to the severity of perianal involvement, extent of disease and its time course. In CD the risk is estimated to be around 30% after 25 years of diagnosis and noted to be higher in patients who receive the diagnosis before the age of 30. Our patient had long standing crohn's colitis, which was uncontrolled due to medication non-compliance. In addition, she was a smoker which increases the risk of malignancy. The stricture was biopsied multiple times on endoscopy and imaged with MR enterogram, which failed to reveal malignancy. Even during surgery, the surgeon did not suspect malignancy on gross examination as the mucosa appeared normal. The pathology specimen (see figure) demonstrates buried glands with adenocarcinoma interspersed within the stricture. Overlying mucosa appears normal. This is the first report where we describe a case of adenocarcinoma buried within the stricture with normal overlying mucosa. It is important for clinicians to have a high suspicion of malignancy in strictures which fail to respond to intensive therapy.Figure 1Figure 2Figure 3

A Case of Rectal Stricture Associated With the Use of a Fecal Management System

A Case of Rectal Stricture Associated With the Use of a Fecal Management System

Resolution of Constipation, Anal Stricture, and Fe Deficiency Anemia After Iron Infusion: An Analogy With Plummer Vinson Syndrome: Presidential Poster

Introduction: Anal stricture is an uncommon and disabling condition which can be unresponsive to conservative management and the complications of dilatations and Anoplasty make it a formidable treatment challenge. Here we report the case of a patient with constipation, anal stricture and iron deficiency anemia (IDA) where the triad resolved with IV iron treatment over 3 months. Case Report: A 69-year-old male presented to us with chronic constipation, rectal pain and easy fatigability. Physical examination revealed conjunctival pallor and laboratory findings were consistent with microcytic hypochromic anemia with iron deficiency (Ht- 31.6, Labs-Table 1). An upper endoscopy, CT Abdomen and Capsule endoscopy did not reveal any source of GI bleeding. Celiac panel was normal and there was no evidence suggestive of any other cause of anemia. Digital rectal examination (DRE) could not be completed because of severe rectal pain and markedly narrow anal canal. Under propofol sedation, Colonoscopy with GIF-Q 180 OLYMPUS scope, confirmed anal stricture with non-specific colitis. Conservative management with laxatives, high fiber diet and local anesthetics was initiated but the patient continued to have symptoms. Patient was referred to the hematologist for an evaluation of anemia and was started on IV Iron infusions. After 3 months of treatment, patient's anemia and all of the symptoms resolved (Ht- 38.3, Table 1). A repeat DRE was painless and the anal stricture had resolved.Table 1: Lab Values Pre and Post Iron Replacement TherapyDiscussion: The triad of Constipation, Anal Stricture and IDA in this patient paints a similar picture as PVS which presents as Dysphagia, Esophageal webs and IDA. The patient's symptoms of constipation and anal stricture resolved with iron treatment which has for long been known to resolve dysphagia and esophageal webs in PVS. Iron deficiency leading to loss of iron-dependant enzymes causes web formation and cancer development of the gastrointestinal tract. Tissue iron has been known to play an important role in the proliferation of epithelial cells. The epithelial layer of the alimentary tract is especially susceptible to iron deficiency because of its high cell turnover. Therefore, Iron replacement may provide a promising medical treatment benefit in high cell turnover GI tract and resolve rectal strictures along with the symptoms associated with them. The cause of PVS still remains a mystery. This analogy with PVS serves as a subject of further research and presents as an intriguing intellectual challenge in front of our medical fraternity.

Does perineural invasion of the myenteric plexus have a key role in annular rectal invasion and digestive system symptoms of prostate carcinoma patients?

Prostate carcinoma is one of the most common cancers globally. It relatively rarely invades the rectum, accounting for only about 4% of resected cases. About half of these cases of rectal invasion show an annular rectal stricture pattern. It has been hypothesized that anatomical structures, namely Denonvilliers fascia, may play an important role in annular rectal involvement of prostate carcinoma. Here, we propose another hypothesis: the reason for annular rectal invasion by prostate carcinoma is its extension along the myenteric plexus (Auerbach’s plexus). We illustrate this using a case presentation and description of the symptoms of such cases. From a review of the literature, autonomic digestive system symptoms of rectal invasion of prostatic carcinoma, such as diarrhea, tenesmus, or fecal incontinence is seen in about half of cases, coinciding with the frequency of annular rectal invasion. Thus, by modifying the long-established hypothesis, our suggestion that prostate carcinoma spreads along the myenteric plexus when cancer cells invade beyond the Denonvilliers fascia to the rectum could explain the cause and frequency not only of the annular rectal invasion but also the digestive system symptoms related to this disease. The prognosis of prostate carcinoma invading the rectum is very poor; however, this new hypothesis might shed light on the digestive system symptoms associated with prostate carcinoma and might lead to recognition and treatment of these cases at a relatively early stage of rectal invasion.

LOWER GASRTOINTESTINAL BLEEDING

Objectives: To determine the etiology of lower GI bleeding based oncolonoscopic findings Study design: Retrospective study. Place and Duration of study: Thisstudy was conducted at gastroenterology unit of Nishtar Hospital Multan from Feb 2013 toAugust 2014. Patients and methods: Two hundred and fifty four patients, ≥ 14 years old whopresented with history of lower GI bleeding to the gastroenterology unit of Nishtar HospitalMultan Results: Out of 254 patients, 59.05% were males and 40.95% were females. Mean ageof patients was 37.22±10.68 years. Most common findings were haemorrhoids (40.9% cases),ulcerative colitis(35.4%), no abnormality (8.2%), solitary rectal ulcer (7.5%), growth (7.1%),proctitis (3.5%), polyps(2%), rectal varix (1.2%), infective colitis (0.8%), uremic colopathy(0.8%), rectal prolapse (0.8%), multiple polyposis coli (0.8%), petechiae (0.8%), stricture (0.8%),diverticula(0.4%)and fissure (0.4%). Conclusion: Colonoscopy is the investigation of choice forpatients of lower gastrointestinal bleeding. More common colonoscopic findings in our studywere haemorrhoids, ulcerative colitis, solitary rectal ulcer, malignancy and proctitis. Polyps anddiverticula which are common in the west were uncommon in our patients. Rectal prolapse,petechiae, stricture, uremic colopathy and multiple polyposis coli were rare causes.

Stapled hemorrhoidopexy: functional results, recurrence rate, and prognostic factors in a single center analysis.

Since its introduction, stapled hemorrhoidopexy (SHP), the so-called Longo procedure, became a widely accepted treatment option for prolapsing hemorrhoids. Nevertheless, from the early years, concerns grew about the early functional results and potential recurrences. In order to evaluate of SHP with special respect to early defecation disorders und recurrences, our single institute high-volume results were evaluated. One thousand one hundred forty-four consecutive patients with SHP for prolapsing hemorrhoids were evaluated in a period from January 2007 to December 2013. In a prospective analysis, patients were followed with special respect to postoperative complications, functional disorders, mainly perianal irritation, stenosis, and recurrence. During the timeframe, a total of 663 men and 481 women were treated for prolapsing hemorrhoids. The mean age was 52.6 years (±14.4 years). Indication for surgery was prolapsing hemorrhoids in all cases. In addition to prolapse, 90 patients (7.9 %) suffered from bleeding, 96 patients (8.4 %) had itching, and 95 (8.3 %) had anal wetness; the mean operative time was 11 min (±4 min). Patients were treated as inpatients; the mean hospital stay was 3 days (±1 day). Early complications were observed in 14 patients (1.2 %). The follow-up revealed inflammatory reaction at the stapleline in 8 patients (0.7 %) and rectal stenosis in 22 cases (1.9 %), and recurrence was observed in 46 cases (4.0 %). The data presented here provide evidence that SHP is a save procedure with a very low rate for functional disorders and low recurrence rate. Therefore, in our hands, SHP remains standard for prolapsing hemorrhoids.

Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms.

Improvements in the endoscopic submucosal dissection (ESD) technique have made circumferential ESD in the rectum possible. However, little is known about the clinical course after extensive ESD in the rectum. The aim of this study was to determine the stricture risk in the rectum after total or subtotal circumferential ESD. A total of 69 patients with 69 rectal tumors that required ≥ 75 % circumferential resection were identified at Kobe University Hospital and an affiliated hospital between April 2005 and May 2014. Among the patients, 61 were available for evaluation of stricture development, either by follow-up colonoscopy or by surgical specimens. The rate and possible risk factors of post-ESD strictures were investigated. Post-ESD rectal strictures developed in 12 patients (19.7 %). Patients who underwent total circumferential ESD developed a stricture (5/7, 71.4 %) more frequently than those with subtotal (≥ 90 %) ESD (7/16, 43.8 %). Patients undergoing an ESD procedure that involved < 90 % of the circumference did not develop strictures. The strictures were membranous or < 10 mm long in all cases. Of the patients with stricture, 11 received endoscopic balloon dilation and one received bougie with short-caliber-tip transparent hood; all strictures improved following dilation therapy. Statistical analysis revealed that ≥ 90 % circumferential resection was an independent risk factor for stricture, whereas morphology and size were not. Patients who underwent total or subtotal circumferential ESD of a rectal tumor had a high risk of stricture formation. Dilation helped to alleviate the stenosis.Study registered at University Hospital Medical Information Network (UMIN 000016559).

EUS-guided recanalization of a complete rectal anastomotic stenosis by use of a lumen-apposing metal stent

EUS-guided recanalization of a complete rectal anastomotic stenosis by use of a lumen-apposing metal stent