Haemorrhoidal artery ligation with and without Doppler guidance in the treatment of haemorrhoidal disease: a single-centre randomized study

Aim. To evaluate the efficacy of haemorrhoidal artery ligation (HA) with a preliminary palpatory determination of its localization supplemented by mucopexy of haemorrhoids as a new surgical method in the treatment of haemorrhoidal disease (HD) and to compare it with HAL-RAR technology.Materials and methods. The randomized controlled clinical trial included patients over 18 years old with Goligher’s grade II, III or IV symptomatic HD. We operated on patients in the study group (n = 75) using palpatory determination of the localization of HA and subsequent mucopexia. In the control group (n = 75) we used HAL-RAR. The primary endpoint (25–30 days after surgery): recurrence rate of HD symptoms. Secondary endpoints: postoperative complication rate, pain intensity on a visual-analogue scale from 1 to 10 points, patient satisfaction with the treatment results on a 10-point scale.Results. According to the initial characteristics (age, gender, body mass index, stage of HD, frequency of clinical symptoms), the groups did not differ. Anal bleeding relapse developed: study group – 11%, control group –14%; relapse of haemorrhoids prolapse: 3% and 5% respectively (p > 0.05). Postoperative complications were noted in 6 (8%) in the study group and 4 (5%) in the control group (p > 0.05). The intensity of pain on the 2nd and 25–30 days after surgery was 6.3 [4.8; 7.4] and 1.2 [0.6; 2.5] points in the study group and 6.5 [4.9; 7.3] and 2.1 [1.9; 4.1] in the control group, respectively (p > 0.05). Patient satisfaction with the treatment results after 12 months was estimated at 8.7 [7.9; 9.2] and 9.4 [8.2; 9.6] in the study and control groups, respectively (p > 0.05).Conclusion. HA ligation with a preliminary palpatory determination of its localization and supplemented with mucopexy of haemorrhoids is no less effective than HAL-RAR in preventing haemorrhoidal bleeding and prolapse of the nodes.

The Management of Retained Rectal Foreign Body

Purpose: Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience.Methods: We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes.Results: All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling.Conclusion: Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study

Background Hemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients. Methods We consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis. Results Forty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36–49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation (p = 0.067) and constipation (p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03–14.2,p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose (p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis. Conclusion We found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.

Risk factors associated with HIV infection among men who have sex with men in China: a meta-analysis

Background: Although human immunodeficiency virus (HIV) prevalence in the general population is very low in China, high infection rate has been reported among men who have sex with men (MSM). We conducted a meta-analysis to identify HIV infection associated risk factors among MSM in China, thus we can further understand the high-risk population and provided basic information to further develop specific and effective interventions of HIV prevention. Methods: A comprehensive literature search was conducted in several public databases, the relevant articles which published from January 2010 to June 2018 were identified, and a meta-analysis was performed according to these included studies. The odds ratio (OR) and its 95 % confidence intervals (CI) of each risk factor among MSM in China were pooled by using a random-effects model or fixed-effects model when appropriate. Results: A total of 23 articles were included and analyzed. The pooled results revealed that non-local residency (OR=2.31, 95% CI: 1.05, 5.08), education less than junior high school (OR=1.73, 95% CI: 1.36, 2.21), engaging in commercial sex (OR=2.99, 95% CI: 1.02, 8.72), preferred receptive sexual role (OR=2.43, 95% CI: 2.09, 2.83), having anal bleeding during anal intercourse (OR=2.22, 95% CI: 1.60, 3.07), having no HIV test in the last 12 months (OR=2.17, 95% CI: 1.45, 3.25), having unprotected anal intercourse (UAI) in the last 6 months (OR=2.06, 95% CI: 1.69, 2.50), recreational drugs use (OR=1.90, 95% CI: 1.53, 2.36), preferred versatile sexual role (OR=1.69, 95% CI: 1.35, 2.21), inadequate HIV related knowledge (OR=1.63, 95% CI: 1.26, 2.11), having multiple sexual partners (MSP) in the last 6 months (OR=1.35, 95% CI: 1.24, 2.47), having infection of syphilis (OR=3.22, 95% CI: 3.02, 3.44) and diagnosed with sexually transmitted infections (STI) in the last 12 months (OR=1.71, 95% CI: 1.30, 2.26) were significantly and positively related to HIV infection. Conclusions: Continuous education and further interventions such as Pre-Exposure Prophylaxis (PrEP) should be prioritized for those MSM who engaged in high-risk behaviors.

ENDOSCOPIC BAND LIGATION FOR THE TREATMENT OF HEMORRHOIDAL DISEASE

ABSTRACT BACKGROUND: There are several therapeutic options for symptomatic hemorrhoids, from hygienic and dietary measures to conventional surgery. The best technique adopted for alternative and non-surgical treatment for intermediate grade (II and III) hemorrhoidal disease is rubber band ligation. More recently, the technique has been used with the aid of a gastroscope and a kit of elastic rubber bands for esophageal varices. This technique was called Endoscopic Rubber Band Ligation of hemorrhoids (ERBL). OBJECTIVE: The objective is Compare the results and the incidence of the immediate and late complications in patients undergoing ERBL. The satisfaction with the treatment of patients undergoing different number of rubber band ligatures were also analyzed. METHODS: This is a cohort study included patients undergoing ERBL from 2007 to 2014 at the hospital. The incidence of early and late complications and the satisfaction with the treatment of patients undergoing until two ligatures and patients undergoing three or more ligatures in the same procedure were compared. RESULTS: The study included 116 patients. The most frequently reported symptom was anal bleeding (n=72; 62.1%). The number of rubber band ligatures performed during the ERBL procedure varied from one to six; 84 (72,4%) patients had three or more rubber band ligatures performed during the procedure. No significant associations were observed between the incidence of early or late complications and satisfaction with ERBL among the group subjected until two rubber band ligatures or three or more rubber band ligatures. CONCLUSION: The endoscopic elastic ligation method proved to be a feasible, safe and efficient for the treatment of symptomatic hemorrhoidal disease grades II and III. The technique had moderate rates of immediate and late complications, but most of the complications are considered of low magnitude, easily resolved and without clinical repercussions, no matter how much ligations were performed in the same procedure.

Acute promyelocytic leukaemia presenting as necrotising fasciitis of the perineum (Fournier gangrene)

We present a case of an unusual presentation of acute promyelocytic leukaemia (APML), which presented with Fournier gangrene (FG). A 38-year-old man presented with malaise, groin swelling, anal bleeding, fever and was found to have FG. Initial workup revealed pancytopaenia, borderline low fibrinogen, prolonged international normalized ratio (INR), which raised the suspicion for leukaemia. The peripheral blood differential revealed leucopaenia with absolute neutropaenia and a 5% abnormal promyelocytes but no blasts, suspicious for APML. Bone marrow biopsy was performed and fluorescence in situ hydridization (FISH), karyotype and PCR confirmed a t(15;17) translocation, establishing a diagnosis of APML. After 1 month of therapy for intermediate risk APML with All-trans retinoic acid (ATRA) and arsenic trioxide (ATO), repeat chromosomal analysis and repeat bone marrow biopsy revealed no evidence of residual APML. After the consolidation phase was started with ATRA and ATO regimen, the wound healed after 2 months and the patient achieved complete remission.

Lesão anal por papilomavírus humano em mulher vivendo com HIV/aids

*** Anal lesion caused by human papillomavirus in a woman living with HIV/AIDS ***AIMS: To describe a case of anal lesion caused by human papillomavirus (HPV) infection in a woman living with HIV/AIDS.CASE DESCRIPTION: A 35-year-old woman, diagnosed with HIV five years ago, reported pruritus ani, anal bleeding, painful defecation, and presence of small warts in the perianal region. The patient was seen at a specialized care center and was subjected to clinical examination with visual inspection, which revealed perianal condyloma. Histopathological examination confirmed the presence of moderate to severe dysplasia associated with HPV-compatible changes. The anal lesion was excised. At the onset of the symptoms, the patient was not on antiretroviral therapy and her HIV viral load was at its highest (2,951 copies/mL) compared with her previous laboratory tests. She had gone through emotional stress and presented with recurrent genital herpes simplex virus infections. These factors may have predisposed her to the development of anal condyloma.CONCLUSIONS: Since HIV infection may alter the history of HPV infection, it is important that screening strategies include cytological analysis of both the cervix and the anal region.

An unusual haemorrhagic complication of an anastomotic leak and a novel method of controlling the haemorrhage

Introduction Restorative proctocolectomy (RP) is undertaken for patients with familial adenomatous polyposis (FAP) and ulcerative colitis, but is associated with a risk of anastomotic leak. Case history A 20-year-old male with a family history of FAP had a RP with a double-stapled J-pouch and covering loop ileostomy. At ileostomy reversal 21 months later, he presented with significant anal bleeding. He proceeded to theatre for endoscopy. Pouchoscopy showed a pouch full of blood and a foreign object trapped in a diverticulum. The foreign object (an undigested tablet) was removed with grasping forceps and the bleeding spot identified. Hemospray® (Cook Medical, Winston-Salem, NC, USA) was deployed in the bleeding cavity to enable immediate control of haemorrhage. Recovery was uneventful and he was discharged home 72 hours later. Conclusions This case: (i) demonstrates a successful and novel method of controlling haemorrhage not amenable to use of conventional haemostatic mechanisms; (ii) highlights the potential problems of using prolonged-release medications in patients with gastrointestinal strictures/diverticulae.