Complications after Stapled Hemorrhoidectomy: A Single Center Experience

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

Diagnosis and Management of Internal Hemorrhoids: A Brief Review

Hemorrhoidal disease is a pathological condition due to the abnormal engorgement of the arteriovenous plexus beneath the anal mucosa. Anatomically, it can be located under the skin on the outer part of the dentate line, known as external hemorrhoid; or inside the anus on the proximal part of the dentate line, called internal hemorrhoid. Internal hemorrhoid may further develop from a painless anal mass into protruded and painful mass throughout the anal canal, often accompanied by inflammation and more severe symptoms. Various management strategies need to be considered carefully to ensure the success of therapy and improve the quality of life of patients with internal hemorrhoids. Conservative management is the initial stage that can be performed, including the provision of high-fiber nutrition, education related to bathroom habits, and the use of flavonoid regimens. Surgical therapy can be divided into outpatient intervention and conventional surgeries. This review will encompass the comprehensive diagnostic approach and management of internal hemorrhoids to help clinicians understand the appropriate management and provide better clinical benefits for the patients.

1399 Anorectal Melanoma: Can Be an Unexpected Diagnosis - A Case Report

Anorectal melanoma is a rare tumour. Few cases are reported in the literature. We report a case of 51 years old male complained of anal induration, itching and bloody and suppurative discharge. Patient had symptoms for 2 years. However, patient expected his symptoms are due to recurrence of haemorrhoids. Therefore, he presented late. Then, he had noticed a progressive increase in size, discharge and two opposing ulcers. Patient had no history of abdominal pain, change in bowel habits, bleeding per rectum, history of groin lumps, incontinence nor erectile dysfunction. Patient underwent haemorrhoidectomy about 11 years ago. On examination, there was a circumferential single ulcer eroding the anus extending deep to the dentate line reaching the rectum on digital rectal examination. Also, there was no inguinal lymphadenopathy detected on exam. Incisional biopsy of the ulcer showed anorectal melanoma. Patient had abdominoperineal resection (APR) with adjuvant radiotherapy. At 12 months follow up, there were no signs of recurrence.

Anorectal polyp

A 71-year-old female with hypertension presented with painless rectal bleeding and found to have a soft mass on rectal exam. The colonoscopy revealed a large pedunculated polyp with patchy discoloration arising from the dentate line (Fig. 1). Biopsies of the polyp were obtained.

Efficacy of Ruiyun procedure for hemorrhoids combined simplified Milligan–Morgan hemorrhoidectomy with dentate line-sparing in treating grade III/IV hemorrhoids: a retrospective study

Background Hemorrhoids are common. Hemorrhoidectomy should typically be offered to patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse (grades III/IV). However, none of the currently used surgical methods could be considered an ideal surgical option that is effective, safe, and painless. We hypothesized that a combination of Ruiyun procedure for hemorrhoids (RPH) and simplified Milligan–Morgan hemorrhoidectomy (sMMH) will increase the safety and effectiveness of surgical treatment hemorrhoids. This study aimed to evaluate the efficacy of Ruiyun procedure for hemorrhoids combined simplified Milligan–Morgan hemorrhoidectomy with dentate line-sparing (RPH + sMMH) to treat grade III/IV hemorrhoid. Methods Total 452 patients with hemorrhoids of grade III/IV were retrospectively reviewed in China-Japan Friendship Hospital, 244 cases were assigned to RPH + sMMH group, and 208 cases in MMH group. The primary efficacy outcome was rate of curative at 3 month after operation, and the recurrence rate within 12 months post operation. Secondary efficacy outcomes included wound healing time, time required to resume normal work, constipation symptom, quality of life, and pain post operation was also evaluated. The safety outcome included postoperative complications. Results There were no differences between the two groups in demographic characteristics. There was no statistically significant difference between the two groups in the curative rate. The recurrence rate after 12 months post operation in the RPH + sMMH (3.0%) was significantly lower than the sMMH group (7.8%) (P = 0.032). The wound healing time was significantly shorter in RPH + sMMH group than that in MMH group (P < 0.001). The time required to resume normal work in the RPH + sMMH group was significantly shorter than MMH group (P < 0.001). Compared with the MMH group, the RPH + sMMH therapy preserve better life quality and lower constipation symptom (all P < 0.05). Patients who underwent RPH + sMMH had significantly less postoperative pain than MMH therapy. The total rate of patients with postoperative complications in the RPH + sMMH group (8.6%) was significant lower than the MMH group (16.3%) (P = 0.012). Conclusion RPH + sMMH may more effective in treating patients with III/IV hemorrhoids, which indicated lower recurrence rate, lower postoperative complications and pain, shorter recovery and return to normal life.

The follow-up of the robotic-assisted Soave procedure for Hirschsprung’s disease in children

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to gastrointestinal surgeons. There were many previous reports on robotic technology in performing Soave colonic resection and pull-through for Hirschsprung’s disease in children. This study described the follow-up of the Robotic-assisted Soave procedure for Hirschsprung’s disease in children. Robotic-assisted endorectal pull-through was performed using three robotic arms and an additional 5-mm trocar. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies. The rest of the procedure was carried out according to the Soave procedure. We left a short rectal seromuscular sleeve of 1.5–2 cm above the dentate line. From December 2014 to December 2017, 55 pediatric patients were operated on. Age ranged from 6 months to 10 years old (median = 24.5 months). The aganglionic segment was located in the rectum (n = 38), the sigmoid colon (n = 13), and the left colon (n = 4). The mean total operative time was 93.2 ± 35 min (ranging from 80 to 180 min). Minimal blood was lost during the surgery. During the follow-up period, 41 patients (74.6%) had 1–2 defecations per day, 12 patients (21.8%) had 3–4 defecations per day, and 2 patients (3.6%) had more than 4 defecations per day. Fecal incontinence, enterocolitis, and mild soiling occurred in three (5.4%), four (7.3%), and two pediatric patients, respectively. Robotic-assisted Soave procedure for Hirschsprung’s disease in children is a safe and effective technique. However, a skilled robotic surgical team and procedural modifications are needed.

A COMPARATIVE STUDY OF 0.2% NIFEDIPINE VERSUS LATERAL SPHINCTEROTOMY IN THE MANAGEMENT OF ANAL FISSURE

Introduction:Anal ssures are longitudinal tears in the squamous epithelium of the anal canal. Anal ssures are located distal to the dentate line, and in around 90% of cases they are located on the posterior midline. The most common pathologies of the anorectal region and can change the quality of life as it causes patient pain and emotional stress while defecation. With a lifetime risk of 11%, anal ssure is a common problem in routine medical care. Anal ssure is mainly treated by relaxing the spasm of the internal sphincter either by dilating the anal canal or sphincterotomy. Reduction of spasticity of anal sphincters is the special treatment for ssure healing. For this purpose, the treatment of anal ssures is performed by lateral sphincterotomy or by anal dilatation. Methods: Out of 100 randomly selected 50 patients with inclusion and exclusion criteria and informed consent were treated with nifedipine ointment and 50 patients with informed consent were treated with lateral sphincterotomy for management of anal ssure. Observations after treatment were recorded at second week, sixth week and twelfth week interval for bleeding, pain and healing and at the twelfth week follow up was documented to analyse the result of treatment. Result: Out of 50 patients undergoing treatment with Nifedipine ointment 42 patients healed completely. 36 patients in the nifedipine group had complaint of bleeding, after treatment with nifedipine ointment 30 patients were relieved from bleeding while 6 were complaining of bleeding on follow up after 3 months. Patients in lateral sphincterotomy group underwent surgery under spinal anaesthesia. In lateral sphincterotomy group, ssure healing was found in 49 (98%)out of 50 patients. In our study out of 50 patients, 48 (96%)were completely relieved from pain and 2 ( 4% ) had pain on follow up at the end of 3 months. In our study , in the lateral sphincterotomy group 34 patients out of 50 patients were complaining of bleeding and after surgery 32 were relieved from bleeding within 12 weeks and 2 were complaining of bleeding. Conclusion:Topical 2% nifedipine should be given as the rst option of treatment for anal ssure. Lateral sphincterotomy, which gives better result to relieve the symptoms but require hospitalization, should be offered to patient who present with relapse and does not respond to pharmacological treatment.