Surgical Treatment of Iatrogenic Low Variety Anal Stenosis with Diamond Flap Anoplasty – A Prospective Study

Background: Anal stenosis results from loss of anoderm with subsequent fibrosis and scarring of underlying tissue. The condition represents a technical challenge in terms of surgical management. It is a serious complication of anorectal surgery, most commonly seen after surgical haemorrhoidectomy. However, stenosis can also occur after perianal circumferential burn due to application of herbal medicine by village doctors. Objective: This study was conducted to see the outcome of diamond-flap anoplasty for the treatment of moderate to severe anal stenosis. Patients and interventions: Unilateral diamond flaps anoplasty was performed for moderate to severe anal stenosis. Final anal calibre of 25 to 26 mm was targeted. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis severity, postoperative complications and the time of return to work were recorded. Results: From July 2012 to January 2017, 18 patients (12 males, 67% and 6 female patients, 33%) with a mean age of 34 years (range, 25-52) were treated. 15 of the patients had a history of previous haemorrhoidectomy and 3 had circumferential perianal chemical burn due to application of herbal medicine by village doctors. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24- 26), and 25 ± 1 mm (range, 23-27). The clinical success rate was 98.9%. No severe postoperative complications were observed. Conclusion: Diamond-flap anoplasty is a highly successful method for the treatment of anal stenosis caused by previous haemorrhoidectomy and perianal circumferential chemical burn by herbal medicine. J Shaheed Suhrawardy Med Coll 2020; 12(2): 67-71

New Techniques in Hemorrhoidal Disease but the Same Old Problem: Anal Stenosis

Anal stenosis, which develops as a result of aggressive excisional hemorrhoidectomy, especially with the stoutly use of advanced technologies (LigaSure, Ultrasonic Dissector, Laser, etc.), has become common, causing significant deterioration in the patient's quality of life. Although non-surgical treatment is effective for mild anal stenosis, surgical reconstruction is unavoidable for moderate to severe anal stenosis that causes distressing, severe anal pain, and inability to defecate. The problem in anal stenosis, unlike anal fissure, is that the skin does not stretch as a result of chronic fibrosis due to surgery. Therefore, the application of lateral internal sphincterotomy does not provide satisfactory results in the treatment of anal stenosis. Surgical treatment methods are based on the use of flaps of different shapes and sizes to reconstruct the anal caliber and flexibility. This article aims to review the functional results, postoperative care, and complications of these methods.

The Comparison of a C-Shaped Partial Stapled Hemorrhoidopexy (C-PSH) Versus Circular Stapled Hemorrhoidopexy (CSH) in Patients with IV Grade Hemorrhoid: A Retrospective Study

Aims The aims of this study were to present a C-shaped partial stapled hemorrhoidopexy (C-PSH) in the treatment of IV grade hemorrhoid and to assess the clinical outcomes of this technique compared with circular stapled hemorrhoidopexy (CSH). Methods Conventional CSH kit matched with an intestinal spatula was used for performing C-PSH. One hundred and fifty eight patients who suffered IV grade hemorrhoid and underwent C-PSH or CSH at Hangzhou Third hospital between December 2017 and July 2019 were retrospected. Intraoperative and postoperative outcomes in both groups were collected and analyzed. Results Operative time, estimated blood loss and hospital stay were similar in both two groups (p values were 0.238, 0.563 and 0.101 respectively). Pain scores on the first defecation, 1st, 2nd, 3rd and 7th postoperative days in the C-PSH group were respectively lower than those in the CSH group, and the numeric rating scale (NRS) scores were 3.29±1.52 vs. 4.23±1.99 (p=0.001), 3.82±1.49 vs. 4.63±1.17 (p<0.001), 3.12±1.51 vs. 3.71±1.85 (p=0.030), 2.67±1.52 vs. 3.37±1.54 (p=0.005) and 1.34±0.92 vs.1.84±1.14 (p=0.003). Fecal urgency incidences in the C-PSH group were lower than those in the CSH group on the 1st, 2nd, 3rd and 7th postoperative days, and the incidences occurred in the C-PSH group vs. CSH group were 44.7% vs. 61.0% (p=0.041), 30.3% vs. 46.3% (p=0.038), 25.0% vs. 43.9% (p=0.013) and 13.2% vs. 35.4% (p=0.001) respectively. Overall postoperative complications rate occurred in the CSH group was higher than that in the C-PSH group, (16/82 vs. 6/76, p=0.035). Six patients suffered from anal stenosis in the CSH group and no patient suffered from stenosis in the C-PSH group (p=0.047). One year recurrence rate in the C-PSH group and CSH group was 8.0% (6/75) vs. 6.3% (5/79), (p=0.687). Conclusions The C-PSH seems to be an efficacy and safety technique in treating IV grade hemorrhoid. It has advantages in alleviating postoperative pain, fecal urgency and anal stenosis compared with CSH. It could be an alternative technique in the treatment of IV grade hemorrhoid.

Modified tissue-selecting therapy stapler combined with complete anal canal epithelial preservation operation for the treatment of circumferential mixed haemorrhoids: a protocol for single-blind randomised controlled study

IntroductionThis protocol designed a randomised controlled trial (RCT) to evaluate the effectiveness, safety and prognostic outcomes of modified tissue selecting technique (M-TST) combined with complete anal canal epithelial preservation (CACP) among patients with circumferential mixed haemorrhoids.Methods and analysisThis study will be single-blinded, and recruit 348 patients who are admitted to the Changshu Hospital Affiliated to Nanjing University of Chinese Medicine and fulfil the inclusion criteria from January 2022 to December 2022. Patients will be randomly assigned to the treatment group and the control group in a 1:1 ratio. The statistician will be blinded for the allocation. The treatment group will receive M-TST combined with CACP (M-TST–CACP), while the control group will receive the procedure for prolapse and haemorrhoids. The two groups will receive the same preoperative and postoperative care. The primary outcome will be recurrence rate. The secondary outcomes will be operation time, intraoperative bleeding, incontinence, pain, postoperative complications (severe bleeding, perianal oedema, urinary retention, faecal urgency, skin tags and anal stenosis), prolapse, recovery time, quality of life, Haemorrhoid Severity Score, and Symptom Severity Score.Ethics and disseminationThis protocol has been approved by the Clinical Ethics Committee of the Changshu Hospital Affiliated to Nanjing University of Chinese Medicine (approval no. 202102001).Trial registration numberChiCTR2100042750.

A Prospective Interventional Study on LigaSureTM Haemorrhoidectomy as a Daycare Procedure

Objective: This study was designed as a prospective and interventional study that evaluated LigaSure™ haemorrhoidectomies with regional anaesthesia as a daycare procedure. Methods: Patients with third- and fourth-degree haemorrhoids were recruited from the clinic from January 2018 to December 2019. The procedure was performed as a day case under regional anaesthesia. Using a LigaSureTM device, excisional haemorrhoidectomies (Milligan– Morgan haemorrhoidectomy) were performed without sutures or an anal sponge. We evaluated wound bleeding, pain and urinary retention per daycare protocols. Results: A total of 264 patients were enrolled. There were 153 males (57.9%) with a median age of 30 years old (range 16 years old–80 years old). A total of 142 patients (54%) had thirddegree haemorrhoids, while the rest had fourth-degree haemorrhoids. The median operating time was 8 min (range 4 min–17 min) and minimal blood loss was observed. During follow-up, the complications were one case (0.3%) had anal stenosis, one case (0.3%) had minimal bleeding and one case (0.3%) had urine retention. Upon discharge, four patients (1.5%) required additional analgesia and another four (1.5%) developed post-spinal headaches. No incontinence was encountered. Conclusion: LigaSure™ excisional haemorrhoidectomy is a safe and effective daycare procedure with acceptable re-admission and complication rates.

Early results of different types of anorectoplasty for anorectal malformations

Objective: To document our experience with the technique of surgical repair in anorectal malformations (ARM) and the short term anatomical and functional outcomes. Methods: This study included total 31 babies. Fourteen were perineal fistula cases with age range between 1 to 4 days. Ten patients had vestibular fistula and seven had rectourinary fistula. Primary diverting colostomy was done for vestibular and rectourinary fistula patients. On the other hand low imperforate anus with anoperineal fistula without associated major anomalies had undergone fistulectomy and simple anoplasty. Results: Simple anoplasty was done for fourteen perineal fistula cases. Anterior sagittal anorectoplasty (ASARP) was done for 10 vestibular fistulae and posterior sagittal anorectoplasty (PSARP) was done in 10 recto-urinary fistula cases. Simple anoplasty and vestibular anus scored good (5-6) in 70% to 71% while PSARP scored fair in 58% of the cases. Postoperative mucosal prolapse, anal stenosis and retraction occurred in two, six and one patient respectively. Redo surgery was done in mucosal prolapse and retraction cases. Four responded to anal dilation and the other needed redo surgery by a simple cutback technique for anal stricture. Continence was assessed in 23 patients whose follow-up periods were longer than 3 years. Twenty one patients had a good score and two had a fair score. No patients had a poor score. Conclusion: Our approach has the following advantages: (i) The operative technique is simple and easy to perform. (ii) Minimal complication rate with good cosmetic results. Mediscope 2021;8(2): 75-79

Evaluation of post-operative complications after Milligan- Morgan haemorrhoidectomy versus Stapled Haemorrhoidopexy techniques

Background Haemorrhoidal disease is one of the oldest illnesses known to mankind. It leads to significant pain, discomfort and poor quality of life. It is one of the common diseases which affect mankind but it is difficult to give an accurate figure of the prevalence because although many patients present with symptoms, many do not and some never bring it to notice of clinicians. The word hemorrhoids means flow of blood, the word pile means a ball, indicating two cardinal symptoms of this disease; bleeding per rectum and mass per anus. Aim of the work Aim of the work is to detect and compare the post-operative complications (Pain, Bleeding and anal stenosis) after 2 of the most commonly used techniques for management of the clinically diagnosed third and fourth stage hemorrhoids: Milligan-Morgan hemorrhoidectomy and stapler hemorrhoidopexy. Patient and Methods After obtaining approval from The College Ethical Committee, the study entitled "Evaluation of Postoperative Complications after Open MM Hemorrhidectomy versus Stapled Hemorrhoidopexy" was conducted on a total of 30 patients with hemorrhoids undergoing either conventional hemorrhoidectomy by Milligan Morgan (MM) technique or stapler hemorrhoidopexy. The patients were selected randomly after fulfilling the inclusion criteria in the department of general surgery, Ain Shams University hospitals over a period of 4 months starting from 1 August 2019 to 1 December 2019. Patients were admitted via surgical outpatient clinic. Patients were randomly distributed to 2 groups (A & B), each group containing 15 patients. Results A total of 30 patients who underwent either conventional hemorrhoidectomy (CH) or stapler hemorrhoidopexy (SH) in The Department of Surgery, Faculty of Medicine, Ain Shams University included in this study for 4 months started from 1/8/2019 and ended in 1/12/2019 and the following results are obtained. Conclusion Haemorrhoidal disease is considered as one of the commonest ano-rectal diseases. Non-surgical measures whatever drug therapy or office procedures, can be presented to the patients with stage 1 and stage 2 haemorrhoids. However, when these measures fail, surgical intervention must be thought for the patients with stage 3 and stage 4 haemorrhoids. Surgical intervention should be tailored to each patient in accordance to the seriousness of symptoms, the magnitude of the external anorectal element and the presence of any concurrent ano-rectal morbidity. At present, there are many surgical interventions obtainable for treatment of prolapsing piles disease and most of them yielding acceptable success rates. Conventional Haemorrhoidectomy (CH) whatever open (Milligan Morgan) or closed (Ferguson) is considered the gold standard for surgical intervention of piles but due to the severe associated post-operative pain, especially with defecation, Stapled Haemorrhoidopexy (SH) seems to present shorter operative time, less post-operative pain, less bleeding and anal stricture and also less time off work in comparison with CH. Although rare but horrible complications have been noted with SH, which dictate that SH should be performed only by experienced surgeons. Eventually we strongly recommend the use of stapler devices for haemorrhoidectomy when and where possible especially for high grade and prolapsing haemorrhoids although more research and study should be made in this concern for more confirmation of our results due to decreased specimen size and short post-operative follow up period in our study.

Comparison of Milligan Morgan Hemorrhoidectomy and Stapled Hemorrhoidectomy In Recent Years For Patients With Grade III And IV Hemorrhoids: A Meta-Analysis

Background Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to compare of milligan morgan (MM) hemorrhoidectomy and stapled hemorrhoidectomy (ST) for patients with grade III And IV Hemorrhoids. Objective To compere between Milligan-Morgan hemorrhoidectomy and Stapled hemorrhoidectomy as regards postoperative anal stenosis and fecal incontinence in recent years for treatment grade III and IV hemorrhoids using a meta-analysis approach. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2020. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion It is concluded that ST appeared to be the best surgical procedure than MM for grade III and IV hemorrhoids based on the current evidence.