Association of Log Odds of Positive Lymph Nodes with Overall Survival in Patients with Primary Malignant Anorectal Melanoma: A Population-Based Study

BACKGROUND

Malignant anorectal melanoma (AM) is a rare tumor characterized by its aggressive behavior. To date, there has been no comprehensive investigation into the association between the log odds of positive lymph nodes (LODDS) and the prognosis of patients with malignant AM who have undergone surgical intervention.

METHODS

Data were extracted from the Surveillance, Epidemiology and End Results (SEER) database for patients diagnosed with primary malignant AM who have undergone surgical intervention between 2000 and 2021. The Kaplan-Meier (KM) method with the log-rank test was used to compare survival curves between different LODDS groups. Multivariate Cox models were employed to evaluate the independent association between LODDS and overall survival (OS). An analysis to explore the potential influence of unmeasured confounders on the relationship between LODDS and OS was conducted using the E value.

RESULTS

The study included a total of 126 eligible patients. KM analysis revealed that patients with low LODDS exhibited significantly improved OS compared to those with high LODDS (p < 0.001). The multivariate Cox analysis demonstrated that LODDS was independently associated with OS. The calculated E value suggested that the potential impact of unmeasured confounders on the association between LODDS and OS was likely minimal.

CONCLUSION

The findings indicate that LODDS is independently associated with the prognosis of patients with AM undergoing surgical intervention. These results may enhance clinicians' understanding of the prognosis of this rare malignancy and provide a basis for guiding therapeutic decisions.

Approaches to Surgical Management of Anorectal Melanoma in the Pre- and Post-Immunotherapy Eras

BACKGROUND

Although revolutionary in cutaneous melanoma, immune checkpoint inhibitors have shown reduced efficacy in anorectal melanoma. Nevertheless, their emergence and the possibility of improved outcomes may have changed the surgical management paradigm.

OBJECTIVE

To review the surgical management of anorectal melanoma in pre- and postimmunotherapy eras.

DESIGN

A retrospective cohort study from the Melanoma Institute Australia Research Database.

SETTINGS

A quaternary melanoma referral center.

PATIENTS

Patients with anorectal melanoma from 1958 to 2021 were included.

INTERVENTIONS

The use of abdominoperineal resection and wide local excision were compared in pre- and postimmunotherapy eras from the first use in 2014.

MAIN OUTCOME MEASURES

Type of surgery performed over time and overall survival.

RESULTS

A total of 56 patients were identified with anal (57.1%), anorectal (16.1%), and rectal melanoma (26.8%). Initial management was abdominoperineal resection (37.5%), low anterior resection (3.6%), wide local excision (46.4%), and nonsurgical (12.5%) in metastatic or unresectable disease. Immunotherapy and targeted therapies were used in 21 patients (37.5%) from 2014, with no difference in mode of surgical management in pre- and postimmunotherapy eras ( p = 0.134). Five-year survival was 12.5% for the entire cohort, with no significant difference comparing patients receiving wide local excision or abdominoperineal resection (15.4% vs 14.3%, log rank p = 0.77). Involved margins were significantly associated with wide local excision (15.4% vs 4.8%, p = 0.016) with similar rates of local recurrence (15.4% vs 14.3%, p = 0.58).

LIMITATIONS

The rarity of anorectal melanoma resulted in a small cohort managed over 63 years. Early checkpoint inhibitor trials excluded patients with mucosal melanoma, limiting access in this cohort.

CONCLUSIONS

Despite the introduction of immunotherapy, surgery remains pivotal in the management of anorectal melanoma. Surgical resection may be curative and prevent morbidity due to locoregional progression, but it can come at the cost of reduced quality of life. Centralized management in experienced centers should be encouraged for optimal multidisciplinary management. See Video Abstract .

ENFOQUES EN EL EL TRATAMIENTO QUIRRGICO DEL MELANOMA ANORECTAL EN LAS EPOCAS PREVIA Y POSTERIOR A LA INMUNOTERAPIA

ANTECEDENTES:Si bien han sido revolucionarios en el tratamiento del melanoma cutáneo, los inhibidores de los puntos de control inmunitario han demostrado reducida eficacia en el tratamiento del melanoma ano-rectal. Sin embargo, su advenimiento y la posibilidad de obtener mejores resultados podrían haber cambiado el paradigma del tratamiento quirúrgico.OBJETIVO:Revisar el tratamiento quirúrgico del melanoma ano-rectal en las épocas previa y posterior a la inmunoterapia.DISEÑO:Estudio retrospectivo de cohortes de la base de datos de investigación del Instituto del Melanoma de Australia (MRD2).ESCENARIO:Centro de referencia cuaternaria para melanomas.PACIENTES:Pacientes con melanoma ano-rectal desde 1958 hasta 2021.INTERVENCIONES:Se comparó la resección abdominoperineal y la excisión local ampliada en las épocas previa y posterior a la inmunoterapia desde su primer uso en 2014.PRINCIPALES MEDIDAS DE RESULTADOS:Tipo de cirugía realizada a lo largo del tiempo y sobrevida general.RESULTADOS:Se identificaron 56 pacientes con melanoma anal (57,1%), ano-rectal (16,1%) y rectal (26,8%). El tratamiento inicial fue la resección abdominoperineal (37,5%), la resección anterior baja (3,6%), la excisión local amplia (46,4%) y el tratamento no quirúrgico (12,5%) en enfermedad metastásica o irresecable. Se utilizaron inmunoterapia y terapias dirigidas en 21 pacientes (37,5%) a partir de 2014 sin diferencias en el modo de tratamiento quirúrgico en las épocas previas y posteriores a la inmunoterapia ( p = 0,134). La supervivencia a 5 años fue del 12,5% para toda la cohorte sin diferencias significativas al comparar a los pacientes que recibieron escisión local amplia o resección abdominoperineal (15,4% frente a 14,3%, log rank p = 0,77). Los márgenes afectados se asociaron significativamente con una escisión local amplia (15,4% frente a 4,8% p = 0,016) con tasas similares de recurrencia local (15,4% frente a 14,3% p = 0,58).LIMITACIONES:El melanoma ano-rectal es poco frecuente, por lo que presentamos una pequeña cohorte tratada a lo largo de ocho décadas. Los primeros ensayos con inhibidores de puntos de control excluyeron a los pacientes con melanoma mucoso, lo que limitó el acceso en esta cohorte.CONCLUSIONES:A pesar del advenimiento de la inmunoterapia, la cirugía sigue siendo fundamental en el tratamiento del melanoma ano-rectal. La resección quirúrgica puede ser curativa y prevenir la morbilidad debido a la progresión locorregional, pero puede tener el costo de una calidad de vida reducida. Finalmente, debe promoverse el tratamiento centralizado en centros experimentados para un tratamiento multidisciplinario óptimo. (Traducción-Dr. Xavier Delgadillo ).

The Effect of Sphincter Pressure and Anal Length on Surgical Decision in Chronic Anal Fissure

Background/Objectives: Chronic anal fissure, an anorectal condition, is characterized by internal anal sphincter fibers at the base of the fissure. The lifetime prevalence is 7-8%. Medical management and lifestyle modifications are the first-line treatments, whereas chemical or surgical internal anal sphincterectomy is an option for refractory cases. The aim of this study was to evaluate the impact of surgical anal canal length and sphincter pressure on postoperative symptom relief and continence outcomes. Methods: A total of 26 patients diagnosed with chronic anal fissures were selected for surgical treatment. Five patients voluntarily withdrew, leaving 21 cases for analysis. In patients undergoing open lateral internal sphincterotomy, anal canal length and sphincter pressure were assessed preoperatively and three months postoperatively using endoanal ultrasonography and high-resolution anal manometry. Results: Postoperatively, all patients experienced complete resolution of pain and bleeding. The expected decrease in resting pressure was not significantly associated with sex. A significant weight gain was observed postoperatively (p = 0.001). Although a significant decrease was observed in preoperative sphincter resting pressure and VAS scores, Wexner scores remained unchanged. Preoperatively and postoperatively, mean sphincter pressure was significantly lower in the spontaneous vaginal delivery group than that in the non-spontaneous vaginal delivery group (p < 0.05). Patients with short anal canal lengths had greater pressures reductions, though not statistically significant. Conclusions: Lateral internal sphincterotomy is an effective and safe treatment for chronic anal fistula when performed by experienced surgeons. Anal canal length may influence postoperative complications and surgical decisions. Larger studies are needed to confirm these findings.

Safety and efficacy of gastrointestinal motility agents following elective colorectal surgery: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Postoperative ileus (POI) is a frequent complication after elective colorectal surgery, delaying gastrointestinal (GI) recovery and discharge. While pharmacologic agents such as laxatives and prokinetics are often included in enhanced recovery after surgery (ERAS) protocols, their efficacy and safety remain uncertain.

METHODS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to evaluate the effect of Gastrointestinal (GI) motility agents on postoperative recovery in elective colorectal surgery. Primary outcomes included GI-2 recovery (tolerance of solid diet and stool passage), time to first defaecation, and safety endpoints. Data was pooled using random-effects models.

RESULTS

Seven RCTs involving 849 patients were included. GI motility agents significantly accelerated GI-2 recovery (mean difference -1.01 days; 95% CI -1.29 to -0.73; p < 0.001) and reduced time to first defaecation (mean difference -1.07 days; 95% CI -1.40 to -0.73; p < 0.001). No significant differences were observed in safety outcomes, including anastomotic leak (OR 0.97; 95% CI 0.53 to 1.77), nasogastric tube reinsertion (OR 0.86; 95% CI 0.49 to 1.51), or readmission rates (OR 1.03; 95% CI 0.62 to 1.72).

CONCLUSION

Motility agents enhance postoperative GI recovery without compromising safety in patients undergoing elective colorectal surgery. Given their low cost, wide availability, and favourable safety profile, gastrointestinal motility agents may be considered for integration into ERAS protocols. However, further high-quality, standardised trials are needed to confirm their benefits across diverse surgical populations.

Management of chronic anal fissures: should fissurectomy be performed with botulinum toxin injection?

BACKGROUND

Despite the superior success rate of lateral internal sphincterotomy for managing chronic anal fissure (CAF), there is a trend towards sphincter-preserving treatment due to the increased risk of incontinence. Botulinum toxin (BT) and fissurectomy are two sphincter-preserving options for CAF. We aim to assess if combining fissurectomy with botox treatment is superior to botulinum toxin alone in the management of CAF.

METHODS

This retrospective cohort study was conducted across two Sydney hospitals over 7 years. All patients with a CAF managed with either BT and fissurectomy (group 1) or BT only (group 2) were included. Primary outcome was healing rate defined as resolution or significant improvement of perianal symptoms at initial follow-up. Secondary outcomes were persistence, recurrence, re-intervention and faecal incontinence rate. Follow-up questionnaire was conducted to compare long-term outcomes between the two groups.

RESULTS

Fifty-seven patients met the inclusion criteria (group 1, 37; group 2, 20). Mean BT dose and injection location between the groups were similar (p = 0.259 and p = 0.427). There was a 65% response rate to the follow-up questionnaire. Median follow-up was 34.3 months (range 0.4-93). There was no difference in healing (56.7% vs. 50%, p = 0.561), recurrence (37.8% vs. 30%, p = 0.383) or re-intervention rate (13.5% vs. 20%, p = 0.888). Long-term incontinence rate was significantly higher in patients group 2 (0% vs. 10%, p = 0.010), with two patients reporting persistent flatus incontinence. Median overall satisfaction score was 3/4 (range 1-4), in both groups (p = 0.469).

CONCLUSION

Botulinum toxin with or without fissurectomy is a safe sphincter-sparing treatment option for CAF. However, the addition of fissurectomy to BT does not improve healing rates and we therefore recommend BT injection alone as a second-line treatment of CAF in patients who fail topical treatment.

Milligan-Morgan hemorrhoidectomy combined with rubber band ligation and polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: a retrospective study

BACKGROUND

Hemorrhoids are one of the most common and annoying benign diseases in the field of colorectal surgery. A Milligan-Morgan hemorrhoidectomy (MMH) is the most frequently applied surgical technique due to its clear efficacy and high success rate, but the reported postoperative complications remain a major problem. This study aimed to retrospectively evaluate the efficacy and safety of a MMH combined with rubber band ligation and polidocanol foam sclerotherapy (MMH + RBL + PFS) for the management of grade III/IV hemorrhoids.

METHODS

This was a single-center retrospective study. A total of 255 patients with grade III/IV hemorrhoids who underwent MMH + RBL + PFS (n = 128) or MMH (n = 127) between May 2022 and June 2023 were included in the study. The primary outcomes included recurrence rates, hemorrhoid severity score (HSS), and patient satisfaction 12 months after surgery. Secondary outcomes included intraoperative outcomes and postoperative outcomes.

RESULTS

Follow-up was conducted by telephone or outpatient visit 12 months after surgery. The recurrence rate was lower in the MMH + RBL + PFS group than in the MMH group (p < 0.05). The patient satisfaction score was higher in the MMH + RBL + PFS group than in the MMH group (p < 0.05), and there was no significant difference in the HSS between the two groups (p > 0.05). The median operation time in the two groups was similar (16 min (15-20 min) vs.16 min (15-18 min), p > 0.05). The median number of incisions in the the MMH + RBL + PFS group was 3 (2-3), while that in the MMH group was 3 (3-4) (p < 0.05). There was no significant difference in intraoperative blood loss between the two groups (p > 0.05). Visual analog scale pain scores were lower in the MMH + RBL + PFS group than in the MMH group at the first postoperative defecation at 12 h and at 1, 3, and 7 days (all p < 0.05). The wound healing time was shorter in the MMH + RBL + PFS group than in the MMH group (27.62 ± 3.74 vs. 28.73 ± 4.48 days, respectively, p < 0.05). The incidence of urinary retention was lower in the MMH + RBL + PFS group than in the MMH group (5.47% vs. 12.60, respectively, p < 0.05). Nine patients (one case in the MMH + RBL + PFS group and eight cases in the MMH group (p < 0.05)) had delayed bleeding and were successfully controlled with manual compression or surgical hemostasis. No cases had anal stenosis in the MMH + RBL + PFS group, and six cases (4.72%) had it in the MMH group, all with mild anal stenosis and successfully treated by dilatation alone (p < 0.01). No incision infection or anal incontinence occurred in either group. At the 12-month follow-up after surgery, the recurrence rate was lower in the MMH + RBL + PFS group (0.78%) than in the MMH group (7.09%) (p < 0.05). The patient satisfaction score was higher in the MMH + RBL + PFS group (91.41%) than in the MMH group (81.10%) (p < 0.05), and there was no significant difference in the HSS between the two groups (p > 0.05).

CONCLUSIONS

Compared with the MMH, the MMH + RBL + PFS surgical procedure is safe and effective for grade III/IV hemorrhoids, which is associated with a lower recurrence rate, a higher patient satisfaction score, a lower postoperative pain score, fewer postoperative complications, and a shorter wound healing time.

Comparison of Rubber Band Ligation and Hemorrhoidectomy in Patients With Symptomatic Hemorrhoids Grade III: A Multicenter, Open-Label, Randomized Controlled Noninferiority Trial

BACKGROUND

The optimal management strategy for grade III hemorrhoids remains a subject of ongoing debate. Hemorrhoidectomy is the criterion standard, but rubber band ligation offers a less invasive outpatient alternative. Treatment variability persists due to a lack of consensus on the preferred strategy.

OBJECTIVE

To directly compare the effectiveness of rubber band ligation and hemorrhoidectomy in the treatment of grade III hemorrhoids.

DESIGN

Open-label, parallel-group, randomized controlled noninferiority trial.

SETTINGS

Multicenter study across 10 Dutch hospitals from October 2019 to September 2022.

PATIENTS

Patients (aged 18 years or older) with symptomatic grade III (Goligher) hemorrhoids were included in this study. Exclusion criteria included prior rectal/anal surgery, more than 1 rubber band ligation/injection within the preceding 3 years, rectal radiation, preexisting sphincter injury, IBD, medical unfitness for surgery (ASA higher than 3), pregnancy, or hypercoagulability disorders.

INTERVENTIONS

Randomized 1:1 to rubber band ligation or hemorrhoidectomy, with up to 2 banding sessions allowed.

MAIN OUTCOME MEASURES

Primary outcomes included 12-month health-related quality of life and recurrence rate. Secondary outcomes included complications, pain, work resumption, and patient-reported outcome measures.

RESULTS

Eighty-seven patients were randomly assigned (47 rubber band ligation vs 40 hemorrhoidectomy). Rubber band ligation was not noninferior to hemorrhoidectomy in quality-adjusted life years (-0.045; 95% CI, -0.087 to -0.004). Recurrence rate was worse in the rubber band ligation group (47.5% vs 6.1%), with an absolute risk difference of 41% (95% CI, 24%-59%). Complication rates were comparable. Pain scores after hemorrhoidectomy were higher during the first week (visual analogue scale 4 vs 1; p = 0.002). Rubber band ligation group returned to work sooner (1 vs 9 days; p = 0.021). Patient-reported hemorrhoidal symptom scores favored hemorrhoidectomy.

LIMITATIONS

The primary limitation of the study was its early termination due to funding constraints, resulting in a relatively small sample size and limited statistical power. Patient recruitment was hindered by significant treatment preferences and the COVID-19 pandemic.

CONCLUSIONS

Hemorrhoidectomy may benefit patients with grade III hemorrhoids in terms of quality of life, recurrence risk, and symptom burden, whereas rubber band ligation allows faster recovery with less pain. These findings can guide clinical decision-making. See Video Abstract .

CLINICAL TRIAL REGISTRATION NUMBER

NCT04621695.

COMPARACIN DE LA LIGADURA CON BANDA ELSTICA Y LA HEMORROIDECTOMA EN PACIENTES CON HEMORROIDES SINTOMTICAS GRADO III ENSAYO MULTICNTRICO, ABIERTO, ALEATORIZADO, CONTROLADO Y DE NO INFERIORIDAD

ANTECEDENTES:La estrategia óptima de tratamiento para las hemorroides grado III sigue siendo un tema de debate continuo. La hemorroidectomía es el estándar de oro, pero la ligadura con banda elástica ofrece una alternativa ambulatoria menos invasiva. La variabilidad del tratamiento persiste debido a la falta de consenso sobre la estrategia preferida.OBJETIVO:Comparar directamente la eficacia de la ligadura con banda elástica y la hemorroidectomía en el tratamiento de las hemorroides grado III.DISEÑO:Ensayo de no inferioridad, controlado, aleatorizado, de grupos paralelos y abierto.ENTORNO CLINICO:Estudio multicéntrico en 10 hospitales holandeses desde octubre de 2019 hasta septiembre de 2022.PACIENTES:Pacientes (≥18 años) con hemorroides sintomáticas grado III (Goligher). Exclusiones: cirugía rectal/anal previa, >1 ligadura con banda elástica/inyección en los tres años anteriores, radiación rectal, lesión preexistente del esfínter, enfermedad inflamatoria intestinal, incapacidad médica para la cirugía (ASA >3), embarazo o trastornos de hipercoagulabilidad.INTERVENCIONES:Aleatorización 1:1 para ligadura con banda elástica o hemorroidectomía, con hasta dos sesiones de ligadura permitidas.PRINCIPALES MEDIDAS DE RESULTADOS:Primarias: calidad de vida relacionada con la salud a los 12 meses y tasa de recurrencia. Secundarias: complicaciones, dolor, reanudación del trabajo y medidas de resultados informadas por el paciente.RESULTADOS:Se aleatorizaron ochenta y siete pacientes (47 ligadura con banda elástica frente a 40 hemorroidectomía). La ligadura con banda elástica no fue no inferior a la hemorroidectomía en años de vida ajustados por calidad (-0,045, intervalo de confianza del 95 %: -0,087 a -0,004). La tasa de recurrencia fue peor en el grupo de ligadura con banda elástica (47,5 % frente a 6,1 %), con una diferencia de riesgo absoluto del 41 % (intervalo de confianza del 95 %: 24 %-59 %). Las tasas de complicaciones fueron comparables. Las puntuaciones de dolor posthemorroidectomía fueron más altas durante la primera semana (escala analógica visual 4 frente a 1; p = 0,002). El grupo de ligadura con banda elástica volvió al trabajo antes (1 frente a 9 días; p = 0,021). Las puntuaciones de síntomas hemorroidales notificadas por los pacientes favorecieron a la hemorroidectomía.LIMITACIONES:La principal limitación del estudio fue su finalización temprana debido a las limitaciones de financiación, lo que dio lugar a un tamaño de muestra relativamente pequeño y a un poder estadístico limitado. El reclutamiento de pacientes se vio obstaculizado por las preferencias significativas de tratamiento y la pandemia de COVID-19.CONCLUSIONES:La hemorroidectomía puede beneficiar a los pacientes con hemorroides de grado III en términos de calidad de vida, riesgo de recurrencia y carga de síntomas, mientras que la ligadura con banda elástica permite una recuperación más rápida con menos dolor. Estos hallazgos pueden orientar la toma de decisiones clínicas. (Traducción- Dr. Francisco M. Abarca-Rendon )NÚMERO DE REGISTRO DEL ENSAYO CLÍNICO:NCT04621695.

Latest Research Trends on the Management of Hemorrhoids

Hemorrhoids manifest with a range of symptoms and severities, prompting the development of various conservative, interventional, and surgical treatments. Selecting the most suitable treatment for each case is challenging, especially with the continuous evolution of new methods. This review aims to advance hemorrhoid treatment and research by exploring recent developments over the last five years. Conservative approaches have focused on isolating active ingredients from traditional herbal remedies to create new products and understand their mechanisms. In office-based treatments, advanced devices such as modified rubber band ligation and polymer clips with stronger binding forces have been introduced. Polidocanol in foam form has shown promise in sclerotherapy, while infrared coagulation is being replaced by alternative energy-based methods. Additionally, endoscopic office treatments and embolization of hemorrhoidal vessels via angiography are increasingly used as safer options for patients with high surgical risks or bleeding issues. Stapled hemorrhoidopexy has shifted to partial resection instead of complete circular resection, and hemorrhoidal artery ligation techniques have been reported to be effective when combined with stapled hemorrhoidopexy or excisional hemorrhoidectomy in severe cases. Evidence is growing that hemorrhoidal artery ligation remains effective even without Doppler guidance. With ongoing research into various methods, there is a need for scientific comparison and evaluation of their advantages and disadvantages, standardization of indicators and treatment protocols, and cost-effectiveness considerations. Surgeons should offer well-informed options and explanations to patients, based on a comprehensive understanding of available treatments.

Fissurectomy with or without anoplasty for chronic anal fissures is a valid alternative to lateral internal sphincterotomy: a retrospective cohort study of 475 patients

BACKGROUND

After the failure of conservative therapy, the most effective surgical treatment for chronic anal fissures (CAFs) is lateral internal sphincterotomy. However, the choice of the procedure must be always evaluated carefully due to the risk of long-term anal continence impairment. The aim of the present study is to report the outcomes of fissurectomy with or without associated anoplasty.

METHODS

This study is a single-center retrospective study including patients with CAFs in whom conservative medical and non-medical treatments failed and who underwent fissurectomy with or without anoplasty from January 2015 to June 2023. Fecal continence, pain, and complications were assessed using specific questionnaires and scores.

RESULTS

Overall, 475 patients [280 males (58.9%)] with CAF underwent fissurectomy, with (n = 392; 82.5%) or without (n = 83; 17.5%) anoplasty. The majority of them (n = 379; 79.8%) had a posterior fissure. The mean follow-up was 49.9 months ± 26.13 months, with a minimum of 1 year, showing no intraoperative complications and a 4.2% postoperative complication rate. Missed healing occurred in 7.15% of patients at 6 months of follow-up, with higher recurrence and sphincterotomy rates in posterior fissures (p = 0.04). Cleveland Clinic Incontinence Scores were higher in patients who underwent anoplasty (p = 0.002). Interestingly, anoplasty led to a significant decrease in visual analogue scale (VAS) scores (p < 0.001), compared with those who did not undergo the procedure, with a consequent faster recovery.

CONCLUSION

Our study showed that fissurectomy, whether performed with or without anoplasty, was a highly effective surgical option for treating CAFs, achieving an overall success rate of 92.8% without significant impairment of continence and with a low complication rate. Further randomized prospective trials are needed to confirm this finding. Interestingly, fissurectomy with anoplasty seems to allow for better short-term outcomes in terms of postoperative pain and recovery time compared with fissurectomy alone.

The comparison of doppler-guided haemorrhoidal artery ligation and the tissue selecting technique for patients with grade III/IV haemorrhoids: a retrospective cohort study

This study aimed to evaluate the efficacy and the safety of Doppler-guided hemorrhoid artery ligation (DG-HAL) and tissue-selecting technique (TST) in patients with grade III/IV hemorrhoids. We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021. Among them, 119 patients had received TST, and the remaining 132 patients received DG-HAL. We collected and compared clinical characteristics of both groups, including post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding). The VAS pain score of the first post-operative defecation and at the post-operative day (POD)1 and 2 for the DG-HAL group was lower than those for the TST group (P = 0.006 and P = 0.029). The incidence of post-operative complications (including bleeding, urinary retention and sensation of rectal tenesmus) in the DG-HAL group was lower than that in the TST group (P = 0.021, P = 0.035 and P = 0.047). At follow-up by telephone or outpatient 3 years after surgery, the recurrence rate (prolapse) was lower in the TST group than in the DG-HAL group (P = 0.013). Subgroup analysis showed a higher prolapse recurrence rate in grade IV patients than grade III patients after DG-HAL (P = 0.013). DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients.

Risk of lymph node metastases and conditional survival in appendiceal neuroendocrine neoplasms

BACKGROUND

National Comprehensive Cancer Network guidelines recommend segmental colectomy for appendiceal neuroendocrine neoplasms >2.0 cm given the risk for lymph node involvement. However, additional clinicopathologic factors are associated with nodal metastases, and thus survival. Given dynamic changes of prognosis over time, conditional overall survival, the probability of surviving after a specific interval, has emerged as a novel oncologic outcome, but is scarcely available for appendiceal neuroendocrine neoplasms.

METHODS

Adults with stage I-III appendiceal neuroendocrine neoplasms who underwent colectomy from 2010-2017 were identified in the National Cancer Database. Tumor histologies included neuroendocrine tumor grade 1, neuroendocrine tumor grades 2 and 3, neuroendocrine carcinoma, mixed neuroendocrine non-neuroendocrine neoplasm, and goblet cell carcinoma.

RESULTS

Of 3,541 patients (median age 51 years, 43% male, 88% White), 16% had positive lymph nodes. Overall, 40% had neuroendocrine tumor grade 1, 4% neuroendocrine tumor grades 2 and 3, 10% neuroendocrine carcinoma, 12% mixed neuroendocrine non-neuroendocrine neoplasm, and 30% goblet cell carcinoma. Increasing depth of invasion, lymphovascular invasion, and increasing size were associated with lymph node metastases. Eighty-seven percent were alive at 2 years. Mortality after 2 years was associated with older age, mixed neuroendocrine non-neuroendocrine neoplasm and goblet cell carcinoma histology, penetration through serosa, nodal involvement, and tumor size.

CONCLUSIONS

In a national cohort, 1 in 6 patients had positive lymph nodes, which was associated with depth of invasion, lymphovascular invasion, and size. These findings indicate additional factors should be considered when determining the extent of surgical resection and surveillance to improve survival outcomes. Additionally, patients with penetration through serosa, and mixed neuroendocrine non-neuroendocrine neoplasm or goblet cell carcinoma histology had worse conditional overall survival, potentially reflecting more aggressive tumor biology that warrants closer follow-up.

Disparities and Health Care Delivery for Patients with Peritoneal Surface Malignancy

Management of peritoneal surface malignancy (PSM) is complex and requires care at a PSM center. Despite the reported benefit of cytoreductive surgery (CRS)/ hyperthermic intraperitoneal chemotherapy (HIPEC) across PSM primaries, the uptake nationwide is low. The reasons are multifaceted and related to factors that disproportionately impact racial and ethnic minorities, rural residents, and other socially vulnerable patient populations. There are significant misperceptions of CRS/HIPEC in the treatment of PSM and the potential benefit for appropriately selected patients. Much work is needed to improve patient and provider education and to expand the reach of expert PSM management to vulnerable patients.

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

PURPOSE

The long-term outcomes and efficacy of partial stapled hemorrhoidopexy (PSH) compared with those of conventional hemorrhoidectomy (CH) are not fully understood. This study aimed to introduce a modified PSH (mPSH) and compare its clinical efficacy and safety with those of CH.

METHODS

A prospective randomized controlled trial was conducted. This study was performed at a single hospital and involved 6 colorectal surgeons. In total, 110 patients were enrolled between July 2019 and September 2020. Patients were randomly assigned to undergo either mPSH group (n=55) or CH group (n=55). The primary outcome was to compare postoperative average pain and postoperative peak pain using visual analog scale score between the 2 groups.

RESULTS

The required duration of analgesia was shorter in the mPSH group than in the CH group, although the difference was not statistically significant (P=0.096). However, the laxative requirement duration (P<0.010), return to work (P<0.010), satisfaction score (P<0.010), and Vaizey score (P=0.014) were significantly better in the mPSH group. The average and peak postoperative pain scores were significantly lower in the mPSH group during the 15 days after surgery (P<0.001). The overall complication rate in both groups was 9.1%, with no significant difference between the groups (P=0.867).

CONCLUSION

The mPSH group demonstrated better improvement in symptoms, lower pain scores, and greater patient early satisfaction after surgery than the CH group. Therefore, this surgical technique appears to be a safe and effective alternative for CH.

Clinical evidence and rationale of topical nifedipine and lidocaine ointment in the treatment of anal fissure and hemorrhoidal disease

INTRODUCTION

Anorectal conditions such as hemorrhoidal disease and anal fissure are frequently painful and debilitating. Pain after hemorrhoidectomy is also common and distressing. These conditions are at least initially managed conservatively. An ointment formulation containing the calcium channel blocker nifedipine and the local anesthetic lidocaine has an established role in the treatment of rectal conditions, particularly conditions associated with anal sphincter hypertonia such as hemorrhoidal disease and anal fissure. This review aimed to compile the evidence for the use of nifedipine 0.3% and lidocaine 1.5% ointment in treating these common but bothersome anorectal diseases.

EVIDENCE ACQUISITION

A comprehensive literature search was conducted, updated to 07 August 2024, using PubMed and MEDLINE databases to identify studies of lidocaine and nifedipine, alone or in combination, for the topical treatment of anal fissure or hemorrhoidal disease. Articles identified in the literature search were supplemented by ad hoc searches and supplemented by relevant literature known to the authors.

EVIDENCE SYNTHESIS

Nifedipine 0.3% and lidocaine 1.5% ointment is effective in relieving pain and aiding the resolution of thrombosed hemorrhoids, reducing resting anal pressure and healing chronic anal fissures, and controlling pain after hemorrhoidectomy. The ointment was significantly better than controls consisting of topical lidocaine 1.5% alone or in combination with hydrocortisone acetate 1%.

CONCLUSIONS

Although the available literature on the topical application of nifedipine and lidocaine in anorectal diseases is limited, nifedipine 0.3% and lidocaine 1.5% ointment should be considered a valid treatment option for clinicians treating anorectal diseases. Further studies are warranted to confirm and extend the results reported.

Statistical models versus machine learning approach for competing risks in proctological surgery

Clinical risk prediction models are ubiquitous in many surgical domains. The traditional approach to develop these models involves the use of regression analysis. Machine learning algorithms are gaining in popularity as an alternative approach for prediction and classification problems. They can detect non-linear relationships between independent and dependent variables and incorporate many of them. In our work, we aimed to investigate the potential role of machine learning versus classical logistic regression for the preoperative risk assessment in proctological surgery. We used clinical data from a nationwide audit: the database consisted of 1510 patients affected by Goligher's grade III hemorrhoidal disease who underwent elective surgery. We collected anthropometric, clinical, and surgical data and we considered ten predictors to evaluate model-predictive performance. The clinical outcome was the complication rate evaluated at 30-day follow-up. Logistic regression and three machine learning techniques (Decision Tree, Support Vector Machine, Extreme Gradient Boosting) were compared in terms of area under the curve, balanced accuracy, sensitivity, and specificity. In our setting, machine learning and logistic regression models reached an equivalent predictive performance. Regarding the relative importance of the input features, all models agreed in identifying the most important factor. Combining and comparing statistical analysis and machine learning approaches in clinical field should be a common ambition, focused on improving and expanding interdisciplinary cooperation.

Stoma reversal after emergency stoma formation-the importance of timing: a multi-centre retrospective cohort study

BACKGROUND

Restoration of intestinal continuity is a key consideration for patients having a stoma created under emergency conditions. There is contrasting evidence about the outcomes of stoma reversal for these patients. This research aims to describe the post-operative outcomes of stoma reversal after emergency formation, and whether these are affected by the timing of reversal.

METHODS

A retrospective review of a prospectively maintained emergency laparotomy (EmLap) database for 4 hospitals was performed between 2018 and 2021. Adult patients undergoing emergency stoma formation were identified and followed up until 2024. Those undergoing stoma reversal surgery were included in the final analysis. A Cox proportional-hazards model was created to identify factors associated with increased time to reversal.

RESULTS

1775 patients had an EmLap, with 505 (28.5%) having a stoma created. Of those patients with a stoma, 97 patients (19.2%) died within one year post-operatively. 146 (28.9%) of the emergency stoma patients underwent stoma reversal, with median time to reversal of 16.9 months. Median post-operative length of stay was 7 days, and 52.1% of patients sustained complications within 30 days post-operatively. Patients reversed within 18 months of stoma formation had fewer significant complications (7.9% v 35.1%, p < 0.001), a shorter length of stay (6 days v 7 days, p < 0.001), and reduced post-operative ileus rates (21.3% v 64.9%, p < 0.001) than those reversed after this period. Receiving adjuvant therapy for malignancy (adjusted Hazard ratio 0.36, 0.17-0.78, p = 0.001) and being male (adjusted Hazard ratio 0.69, 0.49-0.97, p = 0.032) were significantly associated with increased time to reversal.

CONCLUSION

Emergency stoma formation is commonly performed during EmLap, but the majority of emergency stomas are never reversed. The complication profile for reversing these stomas is significant, but early reversal is associated with better post-operative outcomes. Standards of care for emergency stoma patients would be welcome in order to improve outcomes for this cohort.

Comparison of melatonin and music therapy as a preoperative anxiolytic for patients undergoing impacted mandibular third molar extraction: a double-blind randomised controlled trial

Dental preoperative anxiety poses significant challenges in healthcare, leading to treatment avoidance and prolonged recovery times. Despite the plethora of pharmacological and psychotherapeutic interventions employed for anxiety management, their relative efficacy remains unclear. This study aims to compare the effectiveness of oral melatonin (6 mg) and music therapy in preoperative anxiety management among patients undergoing surgical extraction of impacted mandibular third molars. A total of 78 patients aged 18-40 years undergoing surgical extraction were selected and randomly assigned into three groups: nil intervention (Group NI) with no intervention, Group ML administered oral melatonin, and Group MT administered 20 min of relaxing music (n = 26). Physiological parameters (pulse rate, blood pressure) and subjective assessments (visual analogue scale for anxiety) were measured on arrival (T1), after the intervention (T2), and after surgical extraction (T3). Salivary cortisol levels, recorded preoperatively and postoperatively, were analysed using ELISA. Results showed significant improvement in physiological parameters for both ML and MT compared with NI (p < 0.05). However, postoperative cortisol levels increased significantly in the NI (0.55 (0.15) - 0.88 (0.32) pmol/ml) and MT groups (from 0.33 (0.15) - 0.62 (0.2) pmol/ml) but decreased in the ML group (from 0.42 (0.19) - 0.3 (0.14) pmol/ml). This indicated a delayed action of melatonin as compared with the immediate impact of music therapy. Understanding the mechanisms and insights obtained can aid in developing advanced anxiety management methods for dental practitioners, thereby enhancing patient care and outcomes in dental practice.

Effects of Sound Interventions on the Mental Stress Response in Adults: Scoping Review

BACKGROUND

This scoping review examines the effects of various sound interventions, including music, natural sounds, and speech, on the stress response in adults.

OBJECTIVE

The review aims to identify key therapeutic factors, including sound type, individual listener characteristics, and environmental influences. It also synthesizes evidence on physiological responses to sound interventions and highlights current research gaps.

METHODS

We conducted a comprehensive search using databases such as PubMed, Web of Science, Scopus, and PsycINFO, focusing on studies from 1990 to 2024. Eligible studies included randomized controlled trials, clinical trials, and laboratory experiments that measured stress through physiological markers (eg, heart rate variability and cortisol) and self-reports. A total of 34 studies were included, and thematic analysis was conducted to identify recurring themes in the findings.

RESULTS

The findings suggest that music, especially classical and self-selected pieces, effectively reduces physiological stress markers, including cortisol levels, heart rate variability, and blood pressure. Nonmusical sounds, such as nature sounds and calming voices, also demonstrate potential for stress relief, although research in this area remains limited. While most sound interventions showed positive effects, some studies reported adverse effects, indicating that sound can both alleviate and induce stress. The outcomes were substantially affected by contextual factors such as personal preferences, delivery methods, cultural context, and emphasizing the importance of personalized interventions.

CONCLUSIONS

Sound interventions offer promising, noninvasive methods for stress reduction. This review suggests that future research should address gaps in the study of nonmusical sound interventions and further investigate the neural mechanisms underlying stress responses to sound.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/54030.

Is it beneficial to add laser ablation to curettage in the treatment of pilonidal sinus disease?

AIM

This study aimed to compare laser application with sinus curettage against only sinus curettage in the treatment of pilonidal sinus disease (PSD) in terms of postoperative complications, wound healing, and recurrence. Additionally, we aimed to investigate factors associated with wound healing and recurrence after PSD surgery.

PATIENTS AND METHODS

This study included patients diagnosed with PSD between February 2019, and September 2022. The patients were randomly assigned to either the laser + curettage (L/C; n = 40) group or the curettage-only (C; n = 40) group. The following data were collected: demographic and anthropometric information, smoking status, comorbidities, number of PSD-related orifices, complicated or uncomplicated disease, prior recurrence, postoperative findings, wound healing problems within 30 days postoperatively, and recurrence within 6 months postoperatively.

RESULTS

The L/C and C groups were similar in terms of age and sex distribution. The groups had similar results for postoperative pain, discharge, bleeding, wound healing problems at 30 days, and recurrence at 6 months. Multivariable logistic regression revealed that, high weight and higher orifice count were independently associated with wound healing problems. Additionally, high weight, higher orifice count and prior recurrence were independently associated with recurrence.

CONCLUSION

Combined curettage and laser therapy showed non-significant but broad benefits over curettage alone, but statistical significance was not achieved in any of the adverse findings, as well as wound healing and recurrence. Higher body weight and higher orifice count were associated with both poor wound healing and recurrence, while prior recurrence was another factor associated with recurrence at 6 months.

Effectiveness of combined botulinum toxin and fissurectomy on chronic anal fissures - a systematic review

BACKGROUND

Anal fissures are a debilitating benign condition, thought to be due to the hypertonicity of the internal anal sphincter resulting in localized ischaemia inhibiting healing. There are several surgical and non-surgical treatment options for chronic anal fissures. Clinical practice surveys report a trend toward sphincter-sparing options, reserving the more successful treatment of lateral sphincterotomy, with an incontinence rate up to 10%, for refractory fissures.

METHODS

A search of MEDLINE, Cochrane Database of Systematic Reviews and EMBASE for studies assessing sphincter-sparing treatment with botulinum toxin and fissurectomy was performed following PRISMA guidelines. Outcomes assessed included healing rate, persistence, recurrence, re-intervention and incontinence rates.

RESULTS

Fifteen non-randomized studies assessed 978 patients managed with botulinum toxin and fissurectomy. The mean age was 40.8 years with a female predominance of 58.9%. Healing rate was reported on 14 of the 15 studies, with a healing rate of 81% (95% CI:0.67, 0.90). Persistence rate was reported as 15% (95% CI:0.07, 0.28) and a recurrence rate of 6% (95% CI: 0.01, 0.19). Re-intervention was required in 8% of patients with 55.1% requiring a repeat dose of botulinum toxin with or without fissurectomy. Incontinence appears to be transient with studies reporting a rate of 1% with median long-term follow up 23 months (range: 5-60 months).

CONCLUSION

Combination fissurectomy and botulinum toxin is a safe and viable sphincter sparing treatment option, with moderate success rate and negligible complications. Randomized controlled trials are required to further strengthen the evidence for its use in chronic anal fissures.

The Initial Exploration of Polidocanol Sclerotherapy for the Treatment of Axillary Osmidrosis: A Retrospective Study

BACKGROUND

Axillary osmidrosis (AO) is a strong, unpleasant odor that originates from the apocrine axillary glands. Treatments of AO include surgical treatment and nonsurgical treatment. The surgical procedure yields effective results with a low recurrence rate but requires a longer recovery time and has more postoperative complications. Nonsurgical treatments are minimally invasive and safe, but short-term recurrence may occur in some cases.

OBJECTIVE

Polidocanol sclerotherapy was first described for management of AO. This retrospective study explored the clinical efficacy in relieving symptom of AO assessed by AO severity using the axillary osmidrosis grading system and safety of polidocanol sclerotherapy in treating AO.

PATIENTS AND METHODS

This retrospective study included 25 patients with AO single-site study, with 12 patients receiving polidocanol (1%) sclerotherapy (the polidocanol group) and 13 receiving botulinum toxin A (BTX-A) injection (the BTX-A group). The short-term efficacy (7 days after injection), the long-term efficacy (6 months after injection), the recurrence rate, and complications were compared between the 2 groups. A p-value of <0.05 was considered statistically significant.

RESULTS

The short-term efficacies of polidocanol sclerotherapy and BTX-A injection were 100% and 69.2%, which was not clinically significant (p > .05), whereas their long-term efficacies were 100% and 46.2%, respectively (p < .05). The recurrence rates in the polidocanol and BTX-A groups were 25.0% and 84.6%, respectively (p < .05). The complications did not differ significantly between the 2 groups (p > .05). Although the short-term efficacy and complications were comparable between the 2 groups, the long-term efficacy of polidocanol sclerotherapy was superior to BTX-A injection. The polidocanol group has a lower recurrence rate than the BTX-A group.

CONCLUSION

Polidocanol sclerotherapy may provide an effective and safe treatment with longer efficacy compared to toxin, which is an effective and safe option for AO treatment.

Survival Outcomes in Patients Undergoing Pelvic Exenteration for Pelvic Mucosal Melanomas: Retrospective Single Institution Australian Study

BACKGROUND

Pelvic mucosal melanomas, including anorectal and urogenital melanomas, are rare and aggressive, with a median overall survival of up to 20 months. Pelvic mucosal melanomas behave differently from their cutaneous counterparts and present late with locoregional disease, making pelvic exenteration its only curative surgical option.

OBJECTIVE

This study aimed to evaluate the survival outcomes after pelvic exenteration in pelvic mucosal melanomas at Royal Prince Alfred Hospital.

DESIGN

Retrospective case series from a prospectively collected pelvic exenteration database from October 1994 to November 2023.

SETTING

Royal Prince Alfred Hospital (quaternary institution), Camperdown, New South Wales, Australia.

PATIENTS

Seven patients undergoing pelvic exenteration for pelvic mucosal melanoma.

MAIN OUTCOME MEASURES

Overall survival, disease-free survival, and complication rates.

RESULTS

Of the 7 patients, most were women (n = 5; 71.4%) and had a median age of 65 years (range, 36-79). Five patients (71.4%) underwent pelvic exenteration for primary pelvic mucosal melanoma, 3 of which were anorectal and 2 vaginal melanomas. Two patients (28.6%) had recurrent anorectal melanoma and received neoadjuvant radiotherapy after an initial wide local excision. Three patients (42.9%) required total pelvic exenteration, whereas 2 required a central pelvic exenteration (28.6%). The remaining procedures included central and lateral pelvic exenteration and anterior, central, and lateral pelvic exenteration. The median length of hospital stay was 19.7 days. Five patients had postoperative complications with 1 major complication (Clavien-Dindo grade IIIa). At the completion of the study, there were 4 mortalities. Mean survival was 23.6 months (range, 2-100) with a recurrence rate of 83%. The median time to recurrence was 3 months, despite 6 patients (85.7%) having R0 resections. Distant recurrence, specifically to bone, the lungs, and the liver, was most common.

LIMITATIONS

Small study cohort due to rarity of disease, limiting generalizability.

CONCLUSIONS

Pelvic exenteration for pelvic mucosal melanoma appears to help control local disease as recurrence is most commonly distant or regional. See Video Abstract .

RESULTADOS DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR MELANOMAS DE LA MUCOSA PLVICA ESTUDIO RETROSPECTIVO AUSTRALIANO DE UNA SOLA INSTITUCIN

ANTECEDENTES:Los melanomas de la mucosa pélvica (MM), incluidos los melanomas anorrectales y urogenitales, son raros y agresivos, con una supervivencia global media de hasta 20 meses. Los melanomas de la mucosa pélvica se comportan de manera diferente a sus contrapartes cutáneas y se presentan tardíamente con enfermedad locoregional, lo que hace que la exenteración pélvica (EP) sea su única opción quirúrgica curativa.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados de supervivencia tras la exenteración pélvica en melanomas de la mucosa pélvica en el Royal Prince Alfred Hospital.DISEÑO:Serie de casos retrospectivos de una base de datos de exenteración pélvica recopilada prospectivamente desde octubre de 1994 hasta noviembre de 2023.ESCENARIO:Royal Prince Alfred Hospital (institución cuaternaria), Camperdown, Nueva Gales del Sur, Australia.PACIENTES:Siete pacientes sometidos a exenteración pélvica por melanoma de la mucosa pélvica.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia general, supervivencia libre de enfermedad y tasas de complicaciones.RESULTADOS:De los siete pacientes, la mayoría fueron mujeres (n = 5, 71,4%) y tenían una edad media de 65 años (rango 36-79). Cinco pacientes (71,4%) fueron sometidos a una exenteración pélvica por melanoma primario de la mucosa pélvica; tres de los cuales eran melanomas anorrectales y dos vaginales. Dos pacientes (28,6%) tuvieron melanoma anorrectal recurrente y recibieron radioterapia neoadyuvante después de una escisión local amplia inicial.Tres pacientes (42,9%) requirieron una exenteración pélvica total, mientras que dos requirieron una exenteración pélvica central (28,6%). Los procedimientos restantes fueron una exenteración pélvica central y lateral; junto con una exenteración pélvica anterior, central y lateral. La duración media de la estancia hospitalaria fue de 19,7 días. Cinco pacientes tuvieron complicaciones postoperatorias con una complicación mayor (Clavien-Dindo IIIa). Al finalizar el estudio, hubo cuatro muertes. La supervivencia media fue de 23,6 meses (rango 2-100) con una tasa de recurrencia del 83%. El tiempo medio hasta la recurrencia fue de tres meses, a pesar de que seis pacientes (85,7%) tuvieron resecciones R0. La recurrencia distante, es decir, en hueso, pulmón e hígado fueron la más comúnes.LIMITACIONES:Cohorte de estudio pequeña debido a la rareza de la enfermedad, lo que limita la generalización.CONCLUSIÓN:La exenteración pélvica para el melanoma de la mucosa pélvica parece ayudar a controlar la enfermedad local, ya que la recurrencia es más comúnmente distante o regional. (Traducción-Dr Osvaldo Gauto ).

Hindu Spiritual Music for Perioperative Anxiolysis and Stress Modulation: An Open-Label, Randomized Comparative Trial in Lower Limb Surgery Patients

Background Perioperative anxiety is a common concern in patients undergoing regional anesthesia, as they remain conscious during surgery. Various non-pharmacological interventions, including music therapy, have been explored to reduce anxiety and stress response. Spiritual interventions, particularly religious music, have been shown to provide emotional stability and enhance coping mechanisms during stressful situations. Objective This study aimed to evaluate the impact of Hindu religious music compared to patient-selected instrumental music on intraoperative anxiety, stress response, and patient satisfaction in individuals undergoing lower limb surgery under regional anesthesia. Methods This prospective, open-label, randomized controlled trial was conducted at Maharani Laxmi Bai Medical College, a tertiary care teaching hospital in Jhansi, India, after obtaining approval from the Institutional Ethics Committee (Certificate No. 5208/IEC/I/2022-2023) and registration with the Clinical Trials Registry of India (CTRI/2024/01/062006, registered on January 30, 2024). The trial included 150 ASA class 1 or 2 patients undergoing elective lower limb surgery under regional anesthesia. Participants were randomly assigned to two groups: Group A (Hindu spiritual music) and Group B (patient-preferred instrumental music). Music was played intraoperatively via noise-canceling headphones. The primary outcomes were intraoperative anxiety (measured using the Visual Analog Scale for Anxiety (VAS-A)) and serum cortisol levels as a biochemical marker of stress. Secondary outcomes included hemodynamic parameters, additional analgesic requirements, incidence of nausea and vomiting, and patient satisfaction. Results Group A had significantly lower intraoperative VAS-A scores compared to Group B (2.13 ± 0.91 vs. 3.41 ± 1.12; p = 0.01). Serum cortisol levels were also significantly lower in Group A at the end of surgery (28.54 ± 6.11 vs. 32.50 ± 8.82 µg/dL; p = 0.001) and remained lower on the first postoperative day (p = 0.001). The incidence of postoperative nausea and vomiting was significantly lower in Group A (6.8% vs. 17.5%; p = 0.028). Patient satisfaction was also higher in the Hindu spiritual music group (p = 0.03). Conclusion Hindu spiritual music reduced perioperative anxiety, attenuated the stress response, and decreased postoperative nausea and vomiting compared to non-spiritual instrumental music. It should be considered a non-pharmacological intervention in the perioperative period to alleviate anxiety and improve patient comfort. However, the study's findings may have limited generalizability to non-Hindu patients. Future research should explore whether similar benefits are observed in religious individuals listening to music of their own faith and cultural background.

Sclerotherapy for hemorrhoidal disease: Recent evolutions of an oldies goldy

Treatments for low degree hemorrhoids (I-III degree) are numerous and so are their counterparts for higher degrees. These treatments present nebulous differences in terms of indications and outcomes among techniques. Methods previously abandoned due to side effects and long-term results have recently rejoined the mainstream due to recent peculiar modifications: Hemorrhoidal sclerotherapy is enjoying a new age of interest due to the use of the foam form of polidocanol, which is more effective than the liquid one. Various articles have already shown promising results and the logical next step is the combination of polidocanol foam with rubber-band ligation (the historical counterpart of sclerotherapy) in a technique called "sclerobanding". In this article, we comment on the publication by Qu et al further modifying the use of sclerobanding through an endoscopic delivery for patients with grade II-III internal hemorrhoids, and present results compared with endoscopic rubber band ligation. The results achieved are promising.

Optimal Timing of Colostomy Reversal Following Hartmann's Procedure: A Retrospective Analysis of Postoperative Outcomes

Background/Objectives: Hartmann's procedure is commonly employed to manage complications of acute sigmoid diverticulitis, such as perforation or abscess formation. However, determining the optimal timing for colostomy reversal remains a topic of debate. This study aims to evaluate the effect of early versus delayed colostomy reversal on postoperative outcomes, focusing on complications, hospital stay duration, and readmission rates. Methods: A retrospective cohort study was conducted on 148 patients who underwent Hartmann's procedure for acute sigmoid diverticulitis at a single tertiary care center between 2014 and 2023. Participants were grouped based on the timing of colostomy reversal: early (45-120 days), intermediate (121-180 days), and late (>180 days). Data on complications, hospital stay length, and readmissions were analyzed. Results: Early reversal was associated with fewer postoperative complications, shorter hospital stays, and reduced readmissions compared to delayed reversal. The late reversal group had higher rates of complications, longer hospital stays, and a higher need for reintervention. Advanced age and comorbidities, such as cardiovascular disease and diabetes, were significant predictors of poor outcomes, contributing to delayed reversal. Logistic regression analysis indicated that late reversal was independently associated with higher complication rates. Conclusions: Early colostomy reversal within 45-120 days following Hartmann's procedure is associated with improved postoperative outcomes, including fewer complications and a shorter hospital stay. The timing of colostomy reversal should be individualized based on patient health status, with early reversal preferred for those without significant comorbidities. Further prospective research is needed to confirm these findings and refine guidelines for optimal reversal timing.

Time to return of bowel function following perioperative probiotics in colorectal cancer surgery (PICCS-1): study protocol for a randomized controlled trial

BACKGROUND

Postoperative ileus occurs in up to 30% of patients following major oncologic surgery for colorectal cancer, leading to significant morbidity, patient distress, as well as increased utilization of healthcare resources. Various modalities to reduce postoperative ileus rates have been explored. One such modality is the perioperative administration of probiotics which have hitherto achieved inconsistent success. Here, we design a trial to determine whether the perioperative administration with probiotics given together with nutritional supplementation can help to reduce postoperative ileus rates.

METHODS

We propose a parallel three-arm randomized controlled trial. In Arm 1, no nutritional supplementation is provided to the patient. In Arm 2, Nestle Isocal is provided to the participant. Nestle Isocal provides nutritional supplementation but without any probiotic. In Arm 3, Nestle Boost Optimum is provided to the patient. Nestle Boost Optimum contains a similar nutritional profile to Isocal, but with the addition of Lactobacillus paracasei. The primary outcome is the time to first bowel movement in days from the day of surgery. Secondary outcomes are time to first flatus, infective complications, and adverse events related to the administration of nutritional supplementation. Statistical analysis will be conducted in an intention-to-treat approach. ANOVA with the Tukey test will be used to compare continuous variables, while the χ2 test will be used for categorical variables.

DISCUSSION

Nutritional supplementation with probiotics is a convenient, non-pill alternative for patients. Furthermore, the interventions are commonly found in the formulary of many hospitals worldwide. If successful, probiotics in nutritional supplementation could be a cost-effective and simple way to reduce postoperative ileus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06456229. This trial was registered on 11 June 2024. Thai Clinical Trials Registry TCTR20240706003. This trial was registered on 6 July 2024.

Nonsteroidal anti-inflammatory drugs in the perioperative period: current controversies and concerns

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2-specific inhibitors provide significant analgesic and opioid-sparing benefits. However, these analgesics are commonly avoided owing to concerns of potential adverse effects. The evidence for NSAID-related adverse effects is conflicting and of poor quality, and these analgesics are safer than what has been implied. Thus, it is imperative that NSAIDs or COX-2-specific inhibitors are administered routinely unless there are well-founded contraindications.

Clinical observation on prognosis of mixed hemorrhoids treated with polidocanol injection combined with automatic elastic thread ligation operation

BACKGROUND

A total of 100 patients diagnosed with mixed hemorrhoids from October 2022 to September 2023 in our hospital were randomly divided into groups by dice rolling and compared with the efficacy of different treatment options.

AIM

To analyze the clinical effect and prognosis of mixed hemorrhoids treated with polidocanol injection combined with automatic elastic thread ligation operation (RPH).

METHODS

A total of 100 patients with mixed hemorrhoids who visited our hospital from October 2022 to September 2023 were selected and randomly divided into the control group (n = 50) and the treatment group (n = 50) by rolling the dice. The procedure for prolapse and hemorrhoids (PPH) was adopted in the control group, while polidocanol foam injection + RPH was adopted in the treatment group. The therapeutic effects, operation time, wound healing time, hospital stay, pain situation (24 hours post-operative pain score, first defecation pain score), quality of life (QOL), incidence of complications (post-operative hemorrhage, edema, infection), incidence of anal stenosis 3 months post-operatively and recurrence rate 1 year post-operatively of the two groups were compared.

RESULTS

Compared with the control group, the total effective rate of treatment group was higher, and the difference was significant (P < 0.05). The operation time/wound healing time/hospital stay in the treatment group were shorter than those in the control group (P < 0.05). The pain scores at 24 hours after operation/first defecation pain score of the treatment group was significantly lower than those in the control group (P < 0.05). After surgery, the QOL scores of the two groups decreased, with the treatment group having higher scores than that of the control group (P < 0.05). Compared with the control group, the incidence of postoperative complications in the treatment group was lower, and the difference was significant (P < 0.05); However, there was no significant difference in the incidence of postoperative bleeding between the two groups (P > 0.05); There was no significant difference in the incidence of anal stenosis 3 months after operation and the recurrence rate 1 year after operation between the two groups (P > 0.05).

CONCLUSION

For patients with mixed hemorrhoids, the therapeutic effect achieved by using polidocanol injection combined with RPH was better. The wounds of the patients healed faster, the postoperative pain was milder, QOL improved, and the incidence of complications was lower, and the short-term and long-term prognosis was good.

Clinical Outcomes and Resource Efficiency of a Telehealth Model for New Lower Gastrointestinal Bleeding Referrals: A Tertiary Colorectal Outpatient Service Audit

Introduction: Amidst the COVID-19 pandemic, telehealth (TH) has gained increasing relevance in colorectal patient care, prompting an audit of the TH clinic at a tertiary colorectal unit. This study evaluated telephone-based consultations' clinical efficacy and diagnostic thresholds for new lower gastrointestinal (LGI) bleeding referrals. Methods: We conducted a quality assurance audit of the per rectal (PR) bleeding TH clinic at Northern Hospital Victoria, evaluating new LGI bleeding referrals. Data from July 2021 to June 2023 were extracted from the Referral Management System (RMS) and analyzed. The study focused on newly referred patients, excluding those previously seen or awaiting procedures. Clinical efficacy was determined through sensitivity, specificity, and predictive values, with a receiver operating characteristic (ROC) curve assessing the TH method's discrimination threshold. Results: Of the 239 patients, 131 met the inclusion criteria, with a compliance rate of 96%. The TH clinic demonstrated a sensitivity of 75.76% and specificity of 52.46% in distinguishing between colorectal and anal pathologies. The average time from referral to a diagnostic procedure was 9.75 weeks, with a reduction in median wait time for first appointments from 19 weeks prepandemic to 3.6 weeks. A cost-benefit analysis highlighted TH clinics' ability to reduce overhead costs and maintain a revenue stream despite reduced face-to-face consultations. Conclusion: Our study concludes that the telecare service model serves as an effective complementary approach for managing new LGI bleeding referrals. Further research on long-term outcomes and cost-effectiveness is necessary to fully assess telecare as a potentially sustainable hybrid model.

Comparison of warm sitz bath and electronic bidet with a lower-force water flow for postoperative management after hemorrhoidectomy (BIDLOW)

AIM

Electronic bidets can be a substitute for sitz baths, but no study has examined the use of electronic bidets to manage anal problems.

METHODS

A randomized, controlled, single-blind, multicenter, parallel group trial was performed. Patients who underwent hemorrhoidectomy were randomly assigned (1:1) to use the electronic bidet or warm sitz baths for 7 days after hemorrhoidectomy. The primary endpoint was the difference in the anal pain VAS score for 7 days posthemorrhoidectomy.

RESULTS

Patients were assigned to the electronic bidet (51) or sitz bath (50) groups. Twenty-six patients dropped out after randomization, and the final analysis included 34 patients in the electronic bidet group and 41 in the sitz bath group. The VAS score for anal pain 7 days posthemorrhoidectomy did not differ between the electronic bidet and sitz bath groups (38.3 ± 21.9 vs. 42.0 ± 21.1, p = 0.453). The upper limit of the 95% confidence interval of the VAS score in the electronic bidet group (81.22) was greater than the margin of noninferiority (46.20).

CONCLUSION

The VAS scores after hemorrhoidectomy did not differ between the electronic bidet and sitz bath groups, but the noninferiority of the electronic bidet to sitz baths for anal pain 7 days posthemorrhoidectomy was not verified.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov (Registration number: NCT02353156, date: 02/02/2015).

Feasibility and impact of sentinel lymph node biopsy in patients affected by ano-rectal melanoma

INTRODUCTION

Anorectal melanoma (ARM) is rare and highly lethal neoplasm. It has a poorer prognosis compared with cutaneous ones. Sentinel lymph node biopsy (SLNB) has become the preferred method of nodal staging method for cutaneous melanoma. The role of SLNB for staging of anal melanoma remains unclear. This study investigates SLN identification and biopsy in patients with ARM.

METHODS AND PATIENTS

We present our experience of patients affected by ARM who underwent to SLNB. Clinical workup included digital rectal examination, anoscopy, rigid proctoscopy, total body (computed tomography) CT scan, pelvic magnetic resonance imaging (MRI), and fludeoxyglucose-18-positron emission tomography-CT (FDG-PET-CT) to obtain an adequate pretreatment staging of the patients. Wide local excision and contemporary SLNB were performed to remove primary neoplasm and detect inguinal lymph node metastases.

RESULTS

In total, five female patients, median age 68 years, were included. All were affected by anal melanoma. Detection rate of SLNB was 100% and scintigraphic migration was unilateral in three patients and bilateral in the other two. Definitive inguinal histological exam revealed unilateral metastases in three patients, bilateral metastases in one case, and the presence of isolated neoplastic cells in the remaining case. SLNB allowed a diagnostic upgrading of inguinal metastases in three of five patients (60%), permitting better staging and further appropriate treatment.

CONCLUSIONS

Our experience demonstrates SLN biopsy is a minimally invasive, cost-effective, and rapid procedure for accurately staging patients with clinically occult disease. In fact, SLNB emerges as an appropriate procedural tool to identify patients with occult lymph node metastases who could undergo immune or target therapy, as well as to avoid unnecessary inguinal lymph node dissection for patients who would not benefit.

EUS-guided lauromacrogol ablation with different concentrations of lauromacrogol for the treatment of pancreatic cystic neoplasm: A randomized controlled study

Objectives

To explore the safety and efficacy of injections of 1%, 2%, or 3% lauromacrogol during EUS-guided lauromacrogol ablation (EUS-LA) for the treatment of pancreatic cystic neoplasms (PCNs) and to determine the optimal concentration of lauromacrogol for use in EUS-LA therapeutic regimens.

Methods

From May 2021 to January 2023, patients who met the indications for EUS-LA were randomly divided into 3 groups: A, B, and C; the patients in these groups were injected with 1%, 2%, and 3% lauromacrogol during EUS-LA, respectively. Safety was evaluated based on the incidence of postoperative complications. Efficacy was comprehensively evaluated by assessing the ablation rate and ablation effect.

Results

Forty-two patients underwent EUS-LA, and 31 patients completed at least 1 postoperative re-examination. No acute pancreatitis was observed in the 1% and 2% lauromacrogol groups, and 1 case of acute pancreatitis occurred in the 3% lauromacrogol group. The total complication rate was 2.4%. The median ablation rates of the groups were 94.1%, 82.0%, and 100.0%, respectively. There were statistically significant differences in the EUS-LA ablation rate between the 1% and 3% lauromacrogol groups and between the 2% and 3% lauromacrogol groups. There was a statistically significant difference in complete disappearance between the 1% and 3% lauromacrogol groups as well as between the 2% and 3% lauromacrogol groups.

Conclusion

The short-term outcomes showed that injections of 1%, 2%, and 3% lauromacrogol were safe for use in EUS-LA, and injection of 3% lauromacrogol was the most effective for EUS-LA.

Opioid use patterns following discharge from elective colorectal surgery: a prospective cohort study

INTRODUCTION

Opioid overprescription after colorectal surgery can lead to adverse events, persistent opioid use, and diversion of unused pills. This study aims to assess the extent to which opioids prescribed at discharge after elective colorectal surgery are consumed by patients.

METHODS

This prospective cohort study included adult patients (≥ 18 yo) undergoing elective colorectal surgery at two academic hospitals in Montreal, Canada. Patients completed preoperative questionnaires and data concerning demographics, surgical details, and perioperative care characteristics (including discharge prescriptions) were extracted from electronic medical records. Self-reported opioid consumption was assessed weekly up to 1-month post-discharge. The total number of opioid pills prescribed and consumed after discharge were compared using the Wilcoxon signed-rank test. Negative binomial regression was used to identify predictors of opioid consumption.

RESULTS

We analyzed 344 patients (58 ± 15 years, 47% female, 65% laparoscopic, 31% rectal resection, median hospital stay 3 days [IQR 1-5], 18% same-day discharge). Most patients received a TAP block (67%). Analgesia prescription at discharge included acetaminophen (92%), NSAIDs (38%), and opioids (92%). The quantity of opioids prescribed at discharge (median 13 pills [IQR 7-20]) was significantly higher than patient-reported consumption at one month (median 0 pills [IQR 0-7]) (p < 0.001). Overall, 51% of patients did not consume any opioids post-discharge, and 63% of the prescribed pills were not used. Increased opioid consumption was associated with younger age (IRR 0.99 [95%CI 0.98-0.99]), higher preoperative anxiety (1.02 [95%CI 1.00-1.04]), rectal resections (IRR 1.45 [95%CI 1.09-1.94]), and number of pills prescribed (1.02 [95%CI 1.01-1.03]).

CONCLUSION

A considerable number of opioid pills prescribed at discharge after elective colorectal surgery are left unused by patients. Certain patient and care characteristics were associated with increased opioid consumption. Our findings indicate that post-discharge analgesia with minimal or no opioids may be feasible and warrants further investigation.

Pediatric pilonidal sinus disease: Recurrence rates of different age groups compared to adults

Background

Pilonidal sinus disease uncommon in pre-pubertal children. The preferred treatment for pediatric pilonidal sinus patients remains unclear. A growing body of evidence indicates that pediatric pilonidal sinus disease recurs earlier than in adults. We therefore aimed to investigate recurrence rates and the recurrence rates of different surgical approaches.

Methods

Some 1217 studies on pilonidal sinus disease, encompassing 134,663 patients were eligible. From them, 5807 pediatric patients were identified. Recurrence rates were compared between adults and children.

Results

Pediatric pilonidal sinus patients have a higher 5-year recurrence rate compared to adults (46 % vs. 11.5 %; p < 0.0001). The subgroup of individuals aged 16-18 years appears to experience recurrences 12 months earlier than those below the age of 16. 46.4 % of all pediatric recurrences occur within 5 years.

Conclusions

Pediatric pilonidal sinus disease seems to follow a different course in terms of recurrence rate compared to adults with a substantially increased probability of developing recurrent pilonidal sinus disease within the first five years after surgery. Due to the limited evidence base, especially in terms of the surgical approach, additional data is required to gain a more detailed insight into the matter and to improve surgical care for children and adolescents.

Injection sclerotherapy for the treatment of haemorrhoids in anticoagulated patients

BACKGROUND

Symptomatic haemorrhoids (SH) are a common condition; however, conventional outpatient treatment, including rubber band ligation, is contraindicated in patients receiving concurrent anticoagulation. Injection sclerotherapy (IST) has been proposed as a treatment option for these patients.

METHODS

A retrospective review of case notes was performed in a colorectal surgery department that sits alongside a tertiary cardiothoracic surgical unit. Patients treated with an IST for SH between 1 April 2014 and 30 November 2021 were identified. Anticoagulation was not stopped in these patients as they were at high risk of developing thromboembolism, except in two patients who required alternative procedures. The primary outcome was symptom resolution, defined as no patient reporting bleeding for at least six months. The secondary outcomes were patient-reported complications, number of IST procedures and number of other procedures performed to achieve symptom resolution.

RESULTS

A total of 20 patients with a median age of 64 years (range 35-86, 14 male) who underwent 32 IST treatments were identified. Symptom resolution was achieved in 18 (90%) patients using IST while continuing anticoagulation treatment, with two (10%) patients requiring alternative interventions. Ten patients (50%) required only one IST procedure, and three patients (15%) required two procedures. The remaining five (25%) patients required three or four interventions. The median time between IST treatments was 32 weeks (range 8-133). No complications were reported.

CONCLUSION

Our study demonstrates that IST can be considered as a potential treatment option for patients with SH who are at a high risk of thromboembolic disease requiring anticoagulation.

Uncommon Anal Cancers

Anal cancer is by itself a rare entity. Even rarer are the uncommon anal tumors described in this article. Diagnosis of these lesions can be challenging as some of these have no symptoms in their initial stages and only cause symptoms once they have progressed to advanced stages. Further, it can be difficult for even the trained eye to make a diagnosis as some of these pathologies mimic benign disease or the more common anal malignancy, squamous cell carcinoma. More data are needed to establish consensus for the management of these unusual pathologies.

Anorectal melanoma: Report of two cases

INTRODUCTION

Anorectal melanoma (AM) is a rare and aggressive type of cancer. Its symptoms often resemble those of common benign anal conditions, such as hemorrhoids, leading to frequent delays in diagnosis. Consequently, about one-third of patients have metastases at the time of their initial diagnosis. The primary treatment for AM is surgical resection, while adjuvant therapies may include immunotherapy, radiotherapy, brachytherapy, and chemotherapy. The prognosis for AM is poor, with a five-year survival rate of only 20 %.

CASE PRESENTATION

In this study, we report two cases of patients who experienced different anorectal symptoms for a long time before their condition worsened, prompting further investigation that revealed a diagnosis of malignant anorectal melanoma. Both patients underwent surgical resection and are currently receiving adjuvant therapy.

DISCUSSION

This article discusses the prognosis of anorectal melanoma, the current lack of consensus on treatment protocols, and the importance of maintaining a high index of suspicion for early diagnosis.

CONCLUSION

Anorectal melanoma is a rare pathology, and its prognosis is poor due to the frequent presence of metastatic forms at the time of diagnosis. Surgery, whether through abdominoperineal amputation or wide local excision, is the treatment of choice for these tumors. The use of radiotherapy (RT) is controversial and is currently indicated either as hypofractionated therapy following local excision (EL) or as palliative treatment.

Clinical Impact of Sarcopenia in the Decision-Making Process for Patients with Acute Diverticulitis

Background: Acute diverticulitis (AD), an inflammatory complication of diverticulosis, affects around 4% of individuals with diverticulosis, with increased incidence in older populations. This study aims to assess the impact of sarcopenia, the age-related loss of muscle mass, on the clinical decision-making and outcomes of patients with AD. Materials and Methods: A retrospective study was conducted on 237 patients admitted to the Emergency Department (ED) between January 2014 and February 2022. Patients diagnosed with AD Hinchey ≥ 2 via contrasted tomography (CT) were included. Sarcopenia was assessed using CT scans at the third lumbar vertebra (L3), with skeletal muscle area (SMA) normalized by height to calculate the skeletal muscle index (SMI). Patients were divided into two groups based on sarcopenia status and analysed for surgical outcomes, non-operative management (NOM) success, and complications. Results: The prevalence of sarcopenia was 46%. Sarcopenic patients were significantly older and had lower BMI and higher frailty scores. A higher proportion of sarcopenic patients underwent Hartmann, while non-sarcopenic patients more often had anastomosis. Sarcopenia did not significantly affect overall morbidity, mortality, or the failure rate of NOM. However, sarcopenic patients with a BMI > 25 had a higher likelihood of requiring redo surgeries. Conclusions: Sarcopenia plays a critical role in the surgical management of AD but does not predict worse clinical outcomes. The decision to perform surgery, particularly Hartmann's procedure, is influenced by sarcopenia, yet morbidity and mortality rates are comparable between sarcopenic and non-sarcopenic patients. These findings highlight the need for sarcopenia to be considered in preoperative assessments.

Subarachnoid anesthesia for sacrococcygeal pilonidal disease treatment: A case report

RATIONALE

Sacrococcygeal pilonidal disease (SPD) is a chronic inflammatory condition primarily affecting young males. This case report details the perioperative anesthetic management of a patient undergoing SPD surgery under subarachnoid anesthesia.

PATIENT CONCERNS

A 48-year-old obese male (body mass index 28 kg/m2) presented with recurrent sacrococcygeal swelling, pain, and purulent discharge for 2 months. Magnetic resonance imaging revealed a pilonidal sinus in the left subcutaneous sacrococcygeal region, with additional findings of degenerative vertebral changes and left paracentral disc protrusion at the fourth or fifth lumbar vertebrae.

DIAGNOSES

SPD with abscess formation.

INTERVENTIONS

Following comprehensive evaluation, the patient underwent SPD excision under subarachnoid anesthesia. Lumbar puncture was performed at the third and fourth lumbar vertebrae interspace, and 2 mL of 0.6% ropivacaine was administered, achieving a sensory block up to the eighth thoracic vertebra level. The patient experienced transient respiratory difficulty during positional change from supine to prone, necessitating immediate reassessment of the block level and appropriate management. Vital signs were closely monitored intraoperatively, with meticulous postoperative follow-up.

OUTCOMES

The surgery was completed successful with stable hemodynamics. No significant anesthesia-related complications were observed within 24 hours postoperatively.

LESSONS

Thorough preoperative assessment of local and systemic infection status is essential in SPD patients undergoing subarachnoid anesthesia. Intraoperative positional changes may affect the level of subarachnoid block, requiring vigilant monitoring of vital signs and respiratory function. Postoperative care should focus on potential anesthetic complications and wound care requirements. Individualized anesthetic management strategies are crucial for ensuring patient safety.

Lipopolysaccharide Effects on Neurotransmission: Understanding Implications for Depression

Immune activation in the body is well studied; however, much less is known about how peripheral inflammation changes brain chemistry. Because depression and inflammation are close comorbidities, investigating how inflammation affects the brain's chemicals will help us to better understand depression. The levels of the monoamines dopamine, serotonin and norepinephrine are thought to be affected by both inflammation and depression. In this Perspective, we review studies that find chemical changes in the brain after administration of the endotoxin LPS, which is a robust method to induce rapid inflammation. From these studies, we interpreted LPS to reduce dopamine and serotonin and increase norepinephrine levels in various regions in the brain. These changes are not a sign of "dysfunction" but serve an important evolutionary purpose that encourages the body to recover from an immune insult by altering mood.

Quantitative proteomics analysis reveals the pathogenesis of obstructed defecation syndrome caused by abnormal expression of dystrophin

BACKGROUND

Obstructed defecation syndrome (ODS) represents the most prevalent form of chronic constipation, affecting a diverse patient population, leading to numerous complications, and imposing a significant burden on healthcare resources. Most ODS patients have insufficient rectal propulsion, but the exact mechanism underlying the pathogenesis of ODS remains unclear.

AIM

To explore the molecular mechanism underlying the pathogenesis of ODS.

METHODS

A total of 30 pairs of rectal samples were collected from patients with ODS (ODS group) or grade IV prolapsed hemorrhoids without constipation (control group) for quantitative proteomic and bioinformatic analysis. Subsequently, 50 pairs of paraffin-embedded rectal specimens were selected for immunohistochemistry and immunofluorescence studies to validate the analysis results. Human intestinal smooth cell contractile function experiments and electrophysiological experiments were conducted to verify the physiological functions of target proteins. Cellular ultrastructure was detected using transmission electron microscopy.

RESULTS

In comparison to the control group, the expression level of dystrophin (DMD) in rectal specimens from ODS patients was markedly reduced. This finding was corroborated using immunohistochemistry and immunofluorescence techniques. The diminished expression of DMD compromised the contractile function of intestinal smooth muscle cells. At the molecular level, nucleoporin protein 153 and L-type voltage-gated calcium channel were found to be overexpressed in intestinal smooth muscle cells exhibiting downregulated DMD expression. Electrophysiological experiments confirmed an excessive influx of calcium ions into these cells. Moreover, vacuolar-like structures which may be associated with excessive calcium influx were observed in the cells by transmission electron microscopy.

CONCLUSION

Decreased DMD expression in intestinal smooth muscle may upregulate L-type voltage-gated calcium channel expression, leading to excessive calcium influx which may cause a decrease in rectal propulsion, thereby contributing to the pathogenesis of ODS.

Use of mesoglycan in the acute phase of hemorrhoidal disease (the CHORMES study): study protocol for a double-blind, randomized controlled trial

BACKGROUND

Hemorrhoidal disease (HD) is associated with substantial economic burden and negative effects on health-related quality of life (HRQoL). The aCute HaemORrhoids treatment with MESoglycan (CHORMES) study aims to evaluate the effects of orally administered mesoglycan, a natural preparation of glycosaminoglycans with antithrombotic and profibrinolytic properties, as an acute treatment in patients with HD.

METHODS

CHORMES is a phase 2, double-blind, randomized controlled trial being conducted at two centers in Italy. Adults aged 18-75 years with Grade I-III HD according to Goligher classification or external thrombosed hemorrhoids, and a Hemorrhoidal Disease Symptom Score (HDSS) of ≥ 5, will be randomly allocated in a 1:1 ratio to mesoglycan or placebo and will be treated for 40 days (two capsules for the first 5 days and one capsule for the subsequent 35 days twice daily [after breakfast and dinner], equivalent to 200 mg in the first 5 days and 100 mg subsequently). Concomitant use of analgesics is permitted in both treatment groups. The trial aims to enroll 50 patients, with 25 patients in each treatment group. The primary objective of the trial is to evaluate the efficacy of mesoglycan in reducing symptoms of HD, assessed via change in HDSS from baseline (day 0) to day 40 in the intention-to-treat population. Secondary objectives include changes in HRQoL from baseline to day 40 using the Short Health Scale for Hemorrhoidal Disease, safety (adverse effects, physical assessments, vital signs and laboratory parameters in the safety population), fecal continence assessed using the Vaizey score, bleeding assessed using the Bleeding score, the amount and type of analgesic taken, and pain. Patient enrolment began on 11 December 2023, and trial completion is expected by December 2024.

DISCUSSION

The CHORMES trial will evaluate the efficacy and safety of mesoglycan, in addition to its impact on HRQoL, analgesic use and pain, in patients with HD. The results of the trial will assist clinicians in determining the most effective treatment for patients with HD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06101992. Prospectively registered on 26 October 2023 at https://clinicaltrials.gov/ct2/show/NCT06101992 .

Catastrophic outcome following misidentification of bowel anatomy during Hartmann's reversal: A case report and technical considerations

BACKGROUND

Reversal of Hartmann's procedure is a complex surgery with potential complications. This case report describes a rare and severe complication following an attempted reversal.

CASE PRESENTATION

A 53-year-old male who had undergone a Hartmann's procedure for non-metastatic sigmoid colon cancer presented with bowel obstruction 10 days after attempted reversal surgery at another hospital. Imaging studies suggested an entero-colic fistula. Emergency laparotomy revealed dense adhesions and multiple bowel injuries. The procedure was terminated, and controlled fistulae were created.

MANAGEMENT AND OUTCOME

The patient required two months of intensive care. A subsequent surgery excised the fistulae and restored intestinal continuity, leaving the patient with an end colostomy and approximately 120 cm of ileum.

CONCLUSION

This case highlights the potential risks of Hartmann's reversal and emphasizes the importance of proper patient selection, timing, and surgical expertise. It underscores the need for thorough preoperative evaluation and preparation when attempting such complex surgeries.

Non-invasive vagus nerve stimulation to reduce ileus after colorectal surgery: randomized feasibility trial and efficacy assessment (IDEAL Stage 2B)

AIM

Ileus is characterized by a period of intestinal dysmotility after surgery, leading to vomiting and constipation. In preclinical models, vagus nerve stimulation reduces intestinal inflammation and prevents smooth muscle dysfunction, accelerating the return of gut function. This study explored the feasibility of a definitive trial of non-invasive vagus nerve stimulation (nVNS) along with an early assessment of efficacy.

METHOD

A multicentre, randomized feasibility trial (IDEAL Stage 2B) of self-administered nVNS was performed. Patients undergoing colorectal surgery were randomized to nVNS or sham before and after surgery. Feasibility outcomes comprised assessments of recruitment, compliance, blinding and attrition. Clinical outcomes were measures of intestinal function and adverse events. All participants were followed up for 30 days. Interviews with patients and health professionals explored barriers to feasibility and perspectives around implementation.

RESULTS

In all, 125 patients were approached about the study and 97 (77.6%) took part. Across all randomized groups, the median compliance to treatment was 19 out of 20 stimulations (interquartile range 17-20). The incidence of adverse events was similar across groups. In this unpowered feasibility study, the time taken for the return of gut function (such as first passage of stool) was similar between nVNS and sham treatments. According to interviews, patients were highly motivated to use the device because it provided them with an opportunity to engage actively in their care. Health professionals were highly driven to tackle the problem of ileus.

CONCLUSION

Powered assessments of clinical efficacy are required to confirm or refute the promise of nVNS, as already demonstrated in preclinical models. This feasibility study concludes that a definitive randomized assessment of the clinical benefits of nVNS is desired and feasible.

Shifting Paradigms in Hemorrhoid Management: The Emergence and Impact of Cap-Assisted Endoscopic Sclerotherapy

Hemorrhoidal disease (HD) is a prevalent proctological condition that has puzzled people since ancient times, and the most common symptom is painless bleeding. Traditional treatments include conservative treatment, nonsurgical office-based treatments, and surgery. Sclerotherapy is one of the oldest forms of nonoperative intervention and is widely used to treat internal hemorrhoids with the development of endoscopy technology. However, sclerotherapy is always accompanied by complications such as bleeding, pain, abscess, etc., when the sclerosant is injected into the wrong site. Cap-assisted endoscopic sclerotherapy (CAES), a new minimally invasive technology, was first time coined in 2015 for the treatment of hemorrhoidal disease. The left-posterior-right-anterior (LPRA) anus positioning method under endoscopy provides reliable methodological support for advancing hemorrhoidal treatment via endoscopy. The current trend is that treatment for HD has shifted from being performed predominantly by the Department of Proctology Surgery to being managed mostly by the Department of Gastroenterology. This review reviewed the shifting paradigms of sclerotherapy for HD and discussed the emerging development of CAES.

Systematic review and meta-analysis comparing outcomes of multi-port versus single-incision laparoscopic surgery (SILS) in Hartmann's reversal

BACKGROUND

Colostomy formation as part of the Hartmann's procedure is often performed during emergency surgery as a damage limitation measure where attempts at bowel anastomosis and continuity are contraindicated. Hartmann's reversal (HR) remains challenging and can be attempted through open surgery and various minimally invasive techniques (laparoscopic and robotic platforms). We aimed to analyse outcomes of conventional multi-port laparoscopy (CL) versus single-incision approach (SILS) in patients undergoing HR.

METHODS

A comprehensive online search of various databases was conducted in accordance with PRISMA guidelines including Medline, PubMed, Embase, and Cochrane. Comparative studies of patients undergoing CL and SILS for HR were included. Analysed primary outcomes were total operative time and mortality rate. Secondary outcomes included post-operative complications, length of hospital stay, risk of visceral injury intra-operatively, and re-operation rate. Combined overall effect sizes were calculated using the random-effects model, and the Newcastle-Ottawa Scale (NOS) was used to assess bias.

RESULTS

Two observational studies matching our inclusion criteria with a total of 160 patients (SILS 100 vs. CL 60) were included. Statistical difference was observed for one outcome measure: operative duration (MD - 44.79 CI - 65.54- - 24.04, P < 0.0001). No significant difference was seen in mortality rate (OR 1.66 CI 0.17-16.39, P = 0.66), overall post-operative complications (OR 0.60 CI 0.28-1.32, P = 0.20), length of stay (MD - 0.22 CI - 4.25-3.82, P = 0.92), Clavien-Dindo III + complications (OR 0.61 CI 0.15-2.53, P = 0.50), risk of visceral injury (OR 1.59 CI 0.30-8.31, P = 0.58), and re-operation rates (OR 0.73 CI 0.08-6.76, P = 0.78).

CONCLUSION

Accounting for study limitations, the SILS procedure seems to be quicker with non-inferior outcomes compared with the conventional multi-port approach. This may lead to better patient satisfaction and cosmesis and potentially reduce the risk of future incisional hernia occurrence. However, well-designed, randomised studies are needed to draw more robust conclusions and recommendations.

Diagnostic difficulties in the differentiation between an ovarian metastatic low‑grade appendiceal mucinous neoplasm and primary ovarian mucinous cancer: A case report and literature review

Low-grade appendiceal mucinous neoplasm (LAMN) is a tumor that primarily originates from the appendix and belongs to the family of appendiceal mucinous neoplasms (AMNs). In 50% of female patients, AMNs (particularly LAMNs) have a tendency to metastasize to organs in the genital tract, where the neoplasm can mimic the features of primary ovarian mucinous cancer (POMC). The present case report reviewed the difficulties in differentiating between these two types of tumors. In the present case report, a 61-year-old female patient was admitted to the Second Department of Gynecological Surgery and Gynecological Oncology, University Clinical Hospital no. 4 at Lublin Medical University (Lublin, Poland) with the diagnosis of a right ovarian mass. After performing ultrasound and computed tomography (CT) scans and laboratory analysis, the patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy and resection of the Douglas peritoneum. Notably, the postoperative pathological assessment revealed LAMN with metastases to the right ovary and omentum. Immunohistochemically, cytokeratin 20 and caudal type homeobox 2 both stained positively, whereas paired box gene 8 stained negatively. After surgery, the patient received the recommended hyperthermic intraperitoneal chemotherapy at the Department of Surgical Oncology at Lublin Medical University. After 1 year, a CT scan was performed, which indicated no evidence of recurrent disease. In conclusion, observations from the present case report suggest that gynecologists should be conscious of the possibility of malignancies of gastrointestinal origin in cases of ovarian tumors instead of making direct assumptions of POMC. If the mucinous mass involves the base of the appendix or if there is a suspicion of positive margins, then cytoreductive surgery and right-sided hemicolectomy must be performed. In addition, identifying the origin of mucinous tumors in the right ovary and/or the appendix requires the histopathological examination of a panel of markers using immunohistochemistry.

Enteroendocrine cells regulate intestinal homeostasis and epithelial function

Enteroendocrine cells (EECs) are well-known for their systemic hormonal effects, especially in the regulation of appetite and glycemia. Much less is known about how the products made by EECs regulate their local environment within the intestine. Here, we focus on paracrine interactions between EECs and other intestinal cells as they regulate three essential aspects of intestinal homeostasis and physiology: 1) intestinal stem cell function and proliferation; 2) nutrient absorption; and 3) mucosal barrier function. We also discuss the ability of EECs to express multiple hormones, describe in vitro and in vivo models to study EECs, and consider how EECs are altered in GI disease.

Contributions of multiple transport mechanisms to intestinal uptake of serotonin

This study aimed to analyze the contributions of multiple transport mechanisms to the intestinal uptake of serotonin (5-HT) by employing a variety of in vitro experimental techniques, focusing on organic cation transporters expressed in the gastrointestinal (GI) tract, such as SERT, PMAT, THTR2, OCT3, and OCTN2. Analysis of the concentration dependence of 5-HT uptake by Caco-2 cells revealed multi-affinity kinetics with high-affinity and low-affinity components, suggesting that multiple transporters are involved in the intestinal 5-HT uptake. Comparative analysis of transporters using Km values obtained in Xenopus oocyte expression systems suggested that SERT is responsible for the high-affinity transport, while PMAT, THTR2, and OCT3 contribute to the low-affinity transport. Further analysis indicated that the relative contributions of SERT and PMAT to the intestinal 5-HT uptake (0.01 µM) are approximately 94.9% and 1.1%, respectively. Interestingly, at the concentration of 10 µM, the reported steady-state concentration of 5-HT in the human colon, the contributions of SERT, PMAT, THTR2, and OCT3 were estimated to be approximately 37.0%, 1.0%, 18.2%, and 20.5%, respectively. In conclusion, the present study indicated that the contributions of multiple transporters to 5-HT uptake in the GI tract are dependent upon the colon luminal concentration of 5-HT.