Anorectal emergencies: WSES-AAST guidelines

Use of TC-325 Hemostatic Powder as a Rescue Monotherapy for Management of Rectal Variceal Bleed

The use of the endoscopic hemostatic powder TC-325 as a rescue monotherapy or as an adjunct agent in achieving hemostasis has been studied in upper gastrointestinal variceal bleeds and nonvariceal lower gastrointestinal bleeds with promising results. In this report, we describe a case of a successful use of TC-325 as rescue monotherapy to manage rectal variceal bleeding in a patient with alcohol-related cirrhosis with no report of bleeding recurrence and no side effects within the first 7 days, 30 days, or 6 months.

Management of Hemorrhoids and Anal Fissures

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

Management of acute perianal abscess: is surgeon specialization associated with improved outcomes?

BACKGROUND

Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate whether surgeon specialization was associated with improved outcomes in perianal abscess.

METHODS

Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database and their medical records reviewed. Patients with IBD, treatment for fistula-in-ano within the preceding year, or perianal sepsis of non-cryptoglandular origin were excluded. Patients admitted under an ASU colorectal (CR) consultant were compared with those under a non-CR general surgeon in a retrospective cohort study. Primary outcome was perianal abscess recurrence. For those without initial fistula, hazard of recurrent abscess or fistula was analysed. Multivariable Cox PH regression analysis was performed.

RESULTS

Four-hundred and eight patients were included (150 CR, 258 non-CR). The CR group more frequently had a fistula identified at index operation (34.0% versus 10.9%, P < 0.0001). However, Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681)). Abscess recurred in 18.7% CR and 15.5% non-CR. Subsequent fistula developed in 14.7% in both groups. For patients without initial fistula, there was no difference between groups in hazard of recurrent abscess or fistula (HR 1.18, 95% CI 0.69-2.01, P = 0.539).

CONCLUSION

Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias. CR surgeons were more proactive identifying fistulas; this raises the possibility that drainage alone may be adequate treatment.

Fournier's gangrene due to rectal cancer: A case report

Fournier's gangrene (FG) is an extremely rare necrotizing fasciitis that is insidious, rapidly spreading and life-threatening. FGs due to rectal cancer occur rarely and there is a lack of clinical reference. In the present study, a severe FG due to rectal cancer perforation was described and the features of this rare disease were summarized with a literature review. A 57-year-old man was admitted because of rectal cancer-induced FG. The patient was misdiagnosed with extensive perianal abscess until the intraoperative biopsy confirmed that rectal cancer was the culprit. Incision, debridement and drainage were carried out to reduce infectious burdens. After that, the patient was transferred to Peking University People's Hospital for the subsequent therapy. Empirical broad-spectrum antibiotic therapy was used at the initial stage. Diversional transverse loop colostomy was performed to control infection and resume oral feeding. After four rounds of vacuum-assisted closure (VAC) therapy, radical resection and wound closure were accomplished. The scrotal defect was repaired by a skin flap. Pathological results indicated a moderately differentiated adenocarcinoma with perforation. The patient was discharged from the hospital on postoperative day 15 without any post-operative complications. No signs of recurrence were observed during a 22-month follow-up. In the setting of rectal cancer-induced FGs, the liquid resuscitation, broad-spectrum antibiotic therapy, and prompt debridement are the cornerstones of the initial management. Diversional colostomy and VAC therapy were effective in the management of severe infection and large wounds. The present case report also provided a clinical reference for the implementation of staged surgeries and the perioperative multidisciplinary management of FGs.

Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial

BACKGROUND

Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula.

METHOD

The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months).

DISCUSSION

This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess.

TRIAL REGISTRATION

EudraCT Number: 2021-003376-14. Registered on November 26, 2021.

Sclerotherapy for hemorrhoidal disease: systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the safety and efficacy of sclerotherapy methods for hemorrhoidal disease (HD) over the past 40 years.

METHODS

The review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A comprehensive literature search was conducted, including studies reporting the use of sclerotherapy in patients with HD. Study eligibility criteria were defined, and data were extracted independently by the authors. Random-effects meta-analyses were performed to assess outcomes of interest.

RESULTS

Out of 1965 records identified, 44 studies met the inclusion criteria, involving 9729 patients. The majority of studies were conducted in Japan, followed by the UK, Italy, and Portugal. The median age of participants was 52 years, and the majority were male. The Goligher grade distribution indicated varying degrees of HD severity. Sclerotherapy was predominantly administered through anoscopy, with polidocanol being the most commonly used agent. The procedure was generally performed without pre-injection analgesia. The meta-analysis of 14 randomized controlled trials (RCTs) revealed that sclerotherapy was not inferior to control interventions in terms of success rate (risk ratio [RR] 1.00, 95% CI 0.71-1.41) and recurrence rate (RR 1.11, 95% CI 0.69-1.77), while resulting in fewer complications (RR 0.46, 95% CI 0.23-0.92).

CONCLUSIONS

This systematic review highlights the safety and efficacy of sclerotherapy for HD, which yields similar success rates and fewer complications compared to other conservative or surgical approaches. Further research is warranted to optimize sclerotherapy techniques and evaluate long-term outcomes.

REGISTRATION

PROSPERO 2023 CRD42023396910.

Anorectal Emergencies

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Meek Micrografting Technique for Reconstruction of Extensive Necrotizing Fasciitis of the Anterior Abdomen and Bilateral Femoral Region: A Case Report

Necrotizing fasciitis is an uncommon yet fatal soft tissue infection. Current recommended treatment includes antibiotics with repeat surgical exploration and wound debridement followed by reconstruction. In burn patients, the Meek micrograft has demonstrated a higher true expansion ratio, faster reepithelialization rate, more resilient toward infection, and reduced risk of graft failure as compared with meshed graft. To our best knowledge, the use of Meek micrografting technique in reconstruction of postdebridement wounds of necrotizing fasciitis has not been reported. Hereby, we present a case of a 57-year-old gentleman who was referred to us for wound reconstruction after surgical debridement of Fournier's gangrene and extensive necrotizing fasciitis involving the anterior abdomen and bilateral femoral region. Meek micrografting technique was used to reconstruct the anterior abdomen as the wound bed was large. Although the graft was complicated with a small area of localized infection, it did not spread across the entire graft and was successfully treated with topical antibiotics and regular wound dressing. In our case, wound reconstruction using Meek micrografting technique in a patient with extensive necrotizing fasciitis was successful and showed positive outcome. Therefore, we suggest further studies to be conducted to investigate the applications and outcomes of the Meek micrografting technique, especially in patients with extensive wound bed and limited donor site availability.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

INTRODUCTION

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.

METHODS

A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.

CONCLUSIONS

In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Evaluation of the Cutting Seton Technique in Treating High Anal Fistula

Objectives Fistula-in-ano is a common condition that negatively affects the quality of life of its sufferers. A high anal fistula poses a significant challenge for surgeons due to its proximity to the anorectal ring and the potential risk of incontinence rather than recurrence. Many modalities have been used in a justified search for a satisfactory cure for the condition, but the seton remains a mainstay of surgical treatment. Therefore, the rationale of this study is to assess the outcome of treating a high anal fistula using the cutting seton technique in a hospital in Al Madinah, Saudi Arabia. The evaluation is intended through a retrospective analysis of patients' outcomes, comparing its effectiveness to similar articles. Methods This is a retrospective study that includes 50 patients with high anal fistulas who were treated with a cutting seton at the National Guard Hospital over a four-year period (2019-2022). Information obtained from medical records included clinical and demographic data. The data collected during the study was compiled and statistically analyzed using the SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.). A p-value of <0.05 was considered statistically significant. Results A total of 50 patients with high anal fistula treated with a cutting seton were included: 82% were males and 18% were females, with 66% below 45 years of age. Approximately 92% had inter-sphincteric fistulas, and only 28% had a recurrent fistula. Almost all patients (98%) had an MRI done before surgery. Around 70% of patients were completely cured, 26% had minor complications, 8% of the operated patients experienced mild incontinence, and only one recurrence (2%). Conclusion The cutting seton is still a valid modality in treating patients with a high anal fistula, as it is considerably safe, effective, and yields good outcomes. Standard preoperative assessment and thorough surgical techniques are cornerstones for achieving a satisfactory outcome.

Awareness and Acceptance of Digital Rectal Examination for the Clinical Evaluation of Anorectal Conditions Among the Saudi Population: A Cross-Sectional Study

INTRODUCTION

Digital rectal examination (DRE) is an important diagnostic tool used by physicians to resolve several confusing clinical situations. The history and physical examination cannot be complete without performing a DRE. Any patient that presents with abdominal complaints (e.g., diarrhea, constipation, nausea, vomiting, abdominal or rectal pain, bleeding) needs a DRE which is important for detecting warning signs of serious conditions that require further investigation and evaluation such as malignancies. Therefore, our aim was to assess and measure the awareness of the Saudi population regarding the importance and acceptance to perform DRE.

METHODS

This cross-sectional study was conducted in Riyadh, the capital city of Saudi Arabia, using an online survey between September 2022 and March 2023; the targeted participants were adults between the ages of 18 to 75.

RESULTS

The study indicated that the general community awareness of DRE is low, with only 59.1% of participants having heard of DRE and 14.6% having undergone the procedure previously. The majority of individuals (60.9%) were willing to undergo DRE if a healthcare provider suggested it. Participants' knowledge of DRE's ability to detect various anorectal diseases varied. While the majority of individuals believed DRE could detect hemorrhoids, just 40.4% believed DRE could help detect colorectal cancer. Chronic constipation or diarrhea, feces-induced stretching, and prolonged sitting were the most oft-cited causes of hemorrhoids. Anemia was the most often reported consequence of hemorrhoids, followed by hypertension and diabetes.

CONCLUSION

The significance of DRE as a screening tool for the early detection and prevention of anorectal problems, as well as the need for adequate care and treatment of hemorrhoids to prevent complications, are highlighted by these findings. Healthcare practitioners should actively recommend and provide information about DRE and other screening technologies, as well as address their patients' concerns and misconceptions.

Successful Treatment of Intractable Rectal Varices with Gelfoam Slurry Embolisation and Coiling

A 57-year-old male with heart failure and decompensated alcoholic liver cirrhosis presented with recurrent haematochesia due to rectal varices. After multiple failed therapy with endoscopic band ligation and surgical sclerotherapy, a discussion with an interventional radiologist was arranged. A transjugular intrahepatic portosystemic shunt (TIPS) was deferred due to a history of heart failure. A shared decision to proceed with transhepatic Gelfoam® slurry embolisation with coiling was made. During the procedure, a variant anatomy of the superior rectal vein was identified. The superior rectal vein was found to drain directly into the left portal vein with no connectivity between the inferior mesenteric vein and the rectal varices. As planned, Gelfoam slurry embolisation and coiling was done to the left and right superior rectal vein along with the common trunk it drains. The patient did not develop any further episodes of gastrointestinal bleeding or worsening ascites on follow-up after 6 months. This case represents a successful treatment of bleeding rectal varices when TIPS is contraindicated.

LEARNING POINTS

Rectal varices are an infrequent outcome of portal hypertension formed by portocaval anastomosis between the superior rectal vein with the inferior mesenteric vein of the portal system upstream, and the middle and inferior rectal vein draining into the internal iliac and internal pudendal vein of the systemic circulation, respectively. Portal system variations are extremely rare.Most common modality of recurrent rectal varices bleed is a transhepatic intrajugular portosystemic shunt. The absolute contraindications to this include congestive heart failure among others.In the presence of multiple co-morbidities and contraindication for TIPS, various interventional radiological modalities on a case-by-case basis are available including percutaneous transhepatic rectal varices obliteration.

Elderly Patients Managed Non-Operatively with Abscesses of the Anorectal Region Have Five Times Higher Rate of Mortality Compared to Non-Elderly

This study's purpose was to investigate risk factors for mortality from anorectal abscesses through a more comprehensive examination. This was a retrospective study that evaluated National Inpatient Sample patient data of adult and elderly patients emergently admitted with a primary diagnosis of anorectal abscess. Data was stratified by variables of interest and examined through statistical analysis, including backward logistic regression modelling. Roughly 40,000 adult patients and nearly 7000 elderly patients were admitted emergently with a primary diagnosis of abscess in anorectal regions. The mean age of adult male patients was 43 years while elderly male patients were, on average, 73 years old. Both adult males (69.0%) and elderly males (63.9%) were more frequently seen in the hospital for anorectal abscess compared to females. Mortality rates were lower in adult patients as only 0.2% (n = 62) of adult patients and 1.0% (n = 73) of elderly patients died in the hospital. Age increased the odds of mortality (OR = 1.03; 95% CI: 1.02-1.04, p < 0.001) as did hospital length of stay (OR = 1.02; 95% CI: 1.01-1.03, p < 0.001). Surgical procedure decreased the odds of mortality by more than 50% (OR = 0.49; 95% CI: 0.33-0.71, p < 0.001). Risk factors for mortality from anorectal abscess included age and non-operative management, which leads to prolonged hospital length of stay. Surgical management of anorectal abscesses offered protective benefits.

[Current WSES-AAST guidelines on anorectal emergencies-Summary and comments]

In 2019, the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) generated consensus recommendations for the treatment of anorectal emergencies in Parma, Italy, and published a guideline in 2021. This is the first global guideline dealing with this important topic for surgeons' everyday work. Seven anorectal emergencies were discussed and the guideline recommendations were given according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery

PURPOSE

For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

METHODS

A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

RESULTS

Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

CONCLUSION

The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.

Rectal prolapse as the initial presentation of rectal cancer-A case report

Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy.

Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system

Introduction

Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system.

Material and Methods

A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment.

Results

Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively.

Conclusion

The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.

Progress in Multidisciplinary Treatment of Fournier's Gangrene

Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.

Sclerotherapy for III- and IV-degree hemorrhoids: Results of a prospective study

Background

In the last 2 years, anorectal surgery has been strongly affected and even surgery for urgent cases cannot be scheduled; also, patients with III- and IV-degree bleeding hemorrhoids should be treated conservatively. The aim was to evaluate the effectiveness of sclerotherapy in patients who had to postpone surgery.

Methods

We included all patients with III- and IV-degree bleeding hemorrhoids who underwent outpatient sclerotherapy. The visual analog scale and the hemorrhoid severity score were used at the baseline and at 4 weeks after the procedure with a telephone interview, and all patients were outpatient-evaluated 1 week, 1 month, and 1 year after the treatment. All pre- and postoperative data were recorded.

Results

From October 2020 to November 2021, 19 patients with III- (12 patients; 63%) and IV-degree (7 patients; 37%) bleeding hemorrhoids were enrolled. The mean operative time was 4.5 min, and no intraoperative complications occurred. One case of tenesmus and three failures were detected. Six months after the procedure, the overall success rate was 84%, although all of the patients enrolled reported persistent bleeding at the end of the study period. Of these, 5 patients (26%) were scheduled for surgery and 11 patients (58%) refused surgery and asked to undergo a re-do sclerotherapy.

Conclusion

Sclerotherapy with 3% polidocanol foam is a safe and effective procedure also in III- and IV-degree bleeding hemorrhoids. The long-term data on the length of the foam remain to be evaluated in additional studies.

A case report of largest rectal prolapse in the literature successfully treated with Altemeier's procedure

Background

The rectal prolapse is defined as the concentric protrusion of full or partial thickness of the rectum or rectosigmoid via the anus. This is an increasing clinical concern that is usually found in old female patients.

Cases presentation

A 39-year-old male patient was referred due to an un-reduceable rectal projection from a week ago. The primary endeavor for reduction of the projection under sedation and after local mannitol treatment at the operation room was unsuccessful, so surgical resection and reduction were planned for the patient.

Conclusion

Management of rectal prolapse has always been one of the challenges of colorectal surgery. For patients with incarcerated prolapse manual reduction under sedation is used. If the reduction is unsuccessful, surgical procedures are used.

•

The rectal prolapse is defined as the concentric protrusion of full or partial thickness of the rectum or rectosigmoid via the anus.

•

Management of rectal prolapse has always been one of the challenges of colorectal surgery.

•

Giant rectal prolapse defined as segment of rectosigmoid larger than 10 cm in length.

Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends

Recent trends in benign anal disease treatment are minimizing surgery to preserve normal anorectal anatomical unit and its functions. However, some surgeons still prefer and are confident with the use of conventional solid surgical methods. In this report, we will investigate the recent trends in the treatment for hemorrhoids, fistula, and anal fissure. The practice guidelines of advanced countries, including UK, Italy, France, USA, Japan, and ESCP, are referred to in this review. Opinions suggested in international meetings were also added. In the management of hemorrhoids, surgical treatments and office procedures were recommended according to a patient's status and preference. For the management of complex anal fistula, novel sphincter-preserving surgical techniques are more widely accepted than a sphincter-dividing procedure of immediate repair following fistulectomy. The treatment of anal fissures is well covered in the guidelines of the ASCRS.

Rectal Foreign Bodies: Surgical Management and the Impact of Psychiatric Illness

Background

Entrapped rectal foreign bodies can be a challenge to manage and are being encountered by acute surgical teams with increasing frequency. The aims of our study were to (a) ascertain the population demographics of patients presenting with this problem in our local area of East Kent, (b) see if an association could be drawn between this presentation and proposed risk factors such as a psychiatric illness or socioeconomic deprivation, and (c) to review how foreign bodies are being removed in the East Kent Hospital University Foundation NHS Trust, United Kingdom and to highlight best practice with regards to this in line with the latest guidelines.

Methodology

Between 2017 and 2021, 32 cases of entrapped rectal foreign bodies were diagnosed and managed at our NHS Trust. Retrospective data taken from the theatre directory and electronic patient records were used to audit patient demographics, co-morbidities, the type of foreign body, and the extraction technique.

Results

The majority of patients (90%) were male (n = 29). The patients’ age ranged from 15 to 95 years, with a median age of 48 years. In total, 12 (37.5%) patients had a medical history of a psychiatric illness. The most common foreign bodies removed were sex toys or vibrators (n = 8) and roll-on deodorant bottles (n = 7). Kent Area B (n = 10) and Kent Area A (n = 9) were the areas with the highest number of cases. Twenty-two (68.8%) patients underwent examination under a general anaesthetic for removal, seven (21.8%) patients had the object manually removed without sedation, and three (9.4%) required a laparotomy with or without bowel resection.

Conclusions

Cases of an entrapped rectal foreign body in this local region typically involved male patients between 40 and 50 years old. A high proportion of this group had a history of a psychiatric illness supporting an association between this presentation and mental health. We have proposed some explanations for this association including the anal canal nervous system interplay with the “brain-gut axis.” Lower socioeconomic status and unemployment may also be risk factors for this surgical problem. A trans-anal approach for management is successful in the majority of cases; however, almost 10% of patients required emergency surgical management. We have highlighted best practice guidelines for the investigation and management of the entrapped rectal foreign body as part of our discussion.

Management and Treatment of External Hemorrhoidal Thrombosis

Background

External hemorrhoidal thrombosis (EHT) is a common complication of hemorrhoidal disease. This condition causes extreme pain, likely resulting from internal anal sphincter hypertonicity, which traps the hemorrhoids below the dentate line thus leading to congestion and swelling. The choice of treatment remains controversial and both conservative and surgical options have been proposed in the last decades.

Methods

This mini-review focuses on the most relevant studies found in literature evaluating conservative and surgical management of EHT. Special conditions such as pregnancy and EHT in elderly patients have been considered.

Results

Traditionally, symptoms duration represents the discriminant in the choice between medical and surgical treatment. Several Coloproctological Societies considered conservative treatment as the first-line approach to EHT and a variety of options have been proposed: wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection and topical application of 0.2% glyceryl trinitrate. Meanwhile, different surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48–72 h: drainage with radial incision, conventional excision, excision under local anesthesia and stapled technique.

Conclusion

The management and treatment of EHT is still controversial since no specific guidelines have been published. Both medical and surgical treatment have been proven effective but randomized clinical trials and structured consensus-based guidelines are warranted.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM)

Background

The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids.

Methods

A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year.

Results

There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18–75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125).

Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred.

Conclusions

Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

A Stepwise Proposal for Low-Grade Hemorrhoidal Disease: Injection Sclerotherapy as a First-Line Treatment and Rubber Band Ligation for Persistent Relapses

Outpatient treatments are actually the techniques of choice in the management of low-grade hemorrhoidal disease. Among these, rubber band ligation (RBL) and injection sclerotherapy (IS) are the most frequently performed. Both techniques are used, without one having been determined to be superior over the other. We analyzed the studies that compare these two techniques in terms of efficacy and safety in order to offer a proposal for treatment choice. RBL seems to be most efficient in terms of symptom resolution for second-degree hemorrhoidal disease and equal or superior for treatment of third-degree disease. However, IS offers lower rates of severe post-operative pain and minor complications. Since outpatient treatments are offered to patients as painless options that allow a prompt recovery, we propose a stepwise protocol using 3% polidocanol or aluminum potassium sulfate and tannic acid IS as the first treatment option, as it has less complications, followed by RBL in cases of relapse.