A. G. Acheson

Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: Systematic review of randomized, controlled trials

PURPOSEThis study was designed to determine whether conventional hemorrhoidectomy or stapled hemorrhoidopexy is superior for the management of hemorrhoids.METHODSA systematic review of all randomized trials comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched using the terms “hemorrhoid*” or “haemorrhoid*” and “stapl*.” A list of clinical outcomes was extracted. Meta-analysis was calculated if possible.RESULTSFifteen trials recruiting 1,077 patients were included. Follow-up ranged from 6 weeks to 37 months. Qualitative analysis showed that stapled hemorrhoidopexy is less painful compared with hemorrhoidectomy. Stapled hemorrhoidopexy has a shorter inpatient stay (weighted mean difference, –1.02 days; 95 percent confidence interval, –1.47 to –0.57; P = 0.0001), operative time (weighted mean difference, –12.82 minutes; 95 percent confidence interval, –22.61 to –3.04; P = 0.01), and return to normal activity (standardized mean difference, –4.03 days; 95 percent confidence interval, –6.95 to –1.10; P = 0.007). Studies in a day-case setting do not prove that stapled hemorrhoidopexy is more feasible than conventional hemorrhoidectomy. Stapled hemorrhoidopexy has a higher recurrence rate (odds ratio, 3.64; 95 percent confidence interval, 1.40–9.47; P = 0.008) at a minimum follow-up of six months.CONCLUSIONSAlthough stapled hemorrhoidopexy is widely used, the data available on long-term outcomes is limited. The variability in case selection and reported end points are difficulties in interpreting results. Stapled hemorrhoidopexy has unique potential complications and is a less effective cure compared with hemorrhoidectomy. With this understanding, it may be offered to patients seeking a less painful alternative to conventional surgery. Hemorrhoidectomy remains the “gold standard” of treatment.

Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis.

Objective:To determine the effect of allogeneic blood transfusion (ABT) on clinical outcomes in patients with colorectal cancer undergoing surgery. Background:Perioperative ABTs may be associated with adverse clinical outcomes. Methods:Systematic review of the literature with odds ratio (OR) and incidence rate ratio (IRR) meta-analyses of predefined clinical outcomes based on a MEDLINE search. Results:In total, 20,795 colorectal cancer (CRC) patients observed for more than 59.2 ± 26.1 months (108,838 patient years) were included, of which 58.8% were transfused. ABT was associated with increased all-cause mortality OR = 1.72 (95% confidence interval [CI] 1.55 − 1.91, P < 0.001); I2 = 23.3% (0 − 51.1) and IRR = 1.31 (1.23 − 1.39, P < 0.001), I2 = 0.0% (0 − 37.0). ABT was also associated with increased ORs (95% CI, P) for cancer-related mortality of 1.71 (1.43 − 2.05, P <0.001), combined recurrence—metastasis—death 1.66 (1.41 − 1.97, P < 0.001), postoperative infection 3.27 (2.05 − 5.20, P < 0.001), and surgical reintervention 4.08 (2.18 − 7.62, <0.001). IRR (95% CI, P) was 1.45 (1.26 − 1.66, <0.001) for cancer-related mortality and 1.32 (1.19 − 1.46, <0.001) for recurrence—metastasis—death. Mean length of hospital stay was significantly longer in transfused compared with nontransfused patients (17.8 ± 4.8 vs 13.9 ± 4.7 days, P = 0.005). Conclusions:In patients with colorectal cancer (CRC) undergoing surgery, ABTs are associated with adverse clinical outcomes, including increased mortality. Measures aimed at limiting the use of ABTs should be investigated further.

International consensus statement on the peri-operative management of anaemia and iron deficiency

Despite current recommendations on the management of pre‐operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best‐practice and evidence‐based statements to advise on patient care with respect to anaemia and iron deficiency in the peri‐operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow‐up. We urge anaesthetists and peri‐operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Management of haemorrhoids

Haemorrhoids or “piles” are enlarged vascular cushions within the anal canal that have been described for many centuries and continue to form a large part of a colorectal surgeon’s workload. The exact incidence of this common condition is difficult to estimate as many people are reluctant to seek medical advice for various personal, cultural, and socioeconomic reasons, but epidemiological studies report a prevalence varying from 4.4% in adults in the United States to over 30% in general practice in London.1 2 The treatment of haemorrhoids is still evolving, and this article provides an update on the role of established and innovative treatments (fig 1)⇓. Fig 1 Suggested algorithm for management of haemorrhoids (dotted arrows indicate failure of initial treatment) Articles were retrieved from the Medline database and Cochrane library under the MeSH subheadings “hemorrhoid” and “haemorrhoid”. We included randomised controlled trials and meta-analyses. #### Summary points The anal canal consists of three fibrovascular cushions that are fed directly by arteriovenous communications. These cushions are supported within the anal canal by a connective tissue framework, and they are important in providing a watertight seal to the anus. The degenerative effects of ageing may weaken or fragment the supporting tissues, and this along with the repeated passage of hard stool and straining produces a shearing force on the cushions, leading to their descent and prolapse. The …

Colonic tattooing in laparoscopic surgery – making the mark?

Objective  Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications.

Quality of life in patients with chronic anal fissure.

Objective  Little is known about the quality of life in patients with the distressing symptoms of chronic anal fissure. This was a prospective study assessing the physical and mental health of fissure patients before and after topical treatment.

The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy

Objective  The treatment of anal fissures has evolved over the last 5 years with the development of topical treatments aimed at reducing sphincter hypertonia. This is thought to improve anal mucosal blood flow and promote healing of the fissure. This study reports the use of topical diltiazem in patients with chronic anal fissures that have failed previous treatment with topical 0.2% glyceryl trinitrate (GTN).

The feasibility and clinical efficacy of intravenous iron administration for preoperative anaemia in patients with colorectal cancer

The study aimed to analyse the feasibility and efficacy of administration of a single intravenous iron infusion (IVI) in the preoperative optimization of colorectal cancer patients with anaemia.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery

Aim  Intra‐operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel.

Topical L-arginine gel lowers resting anal pressure: possible treatment for anal fissure.

AbstractPURPOSE: Exogenous nitric oxide donors, such as glyceryl trinitrate, have been used as treatment for anal fissures; however, headaches develop in 60 percent of patients. Nitric oxide produced from the cellular metabolism of L-arginine mediates relaxation of the internal anal sphincter. This study investigated whether topical L-arginine gel reduces maximum anal resting pressure in volunteers. METHOD: In a two-center study, volunteers received a single topical dose of L-arginine or placebo (AquagelTM). Anal manometry was performed for two hours after application of 400 mg of L-arginine gel or placebo gel to the anal verge in 25 volunteers. Side effects were recorded after single application and also after repeated dosing for three days. RESULTS: L-Arginine reduced maximum anal resting pressure by 46 percent from a median of 65 cm of water to a minimal value of 35 cm of water (P < 0.001, Wilcoxon’s signed-rank test). The difference between L-arginine and placebo using repeated-measures testing was significant at P < 0.005. No side effects occurred with either gel; in particular, no episodes of headache were recorded. CONCLUSION: Topical L-arginine gel significantly lowers maximum anal resting pressure; its onset of action is rapid, and duration is at least two hours (P < 0.01). L-arginine may have therapeutic potential, but further evaluation is needed before it can be used as a possible alternative treatment for chronic anal fissure.