The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Australia ; General Surgery ; education ; Internship and Residency ; Job Satisfaction ; New Zealand

PURPOSE: Indoor risk factors for allergic diseases in low-income households in Korea have been characterized only partially. We evaluated the prevalences of atopic dermatitis, asthma, and allergic rhinitis in Seoul, Korea, to identify key housing and behavioral risk factors of low-income households. METHODS: Statistical analysis of the prevalence of these diseases and various risk factors was conducted using data from a 2010 Ministry of Environment household survey. Logistic regression models were generated using data from 511 low-income household apartments in districts of Seoul. RESULTS: In general, housing factors such as renovation history (P<0.1) and crowding status (P<0.01) were associated with allergic rhinitis, whereas behavioral factors such as frequency of indoor ventilation (P<0.05) and cleaning (P<0.1) were inversely correlated with atopic dermatitis. Indoor smoking was a major trigger of asthma and atopic dermatitis in low-income households (P<0.05). The presence of mold and water leakage in houses were the most important risk factors for all three diseases (P<0.05). CONCLUSIONS: Various risk factors play a role in triggering allergic diseases among low-income households in Seoul, and health or environmental programs mitigating allergic diseases should be tailored to address appropriate housing or behavioral factors in target populations.
Asthma ; Crowding ; Dermatitis, Atopic ; Family Characteristics* ; Fungi ; Health Services Needs and Demand ; Housing ; Korea ; Logistic Models ; Poverty ; Prevalence* ; Rhinitis ; Risk Factors* ; Seoul ; Smoke ; Smoking ; Ventilation ; Water

Purpose: To evaluate the therapeutic effects and safety of oral spironolactone (SPRL) in patients with central serous chorioretinopathy (CSC). Methods: Medical records and imaging data from consecutive patients diagnosed with CSC and treated with SPRL were reviewed. Changes in central macular thickness (CMT), subretinal fluids (SRF), subfoveal choroidal thickness (SFCT), and best corrected visual acuity (BCVA) were measured at baseline and follow-up visits. Follow-up visits were performed at 1, 3, 6, and 12 months after treatment. The patients were divided into two groups; acute and chronic, and the therapeutic outcomes were compared. The occurrence of side effects and recurrence after complete resolution of SRF were also assessed. Results: A total of 42 patients with 45 eyes were included. CMT and SRF after using SPRL improved significantly at 1, 3, 6, and 12 months and SFCT improved at 3, 6, and 12 months. However, BCVA showed no significant change at any time. Acute patients showed similar results. However, in chronic patients, CMT showed significant differences at 1 and 3 months, SRF at 1 and 6 months, and SFCT at 6 months. A total of 15.6%, 38.2%, 45.8%, and 50.0% of eyes showed complete resolution of SRF at each follow-up period, respectively, and 8.9% of eyes showed recurrence after complete resolution. Two male patients experienced gynecomastia and one patient showed mild elevation of serum creatinine. Conclusions Our study supported the therapeutic benefits of SPRL in patients with CSC, especially in anatomical structures. However, careful observation is required because of side effects and recurrence after complete resolution.

Purpose: To evaluate the therapeutic effects and safety of oral spironolactone (SPRL) in patients with central serous chorioretinopathy (CSC). Methods: Medical records and imaging data from consecutive patients diagnosed with CSC and treated with SPRL were reviewed. Changes in central macular thickness (CMT), subretinal fluids (SRF), subfoveal choroidal thickness (SFCT), and best corrected visual acuity (BCVA) were measured at baseline and follow-up visits. Follow-up visits were performed at 1, 3, 6, and 12 months after treatment. The patients were divided into two groups; acute and chronic, and the therapeutic outcomes were compared. The occurrence of side effects and recurrence after complete resolution of SRF were also assessed. Results: A total of 42 patients with 45 eyes were included. CMT and SRF after using SPRL improved significantly at 1, 3, 6, and 12 months and SFCT improved at 3, 6, and 12 months. However, BCVA showed no significant change at any time. Acute patients showed similar results. However, in chronic patients, CMT showed significant differences at 1 and 3 months, SRF at 1 and 6 months, and SFCT at 6 months. A total of 15.6%, 38.2%, 45.8%, and 50.0% of eyes showed complete resolution of SRF at each follow-up period, respectively, and 8.9% of eyes showed recurrence after complete resolution. Two male patients experienced gynecomastia and one patient showed mild elevation of serum creatinine. Conclusions Our study supported the therapeutic benefits of SPRL in patients with CSC, especially in anatomical structures. However, careful observation is required because of side effects and recurrence after complete resolution.

Purpose: Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with rectocele. The purpose of this study was to evaluate the clinical outcome in a consecutive series of patients who underwent transperineal repair of rectocele when presenting with fecal incontinence as the predominant symptom. Methods: Twenty-three consecutive patients from April 2000 to July 2015 with symptomatic rectocele underwent transperineal repair by a single surgeon. Results: All patients had a history of vaginal delivery, with or without evidence of associated anal sphincter injury at the time. The median age of the cohort was 53 years (range, 21–90 years). None were fully continent preoperatively. However, continence improved to just rare mucus soiling or loss of flatus in all patients 6 months after their surgery. There was no operative mortality. Postoperative complications including urinary retention and wound dehiscence occurred in 3 patients. Conclusion Fecal incontinence associated with rectocele is multifactorial and may be caused by preexisting anal sphincteric damage and attenuation. Our experience suggests that transperineal repair provides excellent anatomic and physiologic results with minimal morbidity in selected patients presenting with combined rectocele and anal sphincter defect.

Since its discovery 50 years ago, Epstein-Barr virus (EBV) has been linked to the development of cancers originating from both lymphoid and epithelial cells. Approximately 95% of the world's population sustains an asymptomatic, life-long infection with EBV. The virus persists in the memory B-cell pool of normal healthy individuals, and any disruption of this interaction results in virus-associated B-cell tumors. The association of EBV with epithelial cell tumors, specifically nasopharyngeal carcinoma (NPC) and EBV-positive gastric carcinoma (EBV-GC), is less clear and is currently thought to be caused by the aberrant establishment of virus latency in epithelial cells that display premalignant genetic changes. Although the precise role of EBV in the carcinogenic process is currently poorly understood, the presence of the virus in all tumor cells provides opportunities for developing novel therapeutic and diagnostic approaches. The study of EBV and its role in carcinomas continues to provide insight into the carcinogenic process that is relevant to a broader understanding of tumor pathogenesis and to the development of targeted cancer therapies.
B-Lymphocytes ; Carcinoma ; Epithelial Cells ; Epstein-Barr Virus Infections ; complications ; Herpesvirus 4, Human ; Humans ; Lymphoma, B-Cell ; Nasopharyngeal Neoplasms ; virology ; Stomach Neoplasms

Purpose: Stapled anastomotic techniques to the distal rectum have gained widespread acceptance due to their procedural advantages. Various modifications in the stapling techniques have evolved since their inception. The triple-staple technique utilizing stapled closure of both the proximal colon and distal rectal stump provides a rapid and secure colorectal anastomosis. The aims of this study were to determine the safety and efficacy of the triple-staple technique and to compare the clinical outcomes with a historical control group for which the conventional double-staple technique had been performed. Methods: One hundred consecutive patients operated on by a single surgeon were included in the study; 50 patients who underwent a double-staple (DSA) procedure and 50 patients undergoing triple-staple anastomosis (TSA). Results: The most common indication for surgery in both groups was rectal cancer followed by diverticular disease and distal sigmoid cancer. There was no significant difference in number of patients requiring loop ileostomy formation in the groups (TSA, 56.0% vs. DSA, 68.0%; P = 0.621). The mean operating time for the TSA group was significantly shorter compared to that of the DSA group (TSA, 242.8 minutes vs. DSA, 306.1 minutes; P = 0.001). There was no significant difference in complication rate (TSA, 40% vs. DSA, 50%; P = 0.315) or length of hospital stay between the two groups (TSA, 11.3 days vs. DSA, 13.0 days; P = 0.246). Postoperative complications included anastomotic leak, prolonged ileus, bleeding, wound infection, and pelvic collection. Conclusion The triple-staple technique is a safe alternative to double-staple anastomosis after anterior resection and effectively shortens operating time.

PURPOSE: Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical technique with the combined benefits of laparoscopic surgery while allowing the use of the surgeon's hand for better tactile control. Obesity has been associated with higher conversion rates with multiport laparoscopic surgery, but not with HALS. This study aimed to examine the versatility of HALS in various clinical contexts. METHODS: All HALSs performed at 2 major tertiary centers in Sydney were prospectively collected for retrospective analysis. Variables including age, sex, body mass index (BMI), previous surgeries, pathologies including size and T-stage, and the number of conversions to a midline laparotomy were examined. RESULTS: A total of 121 HALS colorectal resections were analyzed. The median age of the patients was 62 years, with 63.6% being women. Seven patients required conversion to a midline laparotomy. Of the 121 patients, 50.2% were overweight or obese, and 52.9% had undergone previous abdominal/pelvic operations. However, neither obesity nor abdominal adhesions from previous operations were an indication for conversion to an open laparotomy in any of the 7 converted patients. The presence of intra-abdominal adhesions did not impact the operative time. HALS allowed access to the entire colon and rectum and allowed resection of the bladder, uterus, and ureter, when these organs were involved. CONCLUSION: HALS is a versatile, minimally invasive technique, which is independent of the patient's BMI, for performing a colorectal resection.
Body Mass Index ; Colon ; Colorectal Surgery ; Female ; Hand ; Hand-Assisted Laparoscopy* ; Humans ; Laparoscopy ; Laparotomy ; Obesity ; Operative Time ; Overweight ; Pathology ; Prospective Studies ; Rectum ; Retrospective Studies ; Surgeons* ; Ureter ; Urinary Bladder ; Uterus

PURPOSE: Mesenteric embolization is an integral part in the management of acute lower gastrointestinal (GI) bleeding. The aim of this study was to highlight our experience after adopting mesenteric embolization in the management of acute lower GI hemorrhage. METHODS: A retrospective review of all cases of mesenteric embolization for acute lower GI bleeding from October 2007 to August 2012 was performed. RESULTS: Twenty-seven patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were three clinical failures (11.1%) in our series. Two patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died one week later. There were no factors that predicted clinical failure. CONCLUSION: Mesenteric embolization for acute lower GI bleeding can be safely performed and is associated with a high clinical success rate in most patients. A repeat embolization can be considered in selected cases, but postembolization ischemia is associated with bad outcomes.
Colon ; Emergencies ; Gastrointestinal Hemorrhage* ; Hemoglobins ; Hemorrhage ; Humans ; Ischemia ; Retrospective Studies