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Background: Hemorrhoidectomy is a common procedure used to treat symptomatic hemorrhoids. However, the necessity and cost-effectiveness of routinely conducting histopathological analysis on excised tissue samples are uncertain., Methods: A systematic review was conducted using MEDLINE and EMBASE up to December 2023 for studies assessing the histopathological outcomes of hemorrhoidectomy specimens. Meta-analysis was performed on articles with combinable results to determine the pooled proportions of cancer and anal intraepithelial neoplasia (AIN) using the random effects model., Results: From 2974 initial search results, 12 studies were included in the review, with 48,365 resected specimens from hemorrhoidectomy. Among these, there were 11 retrospective studies and one prospective study. A meta-analysis of 11 studies revealed that the prevalence of anal cancer was low, at 0.13% (95% CI: 0.05%-0.31%). The prevalence of anal cancer and AIN combined was 1.16% (95% CI: 0.53%-2.52%)., Conclusion: This literature review estimated the probability of malignancy detection in hemorrhoid specimens sent for histopathological evaluation. The low incidence of malignant findings implies that routine analysis of hemorrhoidectomy samples may not be cost-effective. However, existing studies have yet to establish definitive risk factors for abnormal histological diagnoses to aid in the selection of specimens for selective histopathology., (© 2024 The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

The aim of the current study was to synthesize silver nanoparticles (PLSNPs) using green technology by means of phytosterol-enriched fractions from Blumea lacera extracts (EAF) and evaluate their toxicological and anti-haemorrhoidal potential. The average size of the synthesized particles was found to be 85.64 nm by scanning electron microscopy and transmission electron microscopy. Energy dispersive spectroscopy showed the elemental composition of PLSNPs to be 12.59% carbon and 87.41% silver, indicating the capping of phytochemicals on the PLSNPs. The PLSNPs were also standardized for total phytosterol content using chemical methods and high-perfromance liquid chromatography. The PLSNPs were found to be safe up to 1000 mg kg -1 as no toxicity was observed in the acute and sub-acute toxicity studies performed as per OECD guidelines. After the induction of haemorrhoids, experimental animals were treated with different doses of EAF, PLSNPs and a standard drug (Pilex) for 7 d, and on the eighth day the ameliorative potential was assessed by evaluating the haemorrhoidal (inflammatory severity index, recto-anal coefficient) and biochemical (tumour necrosis factor-alpha and interleukin-6) parameters and histology of the recto-anal tissue. The results showed that treatment with PLSNPs and Pilex significantly ( p < 0.05) reduced haemorrhoidal and biochemical parameters. This was further supported by restoration of altered antioxidant status. Further, a marked reduction in the inflammatory zones along with minimal dilated blood vessels was observed in the histopathological study. The results of molecular docking studies also confirmed the amelioration of haemorrhoids via AMP-activated protein kinase (AMPK)-mediated reduction of inflammation and endothelin B receptor modification by PLSNPs. In conclusion, PLSNPs could be a good alternative for the management of haemorrhoids., (© 2024 IOP Publishing Ltd.)

Dear editor, 50 years-old female with personal history of mutation of the gene BRCA1 and previous prophylactic double anexectomy consulted for rectal bleeding without pain since two weeks. A blood test was performed, with hemoglobin levels of 13.1g/dl and without iron deficiency. In the anal inspection there were neither external hemorrhoids nor anal fistulas, so a colonoscopy was requested. In the colonoscopy, all the colon mucosa was normal but, in the rectal retroflexion, apart from internal engorged hemorrhoids, surrounding the 50% of the anal opening an erythematous and indurated mucosa was found (figure 1). Biopsies were taken. The pathology report informed of proliferation of spindle-shaped cells exclusively in the lamina propria with eosinophilic cytoplasm and unclear cell borders (figure 2). Not nuclear atypia or mitotic activity were observed. On immunohistochemistry, S-100 protein was strongly positive (figure 3) and CD34, SMA, EMA and c-kit were negative. These results are concordant with the diagnosis of Schwann cells in the context of a mucosal Schwann cell hamartoma (MSCH). Given that these lesions seem to not have malignant potential, the patient was discharged without control colonoscopies. The episodes of rectorrhagia were attributed to the presence of internal hemorrhoids. Discussion: MSCH are benign and intramucosal tumors with a mesenchymal origin. They are most commonly located in the distal colon, but they were also found in the gallbladder, the esophagogastric union and in the antrum. They are observed most frequently in middle aged women (around 60 years-old) and they are generally asymptomatic. They are presented as polyps between 1 and 6mm, but in other cases they appeared as small whitish nodules, protruding lesions with normal superficial mucosa or even they were found in random biopsies of the colon. The MSCH are a rare entity with an unknown prevalence. Less than 100 cases are described in the literature. It is essential the differentiation between this entity and the Schwanomas or the gastrointestinal stromal tumors (GIST). Schwanomas are rare in the colon, they are well circumscribed (in contrast with the MSCH) and they are not limited to the lamina propria. GIST are more frequently located in the stomach and they are positive for c-kit. MSCH are not associated with hereditary syndromes such as neurofibromatosis and, in contrast with Schwanomas or GIST, they do not require surveillance because they are benign.

We investigated the findings of rectoanal lesions in 190 patients who underwent colon capsule endoscopy (CCE) at our hospital. Internal hemorrhoids were observed in 70 (36.8%) patients and rectal polyps in 19 (10%) patients. When conventional endoscopy (colonoscopy and double balloon endoscopy) was considered the gold standard, the sensitivity and specificity of rectal polyps were 75% and 93.4%, respectively, and those of internal hemorrhoids were 88.9% and 92.7%, respectively. The prevalence of constipation was significantly higher in the false-negative group for internal hemorrhoids, and the colonic transit time was significantly shorter in the false-negative and false-positive groups for rectal polyps. No adverse events occurred in any of the patients. CCE might be a useful and safe examination method for rectoanal lesions.

The non-specific clinical symptoms of anorectal brownish-black mass do not help to differentiate colorectal cancer, hemorrhoids, rectal ulcers which result in a delayed diagnosis or lead to inadequate management of lethal anorectal melanoma. Primary malignant melanoma of the anorectal region is an uncommon tumor, constituting approximately 1% of anal canal tumors which may be misdiagnosed clinically as hemorrhoids. Because of aggressive behavior and poor prognosis, efficient and prompt diagnosis is required in these cases. We report 2 cases of this rare tumor., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Hemorrhoids and fistula are considered the most common anorectal conditions in the general population. These conditions affect the quality of a patient's life by causing pain and bleeding during defecation or even in the resting state. Lower grades of hemorrhoids may be controlled by traditional measures. However, surgery is an effective treatment option in recurrent‑lower and higher‑grade hemorrhoids. Surgical procedures are associated with various complications, including pain and delayed wound healing. Recurrence of hemorrhoids is also a major concern in the post‑operative period. An anal fistula is the connection between the anus and the skin and causes severe pain, swelling, as well as blood and pus discharge. Fistula has serious social and economic consequences. Hence, it is important to understand the pathophysiology and molecular pathology of hemorrhoids and fistula, to identify the molecular targets and to develop pharmacological‑interventions. In a previous study by our group, the polyherbal formulation Anoac‑H was developed for the treatment of different stages of hemorrhoids and fistula, and it was demonstrated that Anoac‑H is an effective formulation for treating hemorrhoids. However, the molecular mode of action of Anoac‑H on hemorrhoids and fistula had remained elusive. In the present study, it was determined that this formulation reduces the migration of mesenchymal (fibroblasts) and immune (RAW 264.7) cells without affecting their viability. It was also observed that Anoac‑H suppresses the expression of regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF in fibroblasts and macrophages. Inflammation and elevated expression of RANTES and VEGF were observed in hemorrhoids and fistula. However, inflammation, as well as the expression of RANTES and VEGF, were significantly reduced in treated human hemorrhoid and fistula tissues as compared to untreated ones, confirming the in vitro results.

Introduction: Hemorrhoidal disease is a very common benign anorectal disease. It affects millions of people around the world, and represent a major medical and socioeconomic problem. However, studies that determine the magnitude and risk factors are limited. Therefore, the aim this study is to assess the prevalence and associated factors of hemorrhoid among adult patients visiting the surgical outpatient department at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) Northwest Ethiopia., Methods: An institution-based cross-sectional study was conducted from February to May 2020. A systematic random sampling technique was used to select a total of 403 participants. The data were collected then entered using EPI DATA version 3.1 and exported to the STATA 14 for analysis. Bivariable and multivariable logistic regression analysis were performed. Adjusted odds ratio (AOR) with 95% confidence interval was used as a measure of association. Variables having P-value < 0.05 from the multivariable analysis were considered to have a significant association with the outcome., Result: Out of the 403 study participants, 13.1% (95%CI; 10.1, 16.8) had hemorrhoids. Constipation (AOR = 4.32, 95% CI; 2.20, 8.48) and BMI ≥25kg/m2 (AOR = 2.6, 95% CI; 1.08, 6.23) had a statistically significant association with hemorrhoid., Conclusion: The overall prevalence of hemorrhoid was high and its prevalence was higher in male subjects. Constipation and being overweight were found to increase the odds of having hemorrhoids. Screening for early identification and intervention of hemorrhoids, especially for risk groups is better to be practiced by health professionals., Competing Interests: There is no any competing of interests related with this work.

Ethnopharmacological Relevance: Solanum melongena L. (eggplant) is used for treatment of rheumatism, beriberi, itching, toothache, bleeding, asthma, bronchitis, cholera, neuralgia and hemorrhoids in traditional medicine (Turkish, Chinese, and Indian). Hemorrhoids from these diseases, are common illness in all over the world, which are treated with various approaches including ethnobotanicals., Aim of the Study: This study aimed to evaluate the anti-hemorrhoidal activity of eggplant, an edible plant, which is commonly utilized around the world., Materials & Methods: In vivo anti-hemorrhoidal activity of the methanolic extract prepared from eggplant was evaluated by experimental hemorrhoid model, subsequently histological and biochemical analysis. Hemorrhoid, which was induced by applying croton oil to the anal area of the rats. Furthermore, the extract was screened for anti-inflammatory activity which is based on the inhibition of acetic acid-induced increase in capillary permeability. The healing potential was comparatively assessed with a reference Pilex® tablet and cream. Phytochemical analysis performed by HPLC. The amount of the major phenolic compound (chlorogenic acid) in extract was found by using HPLC method., Results: Histological and biochemical analysis demonstrated that eggplant extract is highly effective against hemorrhoid in comparison to the controls and the commercial preparation. In addition, the methanolic extract demonstrated significant inhibitory effect on acetic acid-induced increase in capillary permeability. The phytochemical studies identified major compound as chlorogenic acid (2.86%) by liquid chromatography., Conclusion: The eggplant calyxes, not edible, are easy to reach, by products/vast from the food sources. This is the first scientific evidence revealing that the eggplant extract has significant anti-hemorrhoidal and anti-inflammatory activity., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p < 0.0001). We estimated that the cost of 14 years of routine pathological examination of haemorrhoids specimens was 133,351.4 euros, each consequential incidental diagnosis costing 4445.03 euros. The incidence of unexpected lesions in routine pathologic examination of haemorrhoidectomy and haemorrhoidopexy specimens is low but not negligible. The vast majority of incidental findings were found among haemorrhoidectomy specimens. Even though the real value of routine pathological examination of haemorrhoids specimens is still uncertain, from a clinical standpoint we were glad to suggest each patients the best follow-up and/or treatment. Future studies should assess preoperative patient's risk stratification and careful intraoperative macroscopic inspection strategies for selective pathology examination of haemorrhoids specimens.

Objective: To study the distribution of nitric oxide synthase (NOS) isoforms and protein levels in human haemorrhoids and rectal tissue., Methods: Protein expression of NOS1, NOS2 and NOS3 was compared between haemorrhoids (n=14) and normal rectal submucosa (n=6) using Western blot analysis. The localisation of all NOS isoforms to specific structures was determined by immunohistochemistry., Results: Western blot analysis showed median (interquartile range) protein levels of all NOS isoforms were 1.5-2.4 times higher in haemorrhoids than rectal tissue; 121.4 (55.2-165.5) vs 50.0 (25.5-73.7) for NOS1 (p=0.020), 32.2 (23.8-140.6) vs 14.8 (9.6-34.0) for NOS2 (p=0.109), and 80.1 (62.0-139.5) vs 54.3 (48.7 -61.7) for NOS3 (p=0.015). Immunohistochemistry revealed a different distribution and location of all NOS isoforms in vascular and non-vascular structure of haemorrhoids and rectal tissues. The number of haemorrhoid specimens showing positive immunoreactivity of NOS in the vascular endothelium was significantly higher than that in rectal tissue for NOS1 (11/14 (79%) vs 1/6 (17%); p=0.018) and NOS3 (8/14 (57%) vs 0/6 (0%); p=0.042), but not for NOS2 (6/14 (43%) vs 4/6 (67%); p=0.63)., Conclusion: Haemorrhoids have significantly higher protein levels of NOS1 and NOS3 than rectal tissue. The vascular endothelium of haemorrhoids also has significantly higher positive immunoreactivity of NOS1 and NOS3 than rectal tissue suggesting that blood vessels in haemorrhoids are exposed to higher NO concentrations than those of rectal tissue. Since haemorrhoids exhibit marked vascular dilatation and present with bleeding or swelling, a reduction in NOS - by applying NOS inhibitors - may potentially improve the symptoms of haemorrhoids., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Purpose: This study aimed to investigate the complications and recurrence rates of the different surgical procedures implemented in recent years for the treatment of grade III and IV hemorrhoids using a network meta-analysis approach., Methods: A systematic literature search was conducted for randomized clinical trials (RCTs) published from January 2013 to August 2018, via PubMed, Embase, the Cochrane Library, and Web of Science. Data related to anal stenosis, fecal incontinence, hemorrhoids thrombosis, and recurrence rates were extracted from the included studies, which were selected based on associations with surgical procedures for grade III and IV hemorrhoids. A network meta-analysis was conducted by using the automated software Aggregate Data Drug Information System (ADDIS) 1.16.8 to evaluate and rank the safety and efficacy of the different surgical methods., Results: Twenty-one studies with 2799 participants involving nine surgical procedures for grade III and IV hemorrhoids were ultimately analyzed. Transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidectomy (SH) exhibited fewer anal stenosis than open hemorrhoidectomy (OH) and Harmonic scalpel (Harmonic). SH presented the highest fecal incontinence rates. OH and Harmonic presented lower hemorrhoids thrombosis than SH and THD. Importantly, SH and THD exhibited the highest recurrence rates, when compared with the other hemorrhoidectomy surgical procedures., Conclusions: In summary, THD and SH were found to be associated with more complications and higher recurrence rates. In addition, the use of OH treatments resulted in less hemorrhoids thrombosis rate but higher recurrence rate. The use of Harmonic resulted in higher anal stenosis rate but lower recurrence rate.

Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visits annually. The etiology of hemorrhoids is speculative. A low-fiber diet and constipation have historically been thought to increase the risk for hemorrhoids, but not proven. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. Research has found that these symptoms were equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber where the results have been inconsistent. A number of office-based interventions such as rubber band ligation and infrared coagulation are widely used and economically favorable for practitioners. Surgical procedures are effective at eliminating hemorrhoids but may be painful. Given the burden of disease and numerous gaps in our understanding, the time has come for targeted research to understand the cause, symptoms, and best treatment for patients with symptomatic hemorrhoids., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: With high incidence of haemorrhoidal disease and significant complication rates of traditional haemorrhoidectomy procedures, transanal haemorrhoidal artery ligation and mucopexy (THD) emerges as a minimally invasive procedure with superior results. However, it is crucial that effectiveness of results and patient satisfaction be gauged based on post-operative experience, symptomology and recurrence., Aim: Our aim is to provide a long-term analysis of efficacy and patient's satisfaction for the procedure, for the largest patient population, in correlation to presenting symptoms and degree of haemorrhoids., Method: A prospective study was conducted for all the patients (324) that underwent THD between 2011 and 2016 in Naas General Hospital. The assessment was done for postoperative complications, symptoms pre- and postoperatively and patients' satisfaction rating. Clinical follow-up was done after 6 weeks and long-term follow-up by standardized questionnaire filled by telephonic clinic., Results: Of the 324 patients who underwent surgery, 256 (79.0%) participated in the study. There were 119 (46.5%) males and 137 (53.5%) females. The average age of patients was 48.40 years (17-82). Two hundred and fifteen (84.0%) patients had no recurrence. Forty-one (16.0%) had recurrence requiring further treatment. There was statistically significant higher recurrence in patients with grade 3 and 4 haemorrhoids and per-rectal bleeding (p < 0.05) while there was no statistically significant recurrence for age, gender, sedentary lifestyle and constipation/pruritus. Two hundred and twenty-four (87.5%) patients were completely satisfied from the procedure and highly recommend the procedure., Conclusion: THD is a comparably pain-free procedure with improved results that prides in higher long-term satisfaction, minimal recurrence and fewer complications, in comparison to other surgical modalities.

Vein segmentation is a vascular remodeling process mainly studied in experimental conditions and linked to hemodynamic factors, with clinical implications. The aim of this work is to assess the morphologic characteristics, associated findings, and mechanisms that participate in vein segmentation in humans. To this end, we examined 156 surgically obtained cases of hemorrhoidal disease. Segmentation occurred in 65 and was most prominent in 15, which were selected for serial sections, immunohistochemistry, and immunofluorescence procedures. The dilated veins showed differently sized spaces, separated by thin septa. Findings associated with vein segmentation were: (a) vascular channels formed from the vein intima endothelial cells (ECs) and located in the vein wall and/or intraluminal fibrin, (b) vascular loops formed by interconnected vascular channels (venous-venous connections), which encircled vein wall components or fibrin and formed folds/pillars/papillae (FPPs; the encircling ECs formed the FPP cover and the encircled components formed the core), and (c) FPP splitting, remodeling, alignment, and fusion, originating septa. Thrombosis was observed in some nonsegmented veins, while the segmented veins only occasionally contained thrombi. Dense microvasculature was also present in the interstitium and around veins. In conclusion, the findings suggest that hemorrhoidal vein segmentation is an adaptive process in which a piecemeal angiogenic mechanism participates, predominantly by intussusception, giving rise to intravascular FPPs, followed by linear rearrangement, remodeling and fusion of FPPs, and septa formation. Identification of other markers, as well as the molecular bases, hemodynamic relevance, and possible therapeutic implications of vein segmentation in dilated hemorrhoidal veins require further studies., (© 2018 S. Karger AG, Basel.)

Anorectal disorders are very common among a wide population of patients. Because patients may be embarrassed about the anatomic location of their symptoms, they may present to care late in the course of their illness. Care should be taken to validate patient concerns and normalize fears. This article discusses the diagnoses and management of common anorectal disorders among patients presenting to a primary care physician., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: We aimed to investigate the MR imaging findings of patients with hematologic malignancies who have symptoms suggesting perianal infection and to demonstrate the importance of imaging., Subjects and Methods: The study included 36 patients with hematologic malignancies who underwent anorectal MR imaging in our department between September 2011-May 2016. Two radiologists experienced in abdominal radiology viewed the MR images in consensus. Abscesses, fistulous or sinus tracts, signal alterations and contrast enhancement in keeping with an inflammation and edema in the perianal region were recorded., Results: Perianal abscess was found in 16 of the 36 patients. In 10 of these 16 patients there was also extensive inflammatory signal alterations in perianal and/or perineal soft tissues. In six of the 36 patients perianal fistula was detected. A sinus tract was seen at the level of subcutaneous external anal sphincter in one patient. Inflammatory signal alterations in the surrounding soft tissues were present in three of these seven patients. There were abscesses in labium majus in two patients and in one patient there were perineal abscesses with accompanying inflammatory signal alterations. In six of the 36 patients no abscess or fistula/sinus tract was seen. There were only inflammatory signal alterations with contrast enhancement in perianal or subcutaneous tissues. In two patients presenting with perianal pain and hemorrhoids, minimal inflammatory changes were detected on MR images. There were two patients with normal MR imaging findings., Conclusion: As digital examination of the anorectum and rectoscopy are avoided in neutropenic patients, MR imaging, which clearly demonstrates the perianal pathology should be preferential., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Over the last decade, many studies were performed regarding treatment options for hemorrhoidal disease. Randomised controlled trials (RCTs) should have well-defined primary and secondary outcomes. However, the reported outcome measures are numerous and diverse. The heterogeneity of outcome definition in clinical trials limits transparency and paves the way for bias. The development of a core outcome set (COS) helps minimizing this problem. A COS is an agreed minimum set of outcomes that should be measured and reported in all clinical trials of a specific disease. The aim of this project is to generate a COS regarding the outcome of treatment after hemorrhoidal disease., Methods: A Delphi study will be performed by an international steering group healthcare professionals and patients with the intention to create a standard outcome set for future clinical trials for the treatment of hemorrhoidal disease. First, a literature review will be conducted to establish which outcomes are used in clinical trials for hemorrhoidal disease. Secondly, both healthcare professionals and patients will participate in several consecutive rounds of online questionnaires and a face-to-face meeting to refine the content of the COS., Discussion: Development of a COS for hemorrhoidal disease defines a minimum outcome-reporting standard and will improve the quality of research in the future.

Aim: The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy., Method: In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria., Results: Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021)., Conclusion: The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)

Background: Distal Doppler-guided transanal hemorrhoidal dearterialization with mucopexy (Doppler-guided THD) seems to be associated with better short-term outcomes than conventional hemorrhoidectomy, but there are little data about long-term recurrence. The aim of this study was to compare Doppler-guided THD for grade III-IV hemorrhoids with conventional hemorrhoidectomy with regard to long-term postoperative morbidity and recurrence., Methods: This was a single-center longitudinal and comparative study of a cohort of patients who underwent either distal Doppler-guided THD with low ligation of the hemorrhoidal artery and mucopexy or conventional excisional hemorrhoidectomy (Milligan and Morgan or Ferguson) for grade III and IV hemorrhoids. Short- and long-term postoperative morbidity was recorded. Severity of hemorrhoid symptoms (bleeding, prolapse, manual reduction, discomfort or pain and impact on quality of life) and fecal continence status (Vaizey score) were evaluated before surgery and at minimum of 1 year after surgery., Results: Eighty-three patients were included in the study. Forty-nine patients (59%) underwent Doppler-guided THD, and 34 (41%) patients underwent conventional hemorrhoidectomy. The 30-day postoperative surgical morbidity was 26.5% in the Doppler-guided THD group and 8.82% in the conventional hemorrhoidectomy group (p = 0.085). No significant differences between the groups were observed in terms of persistence of bleeding, prolapse, need for manual reduction in prolapse and pain. One (2%) patient in the THD group and 2 (5.4%) patients in the conventional hemorrhoidectomy group needed further surgical procedures. Minor fecal incontinence occurred only after conventional hemorrhoidectomy in 2 (5.4%) patients., Conclusions: Our results showed that Doppler-guided THD is not inferior to conventional excisional hemorrhoidectomy for advanced hemorrhoidal disease in terms of postoperative complications and long-term recurrence of symptoms.

Background and Purpose: Haemorrhoids is a common anorectal condition affecting millions worldwide. We have studied the effect of endothelin-1 (ET-1) and the role of endothelin ET A and ET B receptors in haemorrhoid tissue., Experimental Approach: Protein expression of ET-1, ET A and ET B receptors were compared between haemorrhoids and normal rectal submucosa using Western blot analysis, with the localization of proteins determined by autoradiography and immunohistochemistry. Effects of ET-1 and sarafotoxin 6a on human colonic and rectal arteries and veins was assessed by wire myography and the involvement of receptor subtypes established by selective antagonists., Key Results: Dense binding of [ 125 I]-ET-1 to haemorrhoidal sections was reduced by selective receptor antagonists. A higher density of ET B than ET A receptors was found in haemorrhoidal, than in control rectal tissue and confirmed by Western blot analysis. ET A and ET B receptors were localized to smooth muscle of haemorrhoidal arteries and veins, with ET B receptors on the endothelium. Human colonic and rectal arteries and veins were similarly sensitive to ET-1 and affected by the ET A selective antagonist, but sarafotoxin S6a-induced contractions were more pronounced in veins and antagonized by a selective ET B receptor antagonist., Conclusions and Implications: ET A and ET B receptors are present in human haemorrhoids with ET B receptors predominating. ET A receptors are activated by ET-1 to mediate a contraction in arteries and veins, but the latter are selectively activated by sarafotoxin S6a - a response that involves ET B receptors at low concentrations. Selective ET B agonists may have therapeutic potential to reduce congestion of the haemorrhoidal venous sinusoids., (© 2017 The British Pharmacological Society.)

The treatment results in patients, suffering chronic hemorrhoidal disease stages III- IV, in accordance to the elaborated method of hemorrhoidectomy, using radio-wave scalpel «Surgitron TM» with further welding of vascular pedicle, applying high-frequency electrocoagulator ЕК-301М1, are presented. In the patients, оperated on in accordance to the method proposed, the intraoperative complications rate and the blood loss severity were essentially lesser than in a comparison group. Owing an adequate level of surgical skills, the operative treatment method elaborated guarantees the reduction of early and late postoperative morbidity, rapid coming back to routine way of living postoperatively.

Background Existing nonsurgical procedures for the treatment of grade I and II internal hemorrhoids are often painful, technically demanding, and often necessitate multiple applications. This study prospectively assessed the safety and efficacy of the HET Bipolar System, a novel minimally invasive device, in the treatment of symptomatic grade I and II internal hemorrhoids. Methods Patients with symptomatic grade I or II internal hemorrhoids despite medical management underwent hemorrhoidal ligation with the HET Bipolar System. Endpoints included resolution or improvement of hemorrhoidal bleeding and/or prolapse from baseline, recurrent or refractory symptoms, and pain. Results Twenty patients were treated with the HET Bipolar System. Two were lost to follow-up. Refractory or recurrent bleeding was present in 8 of 18 (44.4%), 4 of 11 (36.4%), and 4 of 8 (50.0%) patients, and prolapse was reported by 1 of 18 (5.6%), 4 of 11 (36.4%), and 1/7 (14.3%) of patients at 1, 3, and 6 months, respectively. Bleeding improved from baseline in 88.2%, 81.8%, and 87.5% of patients, and resolution of baseline prolapse was seen in 11 of 11 (100%), 4 of 7 (57.1%), and 5 of 5 (100%) patients at the same intervals. Thirteen of 18 (72.2%) patients did not require additional treatment for their symptoms. Conclusions The HET Bipolar System is safe and easy to use with short-term effectiveness comparable to that of currently used techniques for the treatment of symptomatic grade I and II internal hemorrhoids. It may be an effective alternative to rubber band ligation in patients with larger internal hemorrhoids and those with hemorrhoids close to the dentate line in which banding may produce debilitating pain., (© The Author(s) 2016.)

Ethnopharmacological Relevance: Amorphophallus paeoniifolius (Dennst.) Nicolson (Family- Araceae) is a crop of south East Asian origin. In India, its tuber is widely used in ethnomedicinal practices by different tribes for the treatment of piles (hemorrhoids)., Aim: The present study evaluated the effect of methanolic and aqueous extract of Amorphophallus paeoniifolius tuber on croton oil induced hemorrhoids in rats., Materials and Methods: The methanolic extract was standardized with the major phenolic compound, betulinic acid, by HPLC. The hemorrhoids were induced by applying 6% croton oil preparation in the ano-rectal region. Rats were orally administered methanolic and aqueous extract at doses of 250 and 500mg/kg, each for 7 days. Pilex (200mg/kg) was used as reference anti-hemorrhoidal drug. Hemorrhoids were assessed on eighth day by measuring hemorrhoidal and biochemical parameters along with histology of ano-rectal tissue., Results: Croton oil application caused induction of hemorrhoids as indicated by significant (p<0.001) increase in plasma exudation of Evans blue in ano-rectal tissue, macroscopic severity score and ano-rectal coefficient as compared to normal rats. It significantly (p<0.001) elevated lactate dehydrogenase and cytokines (TNF-α and IL-6) levels in serum and increased myeloperoxidase activity and lipid peroxidation in ano-rectal tissue along with marked histological damage as compared to normal rats. Treatment with tuber extracts and pilex significantly (p<0.05-p<0.001) ameliorated Evans blue exudation, hemorrhoidal parameters and other biochemical parameters with attenuation of tissue damage compared to hemorrhoid control rats. The results indicate that tuber extracts exhibited curative action on hemorrhoids. The aqueous extract showed more pronounced effect than methanolic extract. The effects may be attributed to anti-inflammatory and antioxidant properties., Conclusion: Results indicate that tuber of Amorphophallus paeoniifolius exhibited curative action on hemorrhoids through anti-inflammatory and antioxidant properties. The study validates the ethnomedicinal use of tuber in hemorrhoids and implicates its therapeutic potential as an anti-hemorrhoidal agent., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The lower rectum close to the dentate line has distinct characteristics, making endoscopic submucosal dissection (ESD) of tumors challenging. We assessed clinical outcomes of ESD for such patients with hemorrhoids., Methods: Sixty-four patients (mean age, 68 years) underwent ESD for anorectal tumors close to the dentate line. We divided patients into those with (Group A, 45 patients) and without hemorrhoids (Group B, 19 patients). We examined en bloc and histological en bloc resection rates, procedure time, complication rates, and postoperative prognosis after ESD., Results: The mean tumor size was 43 mm. Histologic diagnoses were adenoma (42 %, 27/64), carcinoma in situ (44 %, 28/64), and T1 carcinoma (14 %, 9/64). There was no significant difference in en bloc resection (93 %, 42/45 vs. 95 %, 18/19) or postoperative bleeding rates (16 %, 7/45 vs. 11 %, 2/19) between Groups A and B, respectively. The mean procedural durations were 120 and 124 min, respectively, in Groups A and B. No perforations occurred. There was no significant difference in postoperative anal pain rate between Groups A (18 %, 8/45) and B (16 %, 3/19), and it resolved within a few days in all cases. There was one case of stricture in Group B. Two patients with T1 carcinoma underwent additional surgery, one underwent chemotherapy, and five had no additional treatment. No recurrence occurred during the follow-up period of 38 months., Conclusions: ESD is safe and effective for anorectal tumors close to the dentate line in patients with hemorrhoids.

Symptomatic hemorhoidal disease is a serious issue affecting the quality of life. The multiplicity of current interventional procedures reflects the failure of covering all pathological aspects, thus justifying the quest for other operative solutions. Any new operative procedure is challenged by the need for broad applicability and less invasive attributes and should fit inside the frame of reasonable costs, fair efficacy, low morbidity and recurrence rate based on a procedural technique that is simple enough, reproducible and easy-tolearn. Aiming to achieve these goals we conceived a procedural variant of hemohrhoidopexy fit for outpatient surgery, a technique that does not require sophisticated/costly medical equipment or disposables and is less invasive. The operative indication concerned 2nd, 3rd and 4th grade hemorrhoids. The surgical indication was represented by 2nd, 3rd and 4th grade hemorrhoids. The needed anesthesia is regional (caudal spinal anesthesia), which qualifies this procedure for private medical services. Prolapse reduction is followed by transmucosal suturing using two rows of slowly absorbable half-step staggered en-X stitches placed just above the dentate line. Preliminary results are encouraging both as therapeutic success rate and legerity of postoperative consequences. This hemorrhoidopexy is a simple and broadly applicable technique, causing mild pain, low morbidity and good efficacy, preferable to other techniques used to treat 3rd grade and selected 4th grade hemorrhoids., (Celsius.)

The identification of statistical SNP-SNP interactions may help explain the genetic etiology of many human diseases, but exhaustive genome-wide searches for these interactions have been difficult, due to a lack of power in most datasets. We aimed to use data from the Resource for Genetic Epidemiology Research on Adult Health and Aging (GERA) study to search for SNP-SNP interactions associated with 10 common diseases. FastEpistasis and BOOST were used to evaluate all pairwise interactions among approximately N = 300,000 single nucleotide polymorphisms (SNPs) with minor allele frequency (MAF) ≥ 0.15, for the dichotomous outcomes of allergic rhinitis, asthma, cardiac disease, depression, dermatophytosis, type 2 diabetes, dyslipidemia, hemorrhoids, hypertensive disease, and osteoarthritis. A total of N = 45,171 subjects were included after quality control steps were applied. These data were divided into discovery and replication subsets; the discovery subset had > 80% power, under selected models, to detect genome-wide significant interactions (P < 10(-12)). Interactions were also evaluated for enrichment in particular SNP features, including functionality, prior disease relevancy, and marginal effects. No interaction in any disease was significant in both the discovery and replication subsets. Enrichment analysis suggested that, for some outcomes, interactions involving SNPs with marginal effects were more likely to be nominally replicated, compared to interactions without marginal effects. If SNP-SNP interactions play a role in the etiology of the studied conditions, they likely have weak effect sizes, involve lower-frequency variants, and/or involve complex models of interaction that are not captured well by the methods that were utilized., (Copyright © 2016 Murk and DeWan.)

Background: Hemorrhoidal disease is a common proctologic disorder. The HemorPex System(®) (HPS) (Angiologica, S. Martino Siccomario PV, Italy) is an innovative surgical technique based on muco-hemorrhoidopexy without Doppler guidance. The aim of this study was to evaluate the efficacy of HPS in on the treatment of grade II and III hemorrhoids., Methods: One hundred patients with grade II and III hemorrhoidal disease were included in the study and operated on using HPS without Doppler guidance. The procedure consists of a mucopexy carried out by means of a dedicated rotating anoscope in the 6 relatively constant positions of the terminal branches of the superior hemorrhoidal artery. A direct follow-up was carried out on 100 patients for up to 3 months. A late analysis (>12 months postoperatively) was conducted by telephone interview. At follow-up the following parameters were considered: pain, bleeding, prolapse, difficulties with hygiene and patient satisfaction with treatment., Results: Operative time was 16 ± 5 min. Three-month follow-up showed significant improvement of symptoms: pain was present in 10 (10 %) patients versus 45 (45 %) preoperatively; bleeding in 13 (13 %) of patients versus 57 (57 %) preoperatively; prolapse in 13 (13 %) of patients versus 45 (45 %) preoperatively and difficulties with hygiene in 1 (1 %) versus 24 (24 %) preoperatively (all p < 0.05). At longer follow-up which was available in 67 patients, 5 patients (7.5 %) had recurrence and were reoperated on at 8, 10, 24, 26 and 36 months, respectively after the first procedure. As regards patient satisfaction, complete satisfaction was reported by 95/100 patients (95 %) at 3 months, 62/67 (92.5 %) at 12 months and 8/56 (85.7 %) at 24 months; partial satisfaction was reported by 3/100 patients (3 %) with intermittent bleeding at 3 months, 3/67 (4.4 %) patients at 12 months and 6/56 (10.7 %) patients at 24 months, all with either intermittent bleeding or prolapse. Dissatisfaction with the procedure was reported by in 1/100 (1 %) patient at 3 months, 2/67 (2.9 %) at 12 months and 2/56 (3.6 %) at 24 months including patients who underwent reintervention., Conclusions: HPS can be used in the treatment of grade II and III hemorrhoidal disease. Our results show that this simple technique may be an effective but due to the important limitations of this study (loss to follow-up, non-comparative study) further studies are required.

Purpose: To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR., Methods: All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan-Meier estimates were calculated for recurrences., Results: A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6-30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2-58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0-53.9) for ERP recurrence and 24.4 % (95 % CI 9.1-39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates., Conclusion: High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Background: Association of Mycobacterium avium subspecies paratuberculosis (MAP) and Crohn's disease (CD) has been controversial due to contradictory reports. Therefore, we determined the prevalence of MAP in patients with CD and intestinal tuberculosis (ITB) and its association with clinical course., Methodology: Blood and intestinal biopsies were taken from 69 CD, 32 ITB patients and 41 patients with haemorrhoidal bleed who served as controls. qPCR targeting of MAP-specific IS900 gene was used to detect the presence of MAP DNA. qPCR results were further validated by sequencing. Immunohistochemistry (IHC) was used to detect the presence of MAP antigen in biopsy specimens. CD and ITB patients were followed-up for disease course and response to therapy., Principal Findings: The frequency of MAP-specific DNA in biopsies by qPCR was significantly higher in CD patients (23.2%, p = 0.03) as compared to controls (7.3%). No significant difference in intestinal MAP presence was observed between ITB patients (12.5%, p = 0.6) and controls (7.3%). MAP presence in blood of CD patients was 10.1% as compared to 4.9% in controls while no patients with ITB were found to be positive (p = 0.1). Using IHC for detection of MAP antigen, the prevalence of MAP in CD was 2.9%, 12.5% in ITB patients and 2.4% in controls. However, long-term follow-up of the patients revealed no significant associations between clinical characteristics and treatment outcomes with MAP positivity., Conclusion: We report significantly high prevalence of MAP in intestinal biopsies of CD patients. However, the presence of MAP does not affect the disease course and treatment outcomes in either CD or ITB patients.

Introduction: An association between hemorrhoidal disease and matrix metalloproteinases (MMPs) has been described previously. MMPs regulate extracellular structural proteins and tissue remodeling. Neutrophil gelatinase-associated lipocalin (NGAL) is involved in the regulation of MMP activity. The aim of this work was to study the relationship between tissue immunoreactive levels of MMPs and NGAL and different stages of hemorrhoids., Methods: In a multicenter, open-label, prospective study, the population under investigation consisted of 2 groups: group I (with symptomatic hemorrhoids; Goligher grade I-IV) and group II (healthy volunteers)., Results: We enrolled 97 patients with hemorrhoids: 21 with grade I hemorrhoids, 37 with grade II, 14 with grade III, and 25 with grade IV. Finally, 90 healthy volunteers (53 males and 37 females; age range, 19-70 years; median, 56) were enrolled in group II. Enzyme-linked immunosorbent assay and Western blot analysis revealed greater levels of immunoreactive MMPs and NGAL in all patients with hemorrhoids. We recorded significantly greater levels of MMP-1 and MMP-3 in grade I and II patients compared with control, and greater levels of MMP-3, MMP-7, MMP-8, and MMP-9 in grade III compared with grade II. MMP-9 and NGAL were particularly increased in patients with grade IV especially in case of thrombosed hemorrhoids., Conclusion: These results provide potentially important insights into the understanding of the natural history of hemorrhoids. MMPs and NGAL play a role in development of disease and may represent molecular markers for the complications such as hemorrhoidal thrombosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Transanal haemorrhoidal dearterialization (THD) is increasingly perceived as an effective and better tolerated alternative to excisional haemorrhoidectomy. The aim of this study was to evaluate outcomes and the patient experience of THD in an Australian population with grade III or IV haemorrhoids., Methods: A retrospective review of prospectively maintained database on patients who had undergone THD over a 3-year period was performed. Data were collected on demographics, operative data, complications, recurrences and readmissions, postoperative pain and further interventions. Patient perceptions and satisfaction with the procedure were assessed with a telephone survey., Results: A total of 85 patients with a mean age of 55 (±14) years with grade III (85%) or grade IV (15%) haemorrhoids underwent THD. Indications for surgery were predominantly bleeding (87%) and prolapse (41%). Median outpatients follow-up was 42 days and median telephone follow-up was 802 days. Median operating time was 25 min (±12). Twenty-four per cent of patients suffered complications, including postoperative bleeding (7%), constipation (7%), local sepsis (6%), anal fissure (5%) and temporary incontinence (2%). Severe postoperative pain occurred in 16% of the patients. The symptom recurrence rate was 19% and reintervention rate was 14%. About 98.8% of patients reported good or excellent overall satisfaction with the procedure., Conclusion: THD is a relatively new technique for the treatment of haemorrhoids, which is increasingly being used as an alternative to excisional haemorrhoidectomy. This study shows that patients' satisfaction with THD is high despite a moderate complication and recurrence rate and significant incidence of postoperative pain., (© 2014 Royal Australasian College of Surgeons.)

Aim: To compare two methods of hemorrhoid treatment., Material and Methods: This prospective study included 240 patients with hemorrhoids stage III-IVA. Stages III and IVA were diagnosed in 156 (65%) and 84 (35%) patients respectively. Randomization was performed using envelopes method in one to one distribution. In group 1 (n=120) Doppler-assisted dearterialization of internal hemorrhoids with mucopexy was performed (DDM), in group 2 (n=120) - hemorrhoidectomy using harmonic scalpel (HE)., Results: Duration of surgery was 17.9±6.1 and 34.5±10.1 minutes in DDM and HE groups respectively (p<0.01). Postoperative pain severity was higher in group 2 (4.8 compared with 2.5 scores of the first group (p<0.01). Narcotic analgesics were used less often in DDM group (1.3 doses compared with 6.1 doses in HE group (p<0.01). Disability period was 14.4±5.2 and 30.3±5.4 days in both groups respectively (p<0.01). Immediate postoperative complications occurred in 9 (7.5%) and 19 (15.8%) patients of DDM and HE groups respectively. Recurrent prolapse of internal hemorrhoids was diagnosed in 2 (1.7%) patients of the 1st group in terms of up to 45 days., Conclusion: DDM is reliable minimally invasive method of hemorrhoids stage III-IVA treatment and has similar efficacy with HE. DDM reduces postoperative pain severity, hospital stay and disability period.

Background: Many researchers studied human Papillomavirus infection in the anal area supposing it represents a risk factor for precursor lesions of anal cancer., Aim: To study the association between histological findings suggestive of injury by the virus in hemorrhoidectomy specimens., Method: Prevalence study was carried out based on histopathological analysis of hemorrhoidectomy specimens to find viral cytopathic effects. These findings were compared with anal condyloma acuminata that had no relationship with hemorrhoidectomy for microscopic comparison., Results: Of the 91 hemorroidectomies analyzed, eight had findings suggestive of viral cytopathic effects, with the presence of irregular acanthosis in 63%, koilocytes in 50% and other indirect viral cytopathic effects, such as hyperkeratosis (38%), parakeratosis (25% ) and papillomatosis (13%)., Conclusion: This study was unable to conclude that there is an association between these two pathologic entities.

The present study investigated the role of epidermal stem cell-expressed microRNA let-7b in the pathogenesis of hypertrophied anal papillae. Hypertrophied anal papillae were examined for the presence of epidermal stem cells. Epidermal stem cells were identified using flow cytometry and immunofluorescent staining for the cell surface markers, integrin α6 and integrin β1 subunits. Expression levels of microRNA let‑7b in α6+/β1+and α6‑/β1‑cells were compared using reverse transcription‑quantitative polymerase chain reaction and northern blotting. Lentivirus‑mediated expression of microRNA let‑7b in epidermal stem cells was utilized in order to study the effects of this microRNA on the cell cycle proteins, cyclin D1 (CCND1) and cyclin‑dependent kinase 4 (CDK4). MicroRNA let‑7b‑overexpressing cells were examined using flow cytometry, in order to determine the effects of the microRNA on cell cycle progression. α6+/β1+epidermal stem cells were identified in hypertrophic anal papillae. Following isolation and enrichment of the α6+/β1+population, these cells were found to have a rapid rate of proliferation in vitro. The expression of cell cycle‑related proteins was elevated in this population, compared with that in α6‑/β1‑cells. The expression of microRNA let‑7b in α6+/β1+epidermal stem cells was significantly lower than that in α6‑/β1‑cells. Two microRNA let‑7b target genes, CCND1 and CDK4, were found to be upregulated in α6+/β1+cells. When the exogenous precursor, microRNA let‑7, was overexpressed in α6+/β1+ epidermal stem cells, the cell proliferation rate was significantly lower than that in cells expressing microRNA let‑7 containing a mutated seed sequence. The addition of exogenous microRNA let‑7 resulted in an increased expression level of mature microRNA let‑7b, while the expression of CCND1 and CDK4 was reduced. Epidermal stem cells transfected with microRNA let‑7b were arrested in the G2/M phase and the percentage of cells in S‑phase was significantly reduced. In conclusion, let‑7b expression results in upregulation of the cell cycle-related proteins, CCND1 and CDK4, resulting in the excessive proliferation that leads to the formation of hypertrophic anal papillae.

The results of treatment of 182 patients, suffering an acute thrombosis of hemorrhoidal nodes of various severity, were studied. In 93 (51.1%) patients (main group) an active surgical tactics was applied. There were conducted urgent, early and postponed operations. In 89 (48.9%) patients (control group) a conservative-expectant tactic was applied. The patients were operated on in terms of 9 - 10 days after admission to hospital. The terms of operation and the method of hemorrhoidectomy were choosed without taking into account the disease severity. Complications in the main group have occurred in 27 (29%) patients, their stationary treatment have lasted 7 - 11 days. In a control group complications were revealed in 27 (30.3%) patients, their stationary stay have lasted from 9 to 28 days.

The results of treatment of 50 patients, suffering postoperative stricture of anal channell (SACH), who were treated in Proctology Department of Ivano-Frankivskiy Rural Clinical Hospital in 2006-2014 yrs, were analyzed. After conduction of hemorrhoidectomy in accordance to Milligan-Morgan method for chronic hemorrhoids grades III-IV a SACH have occurred in 46 (92%) patients, excision of a chronic anal fissura was performed in 3 (6%) and excision of perianal pointed condylomas--in 1 patient. In 2006-2007 yrs 11 (22%) patients were operated in accordance to approaches, which were conventional at that time (comparison group). In 2008 - 2014 yrs 39 (78%) patients were admitted to hospital (main group), in whom new approaches for diagnosis, conservative and surgical treatment were applied, 30 (76.9%) of them were operated. The proposed method on isolated roentgen contrast investigation of anal channell have permitted to determine objectively a form, diameter and grade of the anal channel stricture, and it may be applied as a screening procedure, as additional objective criterion while choosing a surgical tactic. Application of the improved operative technique for SACH have permitted to lower its occurrence rate from 45.4 to 6.7%.

Background: The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45-65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids., Materials and Methods: A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson's trichrome, CD34, and smooth muscle actin., Results: The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease., Conclusion: MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.

Aim: One major obstacle in assessing the efficacy of treatment of haemorrhoids and the comparison of trials has been the lack of a standardized, validated symptom severity score. This study aimed to develop an objective, validated symptom-based score of severity for haemorrhoids that can be used to compare treatments, monitor disease and assist in surgical decisions., Method: A symptom and quality-of-life questionnaire was developed from the literature in conjunction with expert surgical opinion. The questionnaire was circulated to patients with confirmed haemorrhoids. A statistical model was used to derive a weighted score of symptoms most affecting patients' quality of life. Patients who were offered operative treatment were independently judged by specialists to have more severe symptoms, with further validation of the scoring system against treatment., Results: Forty-five patients were included in final validation analysis, of whom 44 (98%) reported multiple symptoms, the most common being rectal bleeding. Patient-reported effects on quality of life were 47.5 ± 36.3 (1-100 visual analogue scale). Calculated symptom severity scores were used to compare patients receiving operative or ambulatory care, with significant difference in the scores (7.7 ± 3.9 vs 2.8 ± 3.5, P = 0.002) and a receiver operating characteristic area under the curve of 0.842., Conclusion: A novel validated score for the assessment of haemorrhoidal disease adopting a standardized global score for symptom severity may have important implications in future for research, assessment and the management of this common pathology., (Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.)

Background: The necessity for routine histopathologic evaluation of hemorrhoidectomy specimens considered free of suspicious areas after careful visual and manual inspection remains controversial., Objective: The purpose of this work was to prospectively study the prevalence of anal intraepithelial neoplasia in macroscopically normal operative specimens., Design and Patients: From October 2005 to September 2010, all hemorrhoidectomy and fissurectomy specimens were sent for routine histopathologic analysis., Setting: This study was conducted at a tertiary referral center., Main Outcome Measures: The primary outcome measured was the histopathologic examination of surgical samples., Results: Among the specimens from 2997 procedures, routine histopathologic evaluation found anal intraepithelial neoplasia in 97 patients (3.2%), despite the fact that visual and manual inspection had determined that the specimens were free of any suspected anal intraepithelial neoplasia or human papillomavirus-related lesion. The pathological diagnoses for these macroscopically normal specimens were AIN1 in 22 (23%) patients, AIN2 in 48 (49%) patients and AIN3 in 27 (28%) patients, making the prevalence of high-grade and low-grade disease 2.5% (anal intraepithelial neoplasia 2/3) and 0.7% (anal intraepithelial neoplasia 1)., Limitations: This study was limited by being a single-center study., Conclusion: This prospective single-center study demonstrated that the prevalence of infraclinical anal intraepithelial neoplasia in macroscopically normal hemorrhoidectomy and fissurectomy specimens is not negligible (3.2% with 2.5% high-grade disease).

Objective: Patients with asymptomatic haemorrhoids are known to be less tolerant of radiation doses lower than known tolerance doses. In the present study, the authors sought to identify the risk factors of acute haemorrhoid aggravation after whole pelvic radiotherapy (WPRT)., Methods: The records of 33 patients with cervical, rectal or prostate cancer with asymptomatic haemorrhoids, which were confirmed by colonoscopy before the start of radiotherapy (RT), were reviewed. Acute anal symptoms, such as anal pain and bleeding, were observed up to 1 month after RT completion. Dosimetric and patient factors were analysed, and subgroup analyses were performed., Results: The median induction dose for acute anal symptoms was 34.1 Gy (range, 28.8-50.4 Gy). Post-operative treatment intent showed more acute anal toxicity of patient factors (p = 0.04). In subgroup analysis, post-operative treatment intent and concurrent chemoradiotherapy were found to be related to acute anal symptoms (p < 0.01). Of the dosimetric factors, V10 tended to be related to acute anal symptoms (p = 0.08)., Conclusion: This study indicates that asymptomatic haemorrhoid may deteriorate after low-dose radiation and that patient factors, such as treatment intent and concurrent chemotherapy, probably influence anal toxicity. In patients with asymptomatic haemorrhoids, WPRT requires careful dosimetry and clinical attention., Advances in Knowledge: The tolerance of anal canal tends to be ignored in patients with pelvic cancer who are undergoing WPRT. However, patients with asymptomatic haemorrhoids may be troubled by low radiation doses, and further studies are required.

Purpose: To establish the necessity of routine histopathologic examination of specimens from hemorrhoids and anal fistula that are diagnosed preoperatively., Methods: We reviewed histopathologic reports from hemorrhoidectomy and anal fistula excision operations performed between 2007 and 2011 in the sixth affiliated hospital of Sun Yat-sen University and Guangdong Province Traditional Chinese Medical Hospital. We evaluated the incidence of unexpected pathologic malignancy and its impact on postoperative management., Results: Among the 10532 patients recruited, 8308 had undergone hemorrhoidectomy and 2224 had undergone excision of an anal fistula. Unexpected pathologic malignancy was discovered in 17 specimens (0.16 %). Overall and subgroup analysis for risk factors of malignant detection revealed unexpected pathologic malignancy was more likely to be found in people over the age of 60 years (OR = 5.516, P = 0.002 overall and OR = 5.442, P = 0.007 for hemorrhoids)., Conclusion: Routine histopathologic examination of specimens from patients undergoing hemorrhoid or anal fistula surgery is of value for identifying unexpected pathologic malignancy. An age older than 60 years may be a remarkable risk factor.

Purpose: To improve the procedures used to treat prolapse and hemorrhoids, novel magnetic rings were invented to use in circumferential mucosectomies to avoid the disadvantages of stapling techniques., Methods: Thirty adult pigs were randomly divided into three groups: Group A (n = 10), which underwent circumferential mucosectomy with novel magnetic rings; Group B (n = 10), which underwent circumferential mucosectomy with conventional magnetic rings and Group C (n = 10), which underwent circumferential mucosectomy with a stapling technique., Results: All pigs underwent the operation successfully, and the mean length of the procedure was similar among the three groups (p > 0.05). There was no bleeding in Group A or Group B, while there was a mean blood loss of 78.32 ± 26.03 ml in Group C (p < 0.01). Three cases of anastomotic stenosis were found in Group C (3/10); two cases were found in Group B (2/10) and no anastomotic stenosis was found in Group A (0/10). The difference between groups A and C was statistically significant (p < 0.05). The cost for the magnetic rings in groups A and B was noticeably lower than that of the stapling techniques in Group C (20.12 ± 3.35 vs. 15.76 ± 2.92 vs. 550.16 ± 29.71 US dollars, p < 0.001). The magnetic rings in groups A and B were spontaneously discharged from the body with the necrotic tissues within 1-2 weeks (8.20 ± 2.73 vs. 9.31 ± 3.62 days, p > 0.05), avoiding the permanent implantation of staples in Group C. The anastomosis site in Group A showed a smoother and more rapid healing process than that in Group B or C., Conclusions: The innovative magnetic rings we developed for circumferential mucosectomies provide a simple and novel surgical procedure for prolapse and hemorrhoids.

Aims and Background: Tolerance of the anal canal tends to be ignored in patients with cervical cancer undergoing whole pelvic radiotherapy. However, patients with hemorrhoids may be troubled with low radiation dose. We tried to analyze the dose-volume statistics of the anal canal in patients undergoing whole pelvic radiotherapy., Methods: The records of 31 patients with cervical cancer who received definite or postoperative radiotherapy at one institution were reviewed. Acute anal symptoms, such as anal pain and bleeding, were evaluated from radiotherapy start to 1 month after radiotherapy completion. Various clinical and dosimetric factors were analyzed to characterize relations with acute anal complications., Results: The anal verge was located an average of 1.2 cm (range -0.6~3.9) below the lower border of the ischial tuberosity and an average of 2.7 cm (range -0.6~5.7) behind the sacral promontory level. The presence of hemorrhoids before radiotherapy was found to be significantly associated with acute radiation-induced anal symptoms (p = 0.001), and the mean induction dose for anal symptoms was 36.9 Gy. No patient without hemorrhoids developed an anal symptom during radiotherapy. Dosimetric analyses of V30 and V40 showed marginal correlations with anal symptoms (p = 0.07)., Conclusions: The present study suggests a relation between acute anal symptoms following radiotherapy and acute hemorrhoid aggravation. Furthermore, the location of the anal verge was found to be variable, and consequently doses administered to the anal canal also varied substantially. Our results caution careful radiation treatment planning for whole pelvic radiotherapy, and that proper clinical management be afforded patients with hemorrhoids during radiotherapy.