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Concept: Prolapse

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INTRODUCTION: The elastic ligature is the most used method for the out-patient treatment of haemorrhoids, with excellent results in control of bleeding. However, the recurrences in prolapse vary between 15 and 40%. We propose a new method for applying the elastic ligatures. PATIENTS: A total of 17 patients with grade iii haemorrhoids were chosen for the vertical ligatures (VL). The first elastic band was placed 3 to 4cm from the pectineal line and 1 or 2 more in the root of the haemorrhoid group. Another 34 randomly selected patients were used as a control group. Data collected included, demographic details, number of bands and sessions, pain scale, complications and results. The patients were followed up at week one, week 3, and 3 months and one year after the intervention. RESULTS: A total of 12 males and 5 females, with a median age of 46 years, were treated with VL. The median follow-up was 10 (from 8 to 19) months. A median of 3 sessions and 7 elastic bands were used, with 6 patients having moderate pain that required analgesic treatment. None of the patients needed urgent treatment for pain or bleeding. There was a complete response to bleeding in 15 patients (88.2%) and to prolapse in 14 (82.2%). Two patients required haemorrhoidectomy due to treatment failure. The measurements of therapeutic effect after one year were: number needed to treat (NNT) of 4 (95% CI, 2 to 22), for prolapse, and NNT of 4 (95% CI, 2 a 15), for bleeding. CONCLUSIONS: Elastic ligatures could become a new treatment option for Grade iii haemorrhoids, improving control of bleeding and prolapse.

Concepts: Controlling for a variable, Scientific control, Patient, Pain, Demographics, Prolapse, Hemorrhoid, Rubber band

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BACKGROUND: Haemorrhoids (piles) are a very common condition seen in surgical clinics. After exclusion of more sinister causes of haemorrhoidal symptoms (rectal bleeding, perianal irritation and prolapse), the best option for treatment, depends upon persistence and severity of the symptoms. Minor symptoms often respond to conservative treatment such as dietary fibre and reassurance. For more severe symptoms treatment such as rubber band ligation may be therapeutic and is a very commonly performed procedure in the surgical outpatient setting. Surgery is usually reserved for those who have more severe symptoms, as well as those who do not respond to non-operative therapy; surgical techniques include haemorrhoidectomy and haemorrhoidopexy. More recently, haemorrhoidal artery ligation has been introduced as a minimally invasive, non destructive surgical option. There are substantial data in the literature concerning efficacy and safety of ‘rubber band ligation including multiple comparisons with other interventions, though there are no studies comparing it to haemorrhoidal artery ligation. A recent overview has been carried out by the National Institute for Health and Clinical Excellence which concludes that current evidence shows haemorrhoidal artery ligation to be a safe alternative to haemorrhoidectomy and haemorrhoidopexy though it also highlights the lack of good quality data as evidence for the advantages of the technique. Methods/design The aim of this study is to establish the clinical effectiveness and cost effectiveness of haemorrhoidal artery ligation compared with conventional rubber band ligation in the treatment of people with symptomatic second or third degree (Grade II or Grade III) haemorrhoids. DESIGN: A multi-centre, parallel group randomised controlled trial. Outcomes: The primary outcome is patient-reported symptom recurrence twelve months following the intervention. Secondary outcome measures relate to symptoms, complications, health resource use, health related quality of life and cost effectiveness following the intervention. Participants: 350 patients with grade II or grade III haemorrhoids will be recruited in surgical departments in up to 14 NHS hospitals. Randomisation: A multi-centre, parallel group randomised controlled trial. Block randomisation by centre will be used, with 175 participants randomised to each group. DISCUSSION: The results of the research will help inform future practice for the treatment of grade II and III haemorrhoids. Trial Registration ISRCTN41394716.

Concepts: Clinical trial, Randomized controlled trial, Efficacy, Dietary fiber, Prolapse, Hemorrhoid, Rubber band ligation, Perianal hematoma

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A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery.

Concepts: Surgery, Evaluation methods, Organ transplant, Polypropylene, Laparoscopic surgery, Laparoscopy, Prolapse, Case series

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INTRODUCTION AND HYPOTHESIS: Avulsion of the puborectalis muscle from its bony insertion is common in women presenting with prolapse. We present a simple vaginal technique for levator reconstruction. METHODS: This is a prospective surgical pilot study comprising 17 patients enrolled to undergo levator repair in the context of prolapse surgery. This was performed through a lateral colpotomy at the level of the hymen using a mesh patch for reinforcement. RESULTS: We performed 20 levator repairs in 17 women (three bilateral). There were no intraoperative complications. Recovery was unremarkable in all cases. Results are given for a mean follow-up of 1.3 years. Most (13/17, 76 %) women were satisfied with the outcome. Six patients complained of symptoms of recurrent prolapse, three of de novo dyspareunia, and four of pain related to the repair site on palpation. There were two mesh erosions, one of which healed with oestrogen treatment. Prolapse recurrence beyond the hymen was observed in five patients. The mean hiatal area on Valsalva was reduced from 36.84 cm(2) to 30.71 cm(2) (P = 0.001). CONCLUSIONS: Direct surgical repair of a levator avulsion is feasible at the time of prolapse surgery. However, its effect on prolapse recurrence and hiatal dimensions is relatively disappointing, suggesting that there often is microscopic trauma and functional muscle impairment in addition to the avulsion.

Concepts: Hospital, Surgery, Physician, Anesthesia, Al-Andalus, Muscular system, Prolapse, Levator ani

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BACKGROUND: In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS. METHODS: Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed. RESULTS: The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively. CONCLUSIONS: LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

Concepts: Time, Obesity, Surgery, Body mass index, Pelvis, Rectum, Prolapse, Rectal prolapse

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To explore the effect of menopause and hormone replacement therapy on pelvic organ prolapse and pelvic floor muscle function.

Concepts: Uterus, Hormone, Menopause, Muscle, Pelvis, Pelvic floor, Prolapse, Rectal prolapse

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: Doppler guidance in hemorrhoidal surgery has become more frequent during the past decade. The method is mainly studied in nonrandomized trials. Data from randomized controlled trials are lacking.

Concepts: Randomized controlled trial, Prolapse, Hemorrhoid

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To investigate attitudes toward hysterectomy in women seeking care for pelvic organ prolapse.

Concepts: Uterus, Hysterectomy, Prolapse, Rectal prolapse

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In spite of rapid growth in the use of vaginally placed mesh in pelvic reconstructive surgery, there are few reports on the long-term efficacy and safety of mesh-augmented repairs.

Concepts: Surgery, Reconstructive surgery, Prolapse, Rectal prolapse, Gasterophilus haemorrhoidalis

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Introduction. Longo’s technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse. Materials and methods. We describe the application of “Double PPH Technique” (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse. Results. In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5). Conclusions. Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo’s procedure for hemorrhoidal prolapse.

Concepts: 2008, Bleeding, Visual analogue scale, Fecal incontinence, Staple, Prolapse, Hemorrhoid