Introduction

Doppler-guided artery ligation with Mucopexy, or HAL-RAR, is a minimally invasive surgical technique that allows for better postoperative comfort. An anoscope linked with a light source and a doppler probe allows the proctologist to locate the submucosal branches of the superior rectal artery and to ligate them via a transfixing parietal approach. Mucosal pexis is performed afterward : the mucosa of the prolapsed hemorrhoidal pedicles is vertically sutured, consequently leading to a plication of the prolapsed muco-hemorrhoidal tissue and its reposition inside the canal anal. Nevertheless, long-term recurrence rate of internal hemorrhoidal disease after this procedure has been poorly studied. The aim of our study is to evaluate the long-term recurrence rate of hemorrhoidal disease post Doppler-guided artery ligation (HAL-RAR) with Mucopexy in our center

Aims & Methods

The aim of our study is to evaluate the long-term recurrence rate of hemorrhoidal disease post Doppler-guided artery ligation (HAL-RAR) with Mucopexy in our center.
Materials and Methods:
An ambispective observational and analytical study was conducted over a 5-year period, from January 2019 to January 2024. Surgical indications included grade II and III internal hemorrhoids that resisted to medical treatment and small localized non-circumferential grade IV hemorrhoids. Patients with external hemorrhoids, bulky grade IV hemorrhoids or pelvic floor disorders were excluded. All data were analyzed using Jamovi version 2.0.0.0 software. Patient characteristics were described as number and percentage for qualitative items and median (interquartile range [IQR]) or mean (± standard deviation) for quantitative ones. A p value of ≤0.05 was deemed to be significant. Our primary objective was to evaluate the rate of recurrence more than 24 months after surgery. The secondary objectives were to determine the clinical features of relapsing patients.

Results

114 patients were included in this study. The mean age was 46.5 ± 9.6 years. The sex ratio was 6 (16f, 98H). Preoperatively, 69% (n=79) of the patients reported proctalgia, 53% (n=60) post-defecation rectal pain and 58% (n=66) prolapse. We staged the internal hemorrhoidal disease according to the Goligher classification, identifying 32 with grade II hemorrhoids, 61 with grade III hemorrhoids and 21 grade IV hemorrhoids. At the end of a median follow-up of 4 years (7-2), 9 patients (7.9%) presented a recurrence, made in 6 cases of a muco-hemorrhoidal prolapse and in 3 cases of post-defecation rectal bleeding. None of our patients presented with anal stenosis or incontinence during the follow-up period. In our study, there was no statistically significant relationship between the recurrence and the preoperative clinical symptomatology (p=0.21) nor with grade of hemorrhoids (p=0.17). Overall, 94% of the patients included were satisfied with this technique. 4 of the patients who relapsed benefited from Milligan-Morgan hemorrhoidectomy. However, they claimed that they were more satisfied following the HAL-RAR procedure

Conclusion

transanal doppler-guided hemorrhoidal artery ligation with mucopexy (HAL-RAR) is a safe, quick, easy to perform technique and can be considered an effective long-term treatment for internal hemorrhoidal disease.

Introduction

Currently, all screenees of the Dutch colorectal cancer (CRC) screening program with a positive faecal immunochemical test (FIT) undergo face-to-face counselling at an outpatient clinic. In order to reduce the burden for screenees and healthcare systems, we have developed a Digital Intake Tool (DIT) for the Dutch CRC screening population. A web-application that facilitates the entire pre-colonoscopy counselling process digitally, eliminating the need for a physician. In this study we evaluated whether the DIT could replace in-person counselling.

Aims & Methods

A prospective non-inferiority trial was conducted in seven centres, including academic and regional hospitals, and endoscopy centres. All participants received DIT-counselling. The DIT guided participants through the counselling process, which included spoken animated videos for patient education, a medical questionnaire for health assessment, and the collection of pre-procedural informed consent. For screenees in who no additional information was required, colonoscopy was scheduled without an in-person visit. The primary outcome was the proportion of participants achieving adequate bowel preparation, defined as a Boston Bowel reparation Scale (BBPS) score of ≥ 6. BBPS scores were compared to patients that received in-person counselling. To assess whether the DIT could replace the ‘human touch’ of in-person counselling, we evaluated patient-reported outcomes related to anxiety, psychological distress and satisfaction as secondary outcomes.

Results

Between October 2021 and September 2023, 1000 (58.8%) out of 1690 approached patients were included. Median age was 64.0 years with 45% being female. DIT-counselling achieved a BBPS of ≥ 6 in 96.5% of the participants, compared to 97.6% after in-person counselling, demonstrating non-inferiority (-1.1%, 95% CI -2.64 – 0.444, non-inferiority margin -8%). A significant reduction in outpatient visits was established, with only 3.4% requiring face-to-face consultations, and 40.9% of the participants could be scheduled for colonoscopy solely via DIT-counselling. After digital counselling, a significant decrease in distress was reported on a 11-point Likert scale (Z = -6.136 p<0.001). Also anxiety levels, measured by the STAI-6, decreased (Z = -3.210 p =0.001). Nearly all participants (98.9%), were satisfied with the information provided, mean score of 8.5 (SD 1.0) and 88.9% would choose the DIT again, while 5.3% preferred face-to-face counselling.

Conclusion

This study showed that digital counselling can replace in-person counselling for FIT-positive screenees of the CRC screening program. An adequate bowel preparation was achieved in >96% of the participants, meeting the 90% requirement of the CRC screening program. A substantial reduction in in-person outpatient visits was established, and patients reported highly positive experiences after digital counselling. Implementing this home-based approach will decrease the burden for patients and healthcare systems. Patients can receive care at the comfort of their own home at their own time, reducing travel and carbon emissions, while healthcare systems increase their outpatient capacity.

Disclosure

This study received a PPP-allowance provided by Health-Holland, Top Sector Life Sciences & Health, to stimulate public-private partnerships.

Introduction

The treatment of symptomatic hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. This vulnerable group benefits the most from less invasive office-based procedures associated with low bleeding complications, namely polidocanol foam sclerotherapy (PFS).

Aims & Methods

The present study aimed to compare the efficacy and safety of polidocanol foam sclerotherapy (PFS) in the treatment of hemorrhoidal disease (HD) in patients with and without bleeding disorders (BD).
This was a prospective, multicentric, cohort study that enrolled patients with symptomatic internal HD grades I-III with BD (group B) and without BD (group A) following a 18-months period. HD baseline severity was assessed using the Goligher classification, the hemorrhoidal disease bleeding grade (HDBG) and the Sodergren hemorrhoid symptom severity (SHSS) scoring system. Both groups were treated with PFS prepared according to the Tessari´s technique. Patients with congenital BD did not perform prior bleeding prophylaxis and patients with acquired BD due to antithrombotic drugs did not discontinue therapy. The efficacy outcomes included therapeutic success (defined by an improvement of HDBG and SHSS score over baseline) and recurrence of HD (defined by HDBG and SHSS score greater than at the end of the intervention period) during a 12-months follow-up period. The safety outcomes comprised the rate and severity of complications related to PFS.

Results

The study included 228 patients (Group A: 155; Group B: 73). At baseline, the group B presented higher HDBG (p<0.001) and SHSS (p=0.019). The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51±0.74, significantly higher for group B (1.68±0.86 vs 1.43±0.65, p=0.013). A 11.4% complications rate was reported, the majority were mild (96.2%); bleeding complications occurred in 4.8% of the patients. No significant differences were reported between the two groups concerning therapeutic success, recurrence rate, and complications rate.

Conclusion

Patients with BD may present with more symptomatic HD at baseline. Nevertheless, PFS decreased hemorrhoidal bleeding and symptom severity with low incidence of complications in these patients, demonstrating similar effectiveness and safety comparing to patients without BD. Notably, performing PFS did not expose patients with BD to an increased thrombotic risk.

Introduction

Laser therapy is a relatively recent technique that allows the treatment of anal fistulas (FIstula-tract LAser Closure: FilaC®), and anal fissure (Laser anal fissure: LSL) with the FilaC fibre, pilonidal sinuses with the SiLaC® fibre (Sinus Pilonidalis treatment), and haemorrhoids with the Laser Hemorrhoido Plasty fibre (LHP®).

Aims & Methods

Our study aims to report the preliminary results of a prospective bicentric study including all patients treated with laser therapy in two private hospitals.​
​This prospective descriptive study includes 141 patients treated with laser therapy for proctological pathology (anal fistulas, pilonidal sinuses, anal fissures, and hemorrhoids) performed in two proctology units. The majority of these procedures were performed under spinal anesthesia. Data were collected directly from the patients using an evaluation form. We studied their clinical data and the immediate and medium-term postoperative follow-up

Results

141 patients were included. The mean age was 44 years (18-76 years). 78% were male and 22% female (sex ratio = 3.5). The anal fistula was the main indication for laser therapy, with FilaC® performed in 105 patients (74.5%), followed by SiLaC® in 16 patients (11.3%), LHP® in 7 patients (5%) and 4 cases of LSL (2.8%). 9 patients benefited from combined treatment: 5 LHP®+ LSL patients (3.5%), 2 FilaC®+ LSL patients (1.4%), 1 FilaC®+ SiLaC® patient (0.7%), and 1 FilaC®+ LHP® case (0.7%). 79 patients (73.2%) benefited from initial drainage of the fistula with a loose seton for 1 to 5 months before FilaC®, while 29 patients (26.8%) with a short direct extrasphincteric fistula benefited from laser therapy.18 patients were lost to follow-up (12,8%). 104 patients (84,5%), all pathologies combined, progressed well with 19 cases of failure (15,5%) with a follow-up time of 1 to 50 months. Fistulas healed in 74 patients (80%). There were 18 confirmed failures. 15 of these were treated surgically with 4 FilaC. Failure was diagnosed within an average of 6 months and was manifested by persistent leakage with no healing of the external orifice. There were no continence problems after the procedure. 16 patients were lost to follow-up. In patients with LHP, 2 patients (15,4%) experienced early post-operative bleeding requiring surgical suturing. All patients treated with SiLaC® had a favorable outcome. The 4 patients treated for anal fissures were satisfied with the procedure.

Conclusion

Laser proctology is a minimally invasive conservative procedure with significant postoperative pain reduction. In the literature, the success rate of this technique ranges from 65 to 80%. Our hospitals were the first in Morocco to introduce this procedure. Preliminary results from our pilot study showed satisfying healing in 84.5% of patients. However, long-term confirmation is required.

References

1- Adegbola SO, Sahnan K, Tozer P, Warusavitarne J. Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes. Clin Exp Gastroenterol. 2021 Dec 6;14:467-475. doi: 10.2147/CEG.S269464. PMID: 34908858; PMCID: PMC8664604.

Introduction

Colorectal neuroendocrine tumors (NETs) and polyps have similar endoscopic manifestations and are easily misidentified. Due to the low incidence of NETs, it is difficult to obtain adequate images to fit deep-learning models. This study introduced a few-shot learning (FSL) model for the ternary classification of NETs and polyps on endoscopic images.

Aims & Methods

Three classes of endoscopic images (56 serrated lesions and polyps [SLPs], 86 traditional adenomas and 53 NETs) were collected from three datasets. First, three images from each class were randomly selected for Support Set (SS), while others for Query Set (QS). Second, ResNet50 V2 was pretrained based on ImageNet and then on esophageal endoscopic images Third, imaging eigenvectors were extracted based on a dual-pretrained model. Fourth, the Euclidean distances to the nine SS images were calculated for each QS image. Finally, a k-nearest neighbor classifier was used for classification based on Euclidean distances. The proposed FSL model was tested in three rounds.

Results

The performance of the FSL model (macro-area under the curve [AUC], 0.731; macro F1-score, 0.674; Matthews Correlation Coefficient [MCC], 0.526; Kappa, 0.523) was better than that of the traditional ResNet50 V2, junior endoscopist, and senior endoscopist. When identifying NETs, the proposed FSL model achieved the highest accuracy 0.823, sensitivity 0.653, precision 0.673 and F1-score 0.659, whereas the senior endoscopist achieved the highest specificity 0.904.

Conclusion

This study presented a FSL method based on transfer learning and metric learning to distinguish between SLPs, adenoma, and NETs on endoscopic images. This suggests that FSL might be an effective method for computer-aided diagnosis of rare diseases.

Introduction

Gastric adenoma is recognized as a premalignant lesion.¹Much of the literature lumps all adenomas together with different classifications. These are few western reports regarding the prevalence, associated risk factors and outcomes of endoscopic management of different subtypes of gastric adenoma.

Aims & Methods

Aims: The aim of this study is to determine the prevalence, potential predictors, and outcomes of endoscopic management of the different subtypes of gastric adenoma.
Methods: Of 162 consecutive patients who underwent endoscopic resection for gastric lesions between 2017 and 2022 at our center, 79 patients were enrolled. All the hyperplastic polyps (n=37) and subepithelial lesions (n=46) were excluded. The patient clinical characteristics, endoscopic and histopathological features of gastric lesions were retrospectively collected. Patients were divided according to the histological types of gastric adenoma into 4 groups: intestinal group (n= 49), foveolar group (n= 23),pyloric group (n= 6) and oxyntic group (n=1). We statistically compared the clinical and endoscopic features of the three groups. In addition to the analysis of the outcomes of endoscopic resection of gastric adenomas.

Results

Of the 79 patients with a mean follow-up of 2622 months, 51 patients were males (65 %) and 28 patients were females (35%). Forty-nine patients (49/79,62%) had intestinal adenoma, 23 patients (29%) showed foveolar adenoma, 6 patients (8%) developed pyloric adenoma and only 1 patient (1%) had oxyntic adenoma. The mean age was significantly older in the intestinal group (71 ± 13 years vs. 64 ± 16 years vs. 58 ± 18 years, p = 0.03). Intestinal adenomas were significantly associated with family history of gastric adenocarcinoma (14% vs. 4% vs. 0%, p = 0.01) and history of statin intake (39% vs. 26% vs. 0%, p = 0.04).Foveolar adenomas were significantly associated with multiple lesions (≥3 lesions) (p < 0.001) and 0-IIa+IIc Paris classification (6/23, 26%). the size of largest polyp was significantly higher among pyloric group (28 ±15, p= 0.00). Among intestinal group, 33/49 patients (67%) had atrophic gastritis. 82% of the adenomas were resected by ESD with histologically complete resection (R0) in 72/79 patients (91%). Although the difference was not statistically significant (p = 0.4), adenocarcinoma was most frequently encountered among the intestinal adenoma group (17/49, 35%). The post endoscopic resection outcome was comparable among 3 groups with overall recurrence rate (group1:8% vs. group 2:17% vs group 3:17%, P = 0.07) with a comparable mean time to recurrence among three groups (21 ± 17 months vs. 20±17months vs. 14 months, p=0.8). Family history of gastric adenocarcinoma (HR=1.33, p< 0.001) and active helicobacter pylori infection (HR=1.14, p < 0.001) were identified as independent predictors of recurrence after endoscopic resection of different gastric adenoma. Among baseline endoscopic characteristics, polyp size ³ 30mm(HR= 2.04, p< 0.001), more than 3 polyps (HR=1.51, p<0.001), lesser curvature as lesion location (HR=1.72, p< 0.001) and morphology as Paris classification IIc are potential predictors of post resection recurrence. In addition to specimen size ³ 15mm (HR=2.19, p< 0.001) and T1b as lesion histology (HR=2.07, p< 0.001), in the histopathological examination.

Conclusion

The present study clarifies the endoscopic and histopathological characteristics of different gastric adenomas, in addition to the potential predictive factors for each subtype. Potential predictors of recurrence after endoscopic resection emphazie the importance of endoscopic follow up.

References

1. Fujiwara, Y. et al. Diagnosis of borderline adenomas of the stomach by endoscopic mucosal resection. Endoscopy 28, 425–430 (1996).