Introduction

Anal fissure is a common reason for consultation in proctology. Surgery is proposed in cases of chronic, complicated, or recurrent anal fissure. Fissurectomy can be performed alone (FS) or combined with anoplasty (F+A). The benefit of the latter compared to fissurectomy alone has never been demonstrated. The objective of the study was to compare the effectiveness and tolerance of the two techniques.

Aims & Methods

This was a retrospective descriptive and analytical study conducted over a period of 18 years from January 2005 to August 2023, involving 2070 patients surgically treated for anal fissure. We included all patients without a proctological surgical history who were operated on for a single, non-infected idiopathic anal fissure. We evaluated postoperative pain, early postoperative complications (bleeding, dysuria, constipation, superinfection), and healing time. Statistical analysis was performed using SPSS 20.0 software. Qualitative variables were compared using the Chi-square test. Predictive factors for healing were identified using a binary logistic regression model in univariate and multivariate analysis.

Results

The overall prevalence of anal fissures compared to other reasons for proctology consultation was 55.9%. The median age of the patients was 40 [21-69], with a female-to-male ratio of 0.85. The anal fissure was posterior in 1493 (72.1%) patients and anterior in 577 (27.9%) patients. Other proctological pathologies (anal fistula, hemorrhoidal disease) were associated in 358 cases (17.3%). FS was performed in 1304 patients (62.9%) and F+A in 766 patients (37%). Sphincterotomy was associated in 357 patients (17.24%). The median postoperative follow-up was 2 [1-3.9] months. Continence was respected in all patients. The time to disappearance of postoperative pain was the same for both procedures: 1.1 +/- 0.5 months vs. 1.0 +/- 1.2 months, p=0.51, respectively for FS and F+A. The overall rate of early complications was 5.29%, with them being more frequent in cases of F+A: 7.1% vs. 2.3%, p=0.031. The healing rate was similar in both procedures: 92.9% vs. 97.7%, p=0.31. The median healing time was shorter in patients who underwent F+A: 1.5 +/- 0.2 months vs. 2.8 +/- 0.4 months, p = 0.0003. In multivariate analysis, independent risk factors associated with delayed healing were age ≥ 40 years [OR = 3.1; 95% CI [1.1 to 14.1] p = 0.004) and a history of diabetes [OR 6.5, 95% CI [1.7 to 43.2] p <0.001. The postoperative recurrence rate was similar in both procedures: 2.1% in the case of FS vs. 3.2% in the case of F+A, p=0.1.

Conclusion

Fissurectomy remains an effective procedure in the management of anal fissures. Our study showed that fissurectomy with anoplasty has the advantage of accelerating healing. However, at present, no technique is consensual, hence the importance of multicenter randomized studies evaluating both surgical techniques.

Introduction

"Complex" anal fistulas are characterized by a tract that cannot be laid open by fistulotomy without risking significant incontinence due to the depth of the tract and/or the patient's condition. Over the past 20 years, several techniques known as "sphincter-saving" have been proposed to address this surgical challenge. Among these techniques, FiLaC™ is one of the most recent. It involves closing the fistula tract by coagulation. The aim of our work is to evaluate the results of this technique in terms of healing of anal fistulas through a series of cases.

Aims & Methods

This is a descriptive prospective study conducted between May 2023 and March 2024 involving 14 patients who underwent treatment for anal fistula using the FiLaC™ technique. All patients underwent an initial surgical intervention to identify the fistula tract, place a loose seton, drain any abscess, and/or lay open any diverticula. The type of fistula tract was determined by the proctologist during this first operation. In cases of doubt about the quality of drainage, multi-operated fistula, and/or Crohn's disease, an MRI was performed. The procedure was performed under spinal anesthesia, and all patients received perioperative antibiotic prophylaxis. We used a 1.2 mm diameter radial fiber powered by the Leonardo Duel© diode laser platform. The primary outcome measure was fistula healing, clinically defined by closure of the internal and external openings and absence of pain and discharge.

Results

Fourteen patients were included, with a mean age of 45.1 +/- 2.1 years. Among our patients, 12 (85%) had cryptogenic fistulas, 1 case had a fistula as part of ano-perineal manifestations of Crohn's disease (CD), and one anal fistula was secondary to perianal tuberculosis. The fistula was classified as Parks 1 in 14.2% of cases, Parks 2 in 57.14% of cases, Parks 3 in 14.2% of cases, and Parks 4 in 14.2% of cases. The internal opening was tight in 64.28% of patients and gaping in 35.72%. The mean operative time before laser closure was 2.07. All patients had a seton drain placed. The mean time for drain removal was 124.90 seconds, and the mean delivered energy was 799.88 Joules. No cases of postoperative complications were reported. The mean follow-up was 2.21 months. Healing was achieved in 78.5% of cases, while in 21.5% of patients, closure of the internal and/or external opening was not achieved, and surgical revision was proposed. No cases of recurrence were reported.

Conclusion

The treatment of complex fistulas still presents a challenge: achieving fistula healing while preserving anal continence. Laser coagulation appears as a promising technique that can meet this challenge.

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

After resection of a malignant colorectal polyp, patients may be proposed for surgical treatment or surveillance, depending on the presence of cure criteria.

Aims & Methods

The aim of this study was to compare the detection of metachronous lesions in patients with malignant polyps undergoing surgery versus surveillance.
Retrospective cohort study including patients with endoscopic removal of malignant polyps. Patients were divided into 2 groups, according to the strategy defined in the oncology group consultation: surveillance (group 1) and surgery (group 2). The diagnosis of metachronous lesions during the follow-up period was the main outcome studied. A metachronous lesion was defined as the detection of adenoma/adenocarcinoma, 6 or more months after index colonoscopy.

Results

77 patients were included, 55.8% in group 1, 44.2% in group 2. Mean age was 65.2±10.8 years, 45.5% were women.
In group 1, significantly more patients developed metachronous lesions compared to group 2 (66.7% vs 33.3%, p=0.036). The mean time to diagnosis of metachronous lesion was significantly shorter in group 1 (18.6±2.8 vs 36.0±5.6 months, p=0.004).
In group 1, 32.1% of patients developed metachronous lesions in the same colonic segment as the endoscopic resection of the malignant polyp.
In histological characterization, the two groups did not present statistically significant differences: low-grade dysplasia in 92.9% (group 1) and 85.7% (group 2); high-grade dysplasia in 7.1% (group 1) and 14.3% (group 2), p=0.457. No adenocarcinomas were detected during the follow-up period.

Conclusion

Surgical approach was associated with a lower incidence of metachronous lesions, suggesting that a significant proportion of the risk of metachronous lesion occurs in the segment of the index lesion.

Introduction

The quality of a colonoscopy is heavily reliant on the effectiveness of bowel cleansing, which can impact the diagnostic accuracy and identification of adenomas. Various bowel cleansing products have been suggested, but their comparative effectiveness remains uncertain.

Aims & Methods

This systematic review and network meta-analysis aims to compare the performance of different bowel preparations for colonoscopy. MEDLINE, Embase, Scopus, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing the efficacy of different bowel preparations administered as split or same-day regimen. The primary outcome was cleansing success (CS) defined as a total BBPS score of ≥6. The secondary outcome was ADR.

Results

On network meta-analysis for CS (22 RCTs, 7179 patients, 14 bowel preparations assessed), 2L PEG+simethicone (RR=1.25 [95%CI=1.13-1.37]), 2L PEG+lactulose (RR=1.22 [95%CI=1.10-1.38]) and 1L PEG+ascorbate (ASC) (RR=1.03 [95%CI=1.01-1.06]) were significantly superior to 2L PEG+ASC. Overall, 2L PEG+lactulose resulted as the best product (SUCRA 0.94), followed by 2L PEG+simethicone (SUCRA 0.93), whereas 2L PEG+ASC showed the poorest performance. On network meta-analysis for ADR (17 RCTs, 6639 patients, 11 bowel preparations assessed), only 2L PEG+simethicone (RR=1.60 [95%CI=1.05-2.43]) resulted significantly superior to 2L PEG + ASC.

Conclusion

2L PEG+simethicone, 2L PEG+lactulose, and 1L PEG+ASC seemed to provide high rates of cleansing success, albeit only 2L PEG+simethicone was associated with a significantly higher ADR. Consequently, these products should be preferred for bowel preparation of colonoscopy. Further randomized studies with adequate sample sizes are needed for a more accurate comparison of these products on ADR.

Introduction

Aims & Methods

Results

Conclusion