‘Distal Doppler‐guided dearterialization’ is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization

Aim Transanal haemorrhoidal dearterialization (THD® Doppler) is a surgical procedure involving Doppler‐guided ligation of haemorrhoidal arteries to reduce arterial flow. With proximal Doppler‐guided dearterialization, arterial ligation is achieved by introducing the proctoscope completely into the anal canal and lower rectum. In the present study, distal Doppler‐guided dearterialization (DDD) is performed in the distal 2 cm of the lower rectum. Immediate and short‐term results were evaluated. Method One hundred patients with bleeding haemorrhoids, with or without muco‐haemorrhoidal prolapse, underwent THD® Doppler procedure, using DDD of the haemorrhoidal arteries 2 cm above the anorectal junction. Mucopexy was performed in patients with haemorrhoidal prolapse. Results The operation time was 20 ± 7 min for dearterialization alone (10 patients), and 30 ± 10 min when mucopexy was added (90 patients). Morbidity included: transient haemorrhoidal thrombosis (two patients); urinary retention (five patients); submucosal abscess (one patient). No patient complained of faecal incontinence. At a median follow‐up of 7.3 (3–17) months, all patients reported an improvement in symptoms. No patients reported bleeding. Conclusion DDD of the haemorrhoidal arteries could be a simplified and more effective method of applying THD.     

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland

Objective To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids. Method In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure. Results During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1–50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety‐seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0–6 days). Two hundred and eighty‐nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6‐week follow‐up, 626 (90.1%) patients were pain free. Five patients required hospital re‐admission for secondary haemorrhage (3), peri‐anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids. Conclusion Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short‐term outcomes. Long‐term follow‐up is required perhaps through a compulsory national register.     

Feasibility case‐controlled study of day‐case haemorrhoidectomy

Introduction: Haemorrhoidectomy is traditionally an inpatient procedure. With many benefits, the day‐surgery arrangement is an attractive alternative. The feasibility of day‐surgery haemorrhoidectomy was explored and the hospital days were calculated in a case controlled design. Methods: A single surgeon’s experience of day‐surgery haemorrhoidectomy between 1 July 1999 and 31 March 2000 was compared with inpatient haemorrhoidectomy during the same period. The operations were performed at United Christian Hospital Department of Surgery, Hong Kong (a government‐funded public hospital). Statistical tests were applied where appropriate. Results: There were 30 day‐surgery and 15 inpatient haemorrhoidectomies. The groups were comparable in terms of age, gender, severity of haemorrhoids, method and duration of haemorrhoidectomy, blood loss, residual haemorrhoids, duration of follow up and unplanned readmission rate. Significantly more day‐patients received general than spinal anaesthesia. Twenty‐six of 30 (87%) patients were successfully discharged after day surgery. Two were admitted for transient fever (< 24 h), one for micturition syncope and one for acute urinary retention. There were four unplanned readmissions after day surgery: one for pain and three for secondary bleeding. All stopped spontaneously. All three unplanned readmissions after inpatient surgery were for secondary bleeding. All stopped spontaneously. Patient stay was significantly shorter for day surgery (1 ± 1 day) than for the inpatient arrangement (4 ± 1.6 days). Conclusion: Day‐surgery haemorrhoidectomy is feasible. The significantly shorter hospital stay implies savings in public medical expenses.     

SARS‐CoV‐2 infection in two patients following recent lung transplantation

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) that causes coronavirus disease 2019 (COVID‐19) has become a global health problem with pandemic character. Lung transplant recipients may be particularly at risk due to the high degree of immunosuppression and the lung being the organ primarily affected by COVID‐19. We describe a 16‐year‐old male and a 64‐year‐old female recently lung transplanted patients with COVID‐19 during inpatient rehabilitation. Both patients were receiving triple immunosuppressive therapy and had no signs of allograft dysfunction. Both patients had close contact with a person who developed COVID‐19 and were tested positive for SARS‐CoV‐2. Subsequently, both patients underwent systematic screening and SARS‐CoV‐2 was ultimately detected. Although the 16‐year‐old boy was completely asymptomatic, the 64‐year‐old woman developed only mild COVID‐19. Immunosuppressive therapy was unchanged and no experimental treatment was initiated. No signs of graft involvement or dysfunction were noticed. In conclusion, our report of patients with asymptomatic SARS‐CoV‐2 infection and mild COVID‐19, respectively, may indicate that lung transplant recipients are not per se at risk for severe COVID‐19. Further observations and controlled trials are urgently needed to study SARS‐CoV‐2 infection in lung transplant recipients.     

Doppler‐guided haemorrhoidal artery ligation in patients with Crohn’s disease

Aim: The outcome of Doppler‐guided haemorrhoidal artery ligation (DGHAL) was assessed in patients with Crohn’s disease (CD) suffering from grade III haemorrhoids. Method: A retrospective study was carried out of patients with CD and symptomatic Grade III haemorrhoids treated by DGHAL. Perioperative and follow‐up data were retrieved from our database of patients undergoing DGHAL. Results: The study included seven men and six women. The mean age was 34 years old. All had CD without anorectal involvement. The median duration of haemorrhoidal symptoms was 6.3 years. There was no mortality, new incontinence, faecal impaction, urinary retention, abscess formation or persistent pain following the procedure. Mean pain score based on a visual analogue scale (VAS) decreased from 2.4 at 24 h postoperatively to 1.6 on the seventh postoperative day. All patients had completely recovered by the third postoperative day. At 18 months, three (77%) of the patients were asymptomatic and three had recurrent symptoms. Conclusion: Doppler‐guided haemorrhoidal artery ligation is safe and effective in treating Grade III haemorrhoids in patients with CD without rectal involvement.     

Management of acute bleeding per rectum

BACKGROUND: Bleeding per rectum is a common indication for acute hospital admissions to the colorectal department. The frequencies of aetiologies in Singapore are different from those in Western populations. A retrospective analysis of the demography, pathology and management of acute bleeding per rectum was performed to determine the outcome and difference in aetiology from the West. METHODS: During the 1-year period from 1 October 1995 to 30 September 1996, 547 patients were admitted to Singapore General Hospital form the emergency department for acute bleeding per rectum. There were 377 males and 170 females; the mean age was 42 years (range, 15-97 years). RESULTS: Of the patients admitted, 87% wer admitted due to perianal conditions diagnosed at bedside proctoscopy, where haemorrhoids mad up 94%. One percent bled from the upper gastrointestinal tract, while 12% bled from colorectal pathology. Massive bleeding form the colorectum was uncommon. Less than one third of the 47 patients required blood transfusions. Colonoscopy was the most useful diagnostic tool for bleeding from the colorectum. The more common colonic pathologies were diverticular disease (33%), adenomas (18%), and malignancy (26%), accounting for the majority of acute patient admissions. Colonic causes of bleeding were less common and were most stable. There were differences in the frequencies of aetiologies in our population compared ot Western populations. Understanding the common pathologies and outcomes guides the management fo our patients.     

Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligation with phenol injection

A prospective randomized clinical trial comparing rubber band ligation (RBL) with phenol injection in 269 patients with symptomatic haemorrhoids presenting to one surgical clinic over a 6 year period, has been carried out. Questionnaires were completed by 215 patients (106 RBL and 109 injection) with an average follow up of 2.75 years. A successful outcome was achieved in 89 per cent of those receiving RBL compared with 70 per cent for injection (P less than 0.001). All symptoms tended to respond more favourably to RBL, the results achieving statistical significance in patients complaining of bleeding and prolapse (P less than 0.01 and P less than 0.05 respectively). Complications from either technique were minimal. It is concluded that RBL is superior to phenol injection in the out-patient treatment of haemorrhoids.     

The gold standard in the treatment of haemorrhoidal disease. Milligan-Morgan haemorrhoidectomy vs Longo mucoprolapsectomy: comparing techniques

AIM: Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease. METHODS: From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation. RESULTS: The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences. CONCLUSION: The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.     

Serum Osteocalcin and CTX‐MMP Concentration in Young Exercising Thoroughbred Racehorses

Bone responds to exercise with changes in bone (re‐)modelling, which might be monitored non‐invasively with biochemical bone markers. The aim of this study was to evaluate the influence of exercise on serum osteocalcin and serum carboxy‐terminal cross‐linked telopeptide of type I collagen generated by matrix metalloproteinases (CTX‐MMP) concentration in young racehorses. Seventy‐one 2 to 4‐year‐old Thoroughbreds were included in this prospective infield study. Blood sampling was performed six times (i.e. six sampling cycles) during a 9‐month period. Serum samples were analysed with commercial osteocalcin and CTX‐MMP radioimmunoassays. Two‐year‐old racehorses had higher serum osteocalcin and CTX‐MMP values than 3‐year‐old horses. Gender and training amplitude did not significantly influence serum osteocalcin and CTX‐MMP values. Two‐year‐old horses showed an increase in osteocalcin values between cycles 2 and 3 and an increase in serum CTX‐MMP values between cycles 1 and 2. Serum osteocalcin and CTX‐MMP concentrations decreased between cycles 4 and 5, and 5 and 6. Three‐year‐old horses showed an increase in serum osteocalcin levels between cycles 3 and 4 and an increase in serum CTX‐MMP concentrations between cycles 1 and 2, and 3 and 4. Serum osteocalcin levels decreased between cycles 5 and 6, whereas serum CTX‐MMP levels decreased between cycles 4 and 5, and 5 and 6. Two‐ and three‐year‐old horses showed a decreased osteocalcin/CTX‐MMP ratio between cycles 1 and 2. Moreover, 2‐year‐old horses showed an increase in the osteocalcin/CTX‐MMP ratio between cycles 2 and 3. Sore shin formation did not significantly influence serum osteocalcin and CTX‐MMP values. Serum osteocalcin and CTX‐MMP are promising bone markers for monitoring exercise induced changes in equine bone metabolism.     

Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler‐guided transanal haemorrhoid dearterialization for third‐degree haemorrhoids

Aim Doppler‐guided transanal haemorrhoid dearterialization (THD) and stapler haemorrhoidopexy (SH) have been demonstrated to be less painful than the Milligan–Morgan procedure. The aim of this study was to compare the effectiveness of THD vs SH in the treatment of third‐degree haemorrhoids in an equivalent trial. Method One hundred and sixty‐nine patients with third‐degree haemorrhoids were randomized online to receive THD (n = 85) or SH (n = 84) in 10 Colorectal Units in which the staff were well trained in both techniques. The mean follow‐up period was 17 (range 15–20) months. Results Early minor postoperative complications occurred in 30.6% of patients in the THD group and in 32.1% of patients in the SH group. Milder spontaneous pain and pain on defecation were reported in the THD group in the first postoperative week, but this was not statistically significant. Late complications were significantly higher (P = 0.028) in the SH group. Residual haemorrhoids persisted in 12 patients in the THD group and in six patients in the SH group (P = 0.14). Six patients in the SH group and 10 in the THD group underwent further treatment of haemorrhoids (P = 0.34). No differences were found in postoperative incontinence. The obstructed defecation score (ODS) was significantly higher in the SH group (P < 0.02). Improvement in quality of life was similar in both groups. Postoperative in‐hospital stay was 1.14 days in the THD group and 1.31 days in the SH group (P = 0.03). Conclusion Both THD and SH techniques are effective for the treatment of third‐degree haemorrhoids in the medium term. THD has a better cost‐effective ratio and lower (not significant) pain compared with SH. Postoperative pain and recurrence did not differ significantly between the two groups.     

Transanal Suture Rectopexy for Haemorrhoids: Chivate’s Painless Cure for Piles

The aim of the study was to evaluate Chivate’s new procedure of transanal suture rectopexy for haemorroids for pain, bleeding, hospital stay, recurrence and complications. During the period between January 2006 and December 2008, the procedure was used for 166 cases symptomatic of grade II, III and IV haemorrhoids, at six different institutes by five different colorectal surgeons. In the series, 92 cases were males and 74 cases were females; average age was 49.5 years; youngest patient was 23 years of age and eldest was of 82 years of age. According to the gradation, II—52 cases, III—86 cases and IV—28 cases were enrolled for the procedure. The piles mass was reduced by head low and manually. The mucosa and submucosa were transfixed to muscle of the rectum by 0.5–1.0 cm long stitches. Similar stitching was continued all along the complete circumference of the rectum, 2 and 4 cm distal to the dentate line. In all cases, antibiotics and anti-inflammatory medicines were prescribed for 5 days. No pain was noticed in 162 cases; in 4 cases a pain dull in nature was described by the patients. All the 166 cases were discharged after 24 h. Intraoperative bleeding from the suture line was observed in 15 cases, which required temporary compression. On proctoscopy, in 3 cases intra-anal grade I, protrusion of piles cushion without bleeding was noticed. No incontinence, no recurrent bleeding, no frequency of stool, or no tenusmus was observed. In 2 cases, 6 months after operation, residual external piles were observed, which required excision. The procedure requires no special costly instruments or any disposables. Patients require short stay for 24 h. The procedure is a painless cure for haemorrhoids.     

Randomized controlled trial comparing rubber band ligation with stapled haemorrhoidopexy for Grade II circumferential haemorrhoids: long‐term results

Objective An improved understanding of the pathophysiology of haemorrhoids has resulted in the introduction of new surgical techniques including stapled haemorrhoidopexy (SH). This randomized controlled trial compared the long‐term effectiveness of SH with rubber band ligation (RBL) in the treatment of grade II circumferential symptomatic haemorrhoids. Method A consecutive cohort of patients was randomly allocated to either SH or RBL. Data on haemorrhoidal symptoms, Cleveland continence scores, sphincter assessment, SF‐36, EQ‐5D, HAD score and prior treatment history were assessed at enrolment and reassessed by long‐term postal questionnaire. The details were analysed using spss ^TM 12.0 from Microsoft^TM Access®. Results Sixty patients were allocated by computer block randomization. Both groups were balanced for age, sex and symptoms. Recurrence favoured SH [3 vs 11; OR 0.18, 95% CI (0.03 to 0.86), P = 0.028] at 1 year and, at a mean of 40.67 (31–47) months [4 vs 12; OR 0.23, 95% CI (0.05, 0.95); P = 0.039]. SH patients experienced prolonged pain [Median (IQR) = 7 (5,7) vs 3 (1,7), P = 0.008] and took a longer time to return to work [6 (3,7) vs 3 (1,6) days, P = 0.018]. This was no significant difference in quality of life. Conclusion Stapled haemorrhoidopexy achieved better disease control at 1 year without any major complication. This was sustained in the long‐term. Further studies with greater patient numbers are needed to confirm this study.     

Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids

BACKGROUND: Patients with acute bleeding from internal haemorrhoids often have to be referred by the general practitioner to the surgeon for definitive treatment with invasive outpatient procedures. At the initial consultation, patients frequently seek postponement of immediate surgery to a more convenient time. Effective and rapid non-invasive control of acute bleeding could be of practical use in scheduling surgery to a time convenient to both patient and surgeon. METHODS: In a 90-day randomized, double-blind study treatment with a micronized purified flavonoid fraction (MPFF) was compared with placebo, in 100 outpatients who presented for treatment of acute internal haemorrhoids of less than 3 days' duration. The primary endpoint was cessation of bleeding on the third day of treatment. RESULTS: Of 50 patients randomized to each group, acute bleeding ceased by the third day in 40 (80 per cent) who received MPFF compared with 19 (38 per cent) who had placebo (P < 0.01). Mean(s.d. ) duration of acute bleeding from onset to cessation of 4.9(1.6) days was 2.1 (95 per cent confidence interval 1.2-2.9) days less than that in patients receiving placebo (P < 0.01). Continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients, compared with 12 of 30 receiving placebo (P < 0.05). CONCLUSION: Patients with acute internal haemorrhoids treated with MPFF had rapid cessation of bleeding and a reduced risk of relapse. This could be of value in the more convenient timing of treatment with invasive outpatient procedures.     

Primary adenocarcinoma of the appendix presenting with fresh bleeding per rectum: A case report

IntroductionPrimary adenocarcinoma of appendix is a rarely diagnosed malignancy accounting for less than 6% of appendiceal neoplastic lesions and less than 0.5% of all gastrointestinal malignancies. It is mostly diagnosed as an incidental finding after appendicectomy.Case summaryAn 81 year old male patient presented with bleeding per rectum in a background of previous rectal polyp, hypertension, diabetes and hypothyroidism. CECT of whole abdomen findings revealed thickening at the appendix and base of the caecum. Colonoscopy showed a sessile polypoid growth at appendicular orifice, at the base of the caecum. Laparoscopy confirmed the clinical suspicion of appendicular carcinoma and laparoscopy assisted radical right hemicolectomy was performed. Final histopathology revealed well differentiated adenocarcinoma of the appendix with no lymph node involvement (pT3N0M0).DiscussionPatients with primary adenocarcinoma of the appendix present with features similar to acute appendicitis whereas anaemia or fresh bleeding per rectum is a rare presentation. Surgery is the mainstay of treatment, the extent of which will depend upon the stage. Tumours staged as T1 may be managed by appendicectomy alone provided the base is free and there are no lymphadenopathies. T2 or above require right hemicolectomy as chances of lymph node metastasis are high. Nodal involvement warrants the need for adjuvant chemotherapy. Distant metastasis to the peritoneum or liver and lungs is very rare.ConclusionWhile investigating unexplained anaemia or bleeding per rectum, full colonoscopic examination up to the appendicular orifice is important and if required, should be combined with CT scan of abdomen, to clinch the rare but possible and potentially curable diagnosis of appendicular carcinoma.     

Living‐donor single‐lobe lung transplantation for pulmonary hypertension due to alveolar capillary dysplasia with misalignment of pulmonary veins

This is a case report of a successful single‐lobe lung transplantation for pulmonary hypertension secondary to alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV). A 6‐year‐old boy underwent living‐donor single‐lobe transplantation with the right lower lobe from his 31‐year‐old mother. The pretransplantation graft size matching was acceptable: the estimated graft forced vital capacity (FVC) was 96.5% of the recipient's predicted FVC, and the graft size measured by computed tomography (CT) volumetry was 166% of the recipient's chest cavity volume. Right pneumonectomy followed by implantation was performed under cardiopulmonary bypass (CPB). The pulmonary arterial pressure was significantly decreased to 31/12 mm Hg immediately after transplantation, and the first PaO₂/FiO₂ in the intensive‐care unit (ICU) was 422 mm Hg. Lung perfusion scintigraphy showed 97.5% perfusion to the right implanted lung 3 months after transplantation. Chest CT showed a mass rapidly growing in the native left upper lobe 6 months after transplantation, which was diagnosed as posttransplant lymphoproliferative disorder (PTLD) by a CT‐guided biopsy. After immunosuppressant reduction and six courses of chemotherapy with rituximab, he underwent native left upper lobectomy for salvage lung resection 13 months after transplantation. Seven months after lobectomy, he has returned to normal school life without any sign of tumor recurrence.     

Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study

Aim We report a multicentric prospective study which aimed to evaluate Doppler‐assisted ligation of the terminal haemorrhoidal arteries (THD) for II and III degree haemorrhoids. Method A total of 112 patients from five colorectal units, including 81 men, mean age 48 ± 13 years, with II degree (39) and III degree (73) haemorrhoids were treated by Doppler‐guided transanal de‐arterialization and anopexy using a new device (THD). Results The mean operative time was 33.9 ± 8.8 minutes, and the mean number of ligatures applied was 7.2 ± 1.5. Postoperatively, 72% of patients did not need analgesics and the other 28% used nonsteroidal anti‐inflammatory drugs 1–3 times/day for less than 2 days. All the patients were operated as a day case. Early postoperative complications included haemorrhoidal thrombosis (2 patients), bleeding (1) treated by haemostatic suture, dysuria (6) and acute urinary retention (1). After a mean follow‐up of 15.6 ± 6.5 months (range 6–32), 2/105 (20.9%) patients complained of minor bleeding, while mild pain was still present in 4/51 patients (7.8%). There were no statistically significant differences in the sample population regarding the gender or stage of the disease. Tenesmus was cured in 15/17 patients, dyschaezia in 20/22 patients and mucous soiling in 10/10 patients. No new cases of altered defaecation or faecal incontinence were recorded. Overall, 85.7% of patients were cured and 7.1% improved. Residual haemorrhoids were treated by elastic band ligation in nine (8%) patients and by surgical excision in further five patients (4.5%). Conclusion Doppler‐assisted ligation of the terminal branches of the haemorrhoidal arteries for II and III degree haemorrhoids is highly effective and painless. Complications are few and the technique can be performed as a day case.     

The internal sphincter and Lord's procedure for haemorrhoids.

Anal pressure and motility have been measured in 56 patients with haemorrhoids and 40 asymptomatic subjects. The anal pressure of patients with haemorrhoids (93-6 cm H2O) was very significantly higher than that of the controls (66-8 cm H2O; P less than 0-001). Ultra-slow pressure waves (amplitude 25-100 cm H2O, frequency 0-9-1-6/min) were present in 39 per cent of patients with haemorrhoids, but in only 7-5 per cent of the controls (P less than 0-001). Ultra-slow waves are present under anaesthesia with the voluntary muscles paralysed and are associated with the highest anal pressure, and so, represent abnormal activity of the internal anal sphincter. Measurements after anal dilatation showed complete abolition of ultra-slow wave activity and a very significant drop in pressure. One year after dilatation 19 patients had a mean anal pressure of 62 cm H2O. Very good results were obtained unless the haemorrhoids were so large that they prolapsed at times other than defaecation. Lord's procedure is a rational treatment since it corrects an underlying overactivity of the internal sphincter.     

Long‐Term Results of Biopsy‐Guided Selection and Allocation of Kidneys From Older Donors in Older Recipients

In our old‐for‐old program, we discard or allocate older extended criteria donor kidneys to single (SKT) or dual kidney transplantation (DKT) depending on histological Remuzzi's score in recipients older than 60 years. Here, we analyze the long‐term results of this program and try to identify independent predictors of patient and graft survival. Between December 1996 and January 2008, we performed 115 SKT and 88 DKT. Discard rate was 15%. Acute rejection incidence was higher in SKT than in DKT (22.6% vs. 11.4%, p = 0.04). Renal function was better in DKT than in SKT up to 5 years after transplantation. Surgical complications were frequent in DKT. Ten‐year cumulative graft survival was significantly lower in the SKT group (31% vs. 53%, p = 0.03). In SKT, histological score 4 provided similar graft survival than 3 or less, whereas in DKT score 4, 5 or 6 displayed similar outcome. Finally, independent predictors of graft survival were history of major adverse cardiac event and 1‐year serum creatinine, rather than SKT or DKT. In conclusion, this biopsy‐guided old‐for‐old strategy resulted in acceptable long‐term graft survival. Our results suggest that DKT should be considered for scores of 5 or 6 only.     

Risk of End‐Stage Renal Disease in HIV‐Positive Potential Live Kidney Donors

New federal regulations allow HIV‐positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end‐stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV‐positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV‐negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV‐positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV‐negative scenarios. For 40‐year‐old HIV‐positive individuals with health characteristics that were similar to those of age‐matched kidney donors, viral load <400 copies/mL, and CD4⁺ count ≥500 cells/μL, the 9‐year cumulative incidence of ESRD was higher than that of their HIV‐negative peers, yet still low: 2.5 versus 1.1 per 10 000 among white women, 3.0 versus 1.3 per 10 000 among white men, 13.2 versus 3.6 per 10 000 among black women, and 15.8 versus 4.4 per 10 000 among black men. HIV‐positive individuals with no comorbidities and well‐controlled disease may be considered low‐risk kidney donor candidates.     

Haemorrhoidectomy with Ligasure™vs conventional excisional techniques: meta‐analysis of randomized controlled trials

Objective To compare the use of LigaSure devices with conventional excisional techniques, circular stapling and use of Harmonic Scalpel in patients with symptomatic haemorrhoids and to review literature on LigaSure technology (Valleylab Inc. USA). Method A literature review was performed using the National Library of Medicine’s Pubmed Database using the keywords Ligasure, haemorrhoidectomy, vessel sealing technology. Randomized trials comparing LigaSure with other techniques of excisional haemorrhoidectomy with valid end points were reviewed in the present article and included in a quantitative meta‐analysis. Results There was no significant difference in the proportion of patients cured after Ligasure haemorrhoidectomy or other excisional techniques (P > 0.05). Patients treated with LigaSure had a significantly shorter operative time (P < 0.001), postoperative pain VAS Score (P < 0.001), wound healing time and time‐off from work (P < 0.001), than the patients submitted to excisional techniques. Postoperative bleeding did not significantly differ between the two groups (P = 0.056); however, the surgeons observed a reduction of intra‐ and postoperative bleeding using LigaSure?. In comparison to the circular stapler and Harmonic Scalpel the authors found similar postoperative outcomes and a slightly favourable trend for LigaSure regarding postoperative complications, ease of handling and length of the procedure. Conclusion Our meta‐analysis shows that Ligasure haemorrhoidectomy is a fast procedure characterized by limited postoperative pain, short hospitalization, fast wound healing and convalescence.