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In the absence of an internationally agreed classification of haemorrhoids, evaluation of the ever increasing number of therapeutic options available is impossible. A new classification is proposed which relates symptoms to our knowledge of haemorrhoidal development, the use of which should provide a more accurate way of comparing treatments and in the evaluation of new techniques. The evidence for such a classification is presented in detail. [ABSTRACT FROM AUTHOR]

Background Internal anal sphincter tone depends on the intrinsic myogenic properties of smooth muscle and external neural influences, specifically a continuous sympathetic input. Reduction of maximum resting anal canal pressure (MRP) increases the vascularity of ischaemic chronic anal fissures and promotes healing. Methods Ten patients with chronic anal fissures (median age 35.5 (28-65) years) and 10 healthy volunteers (median age 28 (21-38) years) were administered 20 mg indoramin (α[sub 1]-antagonist) or 4 mg salbutamol (&beta[sub 2]-agonist) orally in a doubleblinded manner. MRP, pulse, and blood pressure were measured prior to and at hourly intervals until 3 h after administration. Results Patients with chronic anal fissures had a significantly higher MRP compared with volunteers (P < 0.05, MannWhitney U-test). In each group there was a significant reduction in MRP at 1, 2 and 3 h (P < 0.05, Wilcoxon signed ranks test). Indoramin and salbutamol demonstrated no significant difference in effect when comparing reduction of MRP in patients and volunteers (Mann-Whitney U-test). The reduction in patients' MRP at 3 h was comparable to that after lateral sphincterotomy. Tremors were noted with salbutamol in four volunteers, and five patients. Three patients complained of light-headedness with indoramin without a significant change in diastolic blood pressure. The reduction in MRP in subjects who took indoramin did not correlate with a reduction in diastolic blood pressure (Pearson correlation coefficient, r = 0. 166, P = NS). Conclusion Oral indoramin causes a sustained reduction in MRP, without serious side effects, and may have a beneficial role in the treatment of anal fissures. (MRP - maximum resting anal canal pressure). [ABSTRACT FROM AUTHOR]

Aim This manuscript provides the introduction and detailed methodology used in subsequent reviews to assess the outcomes of surgical interventions with the primary intent of treating chronic constipation in adults and to develop recommendations for practice. Method PRISMA guidance was adhered to throughout. A literature search was performed in public databases between January 1960 and February 2016. Studies that fulfilled strictly-defined PICOS (patients, interventions, controls, outcome, and study design) criteria were included. The process involved two groups of participants: (i): 'a clinical guidance group' of 18 UK experts (including junior support) who performed the systematic reviews and produced summary evidence statements ( SES) based strictly on data synthesis in each review. The same group then produced prototype graded practice recommendations ( GPRs) based on coalescence of SES and expert opinion; (ii): a European Consensus group of 18 ESCP (European Society of Coloproctology) nominated experts from nine European countries evaluated the appropriateness of each prototype GPR based on published RAND/ UCLA methodology. Results An overview of the search results is provided in this manuscript. A total of 156 studies from 307 full text articles (from 2551 initially screened records) were included, providing data on procedures characterized by: (i) colonic resection ( n = 40); (ii) rectal suspension ( n = 18); (iii) rectal wall excision ( n = 44); (iv) rectovaginal septum reinforcement ( n = 47); (v) sacral nerve stimulation ( n = 7). The overall quality of evidence was poor with 113/156 (72.4%) studies providing only Oxford level IV evidence. The best evidence was extracted for rectal excisional procedures, where the majority of studies were Oxford level I or II. The five subsequent reviews provide a total of 99 SES (reflecting perioperative variables, efficacy, harms and prognostic variables) that contributed to 100 prototype GPRs covering patient selection, procedural considerations and patient counselling. The final manuscript details the 85/100 GPRs that were deemed appropriate by European Consensus (remaining 15 were all uncertain) and future research recommendations. Conclusion This manuscript and the following 6 papers suggest that the evidence base for surgical management of chronic constipation is currently poor although some expert consensus exists on best practice. Further studies are required to inform future commissioning of treatments and of research funding. [ABSTRACT FROM AUTHOR]

Aim This manuscript forms the final of seven that address the surgical management of chronic constipation ( CC) in adults. The content coalesces results from the five systematic reviews that precede it and of the European Consensus process to derive graded practice recommendations ( GPR). Methods Summary of review data, development of GPR and future research recommendations as outlined in detail in the 'introduction and methods' paper. Results The overall quality of data in the five reviews was poor with 113/156(72.4%) of included studies providing only level IV evidence and only four included level I RCTs. Coalescence of data from the five procedural classes revealed that few firm conclusions could be drawn regarding procedural choice or patient selection: no single procedure dominated in addressing dynamic structural abnormalities of the anorectum and pelvic floor with each having similar overall efficacy. Of one hundred 'prototype' GPRs developed by the clinical guideline group, 85/100 were deemed 'appropriate' based on the independent scoring of a panel of 18 European experts and use of RAND- UCLA consensus methodology. The remaining 15 were all deemed uncertain. Future research recommendations included some potential RCTs but also a strong emphasis on delivery of large multinational high-quality prospective cohort studies. Conclusion While the evidence base for surgery in CC is poor, the widespread European consensus for GPRs is encouraging. Professional bodies have the opportunity to build on this work by supporting the efforts of their membership to help convert the documented recommendations into clinical guidelines. [ABSTRACT FROM AUTHOR]

Aim Permacol™ collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. Method Patients ( N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. Results Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. Conclusion Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects. [ABSTRACT FROM AUTHOR]

Aim The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research. Method MEDLINE, EMBASE and Pub Med were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient. Results Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence. Conclusion Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research. [ABSTRACT FROM AUTHOR]

Aim Intra-abdominal desmoid disease is one of the most common extra-intestinal manifestations of familial adenomatous polyposis. Small bowel obstruction occurs frequently in affected patients and is notoriously difficult to treat. The aim of this study was to review the management and outcome of desmoid-related small bowel obstruction. Method This was a retrospective, descriptive study of patients with familial adenomatous polyposis and intra-abdominal desmoid disease who developed small bowel obstruction. Demographic data and data concerning the presentation, diagnosis and treatment of the bowel obstructions were abstracted from the polyposis database or patients' records. Patients with obstruction unrelated to desmoid disease were excluded. Results There were 47 patients (30 women and 17 men). Median age at first bowel obstruction was 24.2 (interquartile range 19.2-34.2) years. The median time from index surgery to first bowel obstruction was 4.1 (interquartile range 1.5-9.0) years. Twenty-two patients had a colectomy and ileorectal anastomosis and 21 a proctocolectomy and ileoanal pouch. Obstruction was treated medically in 29% of cases and surgically in 69%. Thirteen patients had total parental nutrition. Thirty (63.8%) had a second episode of small bowel obstruction at a mean of 5.3 years after the first, 50% of which were treated medically. Eighteen (37.5%) patients had more than two episodes of bowel obstruction. There were 118 operations, including lysis of adhesions (29), small bowel resection (14), bypass (12), ileostomy (12), desmoid excision (9) and stricturoplasty (2). Conclusion Desmoid-related small bowel obstruction in familial adenomatous polyposis patients requires multiple surgical strategies to restore a patent gastrointestinal tract. What does this paper add to the literature? This is the only series in the literature specifically addressing small bowel obstruction in patients with familial adenomatous polyposis and intra-abdominal desmoid disease. The data show that small bowel obstruction is common, tends to recur, but can be successfully managed by a combination of medical and well selected surgical treatment. [ABSTRACT FROM AUTHOR]

The article offers information on studies related to colorectal diseases published in the previous issues of various journals. A paper from the "Diseases of the Colon and Rectum" talks about the Moloney Antegrade Continent Enema technique used for treating patients with severe defacaetory disorders. A paper from "Archives of Surgery" talks about the risk factors for the development of abdominal abscess formation after perforated appendicitis in children. Other papers are also cited.

The article features a set of abstracts of various research papers presented at the meeting of Royal Society of Medicine, London on November 23, 2003. Some of the papers presented are Sacral nerve stimulation (SNS) for faecal incontinence in the Great Britain; Fatigability of the external anal sphincter in faecal incontinence; Treatment of persistent perineal sinus with pedicled flap: experience of a single colorectal surgeon etc. SNS is safe effective in the medium to long term for treatment of faecal incontinence when conservative treatment has failed.

Aim This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. Method We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. Results Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. Conclusion There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy. [ABSTRACT FROM AUTHOR]

Information about several papers discussed at a consensus conference on internal medicine is presented. Surgeons expressed their concerns on the safety and efficacy of anal fistula plug for the treatment of anal fistula. The conference featured several surgeons including Herand Abcarian, H. Randolph Bailey, and Bradley J. Champagne.

Objective The aim of this paper was to analyse the results of treatment of anal fistulas retrospectively. Methods Between 1992 and 2004, 407 patients were operated on for perianal fistula. In the follow-up period, 107 patients were lost, so 300 patients were analysed in the study. The mean follow-up time was 4.2 years. Analysed parameters included: types of surgical procedures in different kinds of fistulas and postoperative complications. Various types of surgical procedures and their effectiveness were described. Late results were assessed taking into account healing time, duration of sick leave, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed according to the Cleveland Clinic Incontinence Score. Results In our study, subcutaneous fistula was diagnosed in 23.3%, inter-sphincteric in 18%, trans-sphincteric in 37.7%, supra-sphincteric in 16% and extra-sphincteric in 5% of patients. Single-tract fistulas were present in 88.7% and multi-tract fistulas were present in 11.3%. Overall, 242 patients had primary fistulas and 58 patients had recurrent fistulas. The most frequently performed procedures were cutting seton (139 patients) and radical fistulectomy (104 patients). Recurrent fistulas developed in 14.3%. Postoperative gas and/or stool incontinence was noticed in 10.7%. The recurrence rate was 5.4% in patients with primary fistula and in 51.7% patients presenting with a recurrent fistula. Gas and stool incontinence developed in 3.7% of patients with primary fistulas and in 39.7% of patients presenting with recurrent fistulas. Recurrence rate was 12% in the patients of single-tract fistulas and 32.4% in the patients of multi-tract fistulas. Postoperative gas and/or stool incontinence occurred in 8.3% of patients of single-tract fistulas and in 29.4% of patients of multi-tract fistulas. Conclusions The complication rate was 10-fold higher in patients presenting with a recurrent fistula than in those with primary fistulas and threefold higher in patients with multi-tract fistulas than in those with single-tract fistulas. [ABSTRACT FROM AUTHOR]

The article presents a list of papers focusing on the various ways to address different kinds of colorectal diseases. They include the "European Journal of Nutrition" which discusses the significance of utilizing a hand dynamometer to evaluate malnutrition of patients in hospitals, "Diseases of the Colon and Rectum" concerning the postoperative effect of tissue welding device and vessel sealing device, and "Digestive Diseases and Sciences" which focuses on the treatment of fistula-in-ano.

The necessity, timing and benefits of follow-up after rectal cancer surgery remain controversial, with two years traditionally considered adequate to detect most local recurrences. This unit has a policy of lifetime follow-up, and this paper investigates, at 23 years, the value of prolonged surveillance.Six hundred and sixty consecutive patients undergoing surgery for rectal cancer were prospectively followed-up between 1978 and 2002, and local or systemic recurrence recorded. This analysis was performed on the 509/660 (76%) patients who underwent potentially curative surgery.Total mesorectal excision (TME) was performed in 422/509 (83%) patients, mesorectal transection in 78 (15%), and local excision in 9 (2%). Follow-up ranged from 1 to 23 years (mean = 9.7). Seven (1.4%) patients had local recurrence alone, 11 (2.2%) local plus systemic, and 86 (17%) systemic recurrence alone. Of the local recurrences 3 (17%) became evident within 1 year, 9 (50%) within 2 years, 16 (89%) within 5 years, and 2 (11%) presented after 5 years, at 5.6 and 5.8 years. Of the systemic recurrences 26 (27%) became evident within 1 year, 57 (59%) within 2 years, 93 (96%) within 5 years, and 4 (4%) presented after 5 years at 5.3, 5.3, 5.4 and 7.9 years.This long-term surveillance of patients undergoing curative surgery for rectal cancer demonstrates that most local and systemic recurrences occur within 5 years. Almost half occurred more than 2 years after surgery. However, those centres wishing to set standards of care, or evaluate current or new therapies in rectal cancer treatment, should be aware that unexpected late recurrences occasionally develop. [ABSTRACT FROM AUTHOR]

The article discusses several studies related to coloproctology. The "Journal of Clinical Diagnosis and Research" featured a paper that discussed the important role of lateral internal anal sphincterotomy (LIAS) in the treatment of chronic anal fissure. A study published in the journal "BMC Infectious Diseases" found the presence of necrotizing fasciitis, caused by Haemophilus influenzae type b, in patients taking Bevacizumab to treat rectal cancer.

The article offers information on various studies and reports related to colorectal diseases. It mentions a study that compares Hispanics and Caucasians with inflammatory bowel disease (IBD) and Crohn's disease (CD). One study found that a high-protein, low-carbohydrate and low-fiber diet may increase the risk of colonic diseases. A paper on how to manage fungating wounds is also discussed.