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A systematic review was conducted to determine if manual decompression is a safe alternative to intraoperative colonic irrigation prior to primary anastomosis in obstructed left-sided colorectal emergencies. Search for relevant articles from 1980 to 2007 was conducted on Medline, Embase and the Cochrane Controlled Trials Register using the keywords “colonic lavage, irrigation, decompression, washout, obstructed and bowel preparation”, either singularly or in combination. Trials in English publications with similar patient characteristics, inclusion criteria and outcome measures were selected for analysis. Thirty-day mortality, anastomotic leak rates and post-operative wound infection were studied as outcome variables. Analysis was performed with RevMan 4.2 software. Seven trials were identified for systematic review, with a total of 449 patients. Data from the single randomised controlled trial and one prospective comparative trial were analysed separately. Results from the remaining five studies were pooled into two arms of a composite series, one with colonic irrigation and one without. Results showed no significant difference in the anastomotic leak rates and mortality rates between the colonic irrigation and manual decompression arms in the randomised and comparative trials. The composite series, however, showed significantly better results with manual decompression (RR 6.18, 95% CI 1.67–22.86). The post-operative infection rate was similar in both groups. Manual decompression was comparable to colonic irrigation for primary anastomosis in obstructed left-sided colorectal emergencies, with no significant increase in mortality, leak or infection rates.

Animal models have highlighted the importance of innate lymphoid cells (ILCs) in multiple immune responses. However, technical limitations have hampered adequate characterization of ILCs in humans. Here, we used mass cytometry including a broad range of surface markers and transcription factors to accurately identify and profile ILCs across healthy and inflamed tissue types. High dimensional analysis allowed for clear phenotypic delineation of ILC2 and ILC3 subsets. We were not able to detect ILC1 cells in any of the tissues assessed, however, we identified intra-epithelial (ie)ILC1-like cells that represent a broader category of NK cells in mucosal and non-mucosal pathological tissues. In addition, we have revealed the expression of phenotypic molecules that have not been previously described for ILCs. Our analysis shows that human ILCs are highly heterogeneous cell types between individuals and tissues. It also provides a global, comprehensive, and detailed description of ILC heterogeneity in humans across patients and tissues.

Stapled haemorrhoidectomy has been performed with different techniques and staplers. We review our initial experience with the new DST EEA 33 stapler and neu@ anoscope. A review of all patients who underwent stapled haemorrhoidectomy using the DST EEA 33 over a 14-month period was conducted. Short-term outcomes of bleeding, pain and retention of urine requiring admission or strictures requiring surgical intervention were studied. There were 1,118 patients operated from August 2007 to October 2008. The median age was 46-year-old (20–82 years) and 51% were females. The median operating time was 15 min (range 5–45 min), and median follow-up was 7 months (range 3–16 months). There were 26 patients (2.3%) who were admitted for inability to pass urine and 20 required catheterisation. Fifty-two patients (4.6%) were admitted for post-operative bleeding. In 32 cases the bleeding stopped spontaneously, while 19 patients required adrenaline injection and packing for hemostasis. Only one patient required surgical hemostasis. Thirty-three patients (2.9%) were admitted for post-operative pain and stayed for a median of 1 day (range 1–4 days). There were 14 patients (1.2%) who developed anorectal strictures requiring surgical intervention. All underwent anoplasty at a median of 3 months post-operatively (range 2–5 months), with good result. There were no recurrent haemorrhoids during follow-up. Stapled haemorrhoidectomy using the DST EEA 33 stapler is safe. The neu@ anoscope provides good visibility and handling, and is a useful tool in this procedure.

Dear Editor: We refer to the article entitled “Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results” published in December 2009.While we congratulate the authors on publishing their results of a randomized controlled trial on what is a new and exciting treatment modality for haemorrhoidal disease, we would like to share our thoughts on the subject. The authors set out to compare Procedure for Prolapsed Haemorrhoids (PPH) with Transanal Haemorrhoidal Dearterialisation (THD) with regards to post-operative complications and short-term results. They used “resolved pre-operative symptoms with no need for further treatment” as a primary end-point. We feel that this is not objective enough. For grade III and IV haemorrhoids, one of the main symptoms would be that of prolapse. Here, the authors have not quantified the nature of prolapse nor investigated the extent of resolution of the pre-operative prolapse after surgery. Further, it appears that there is only one patient in the PPH arm with grade IV haemorrhoids, compared with four patients in the THD arm. Could the observed difference in persistent prolapse between the two arms at 6 weeks be due to this? Overall, the small sample size suggests that the study may be inadequately powered to show a true difference between the two treatment modalities. It would have been helpful to include information on power calculations. With respect to the technical details of surgery, it was unclear how exactly THD was performed. It would also be helpful if the authors clarified whether three-, fouror six-point ligation was performed. In addition, was a plicating stitch or anopexy routinely performed in all cases? Finally, we wish to point out that this study did not look specifically into the costs and learning curve for performing both procedures. As such, the last statement that THD is “more easily learned and less costly” remains to be proven. In our ongoing study of 140 patients who had undergone THD, we have found persistent prolapse at 6 weeks in 19.2% of patients with grade III piles. This compares with 22.2% of patients in the current study who complained of persistent prolapse at 6 weeks. The authors mentioned that, in their PPH arm, only 11.1% had persistent prolapse. There appears to be twice the risk of persistent prolapse if grade III or IV haemorrhoids were operated on using THD instead of PPH. Based on the results reported in this study, perhaps we should only recommend THD for haemorrhoidal bleeding and not prolapse at this point in time.