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Purpose: Hemorrhoids are a common etiology of anal discomfort affecting up to half of the population. Treatment of hemorrhoids is variable; the choice of treatment is dependent on their grading. Surgical excision via conventional hemorrhoidectomy (CH) remains the gold standard treatment for high grade hemorrhoids. Transanal hemorrhoidal dearterialization (THD) is a less painful alternative to CH but associated with higher recurrence rates. A hybrid procedure has been recently adopted at the American University of Beirut Medical Center (AUBMC) in which hemorrhoidal artery ligation and conventional hemorrhoidectomy are combined. The aim of this study was to compare the recurrence rate between the pure hemorrhoid artery ligation procedure and the hybrid procedure as treatment modalities for hemorrhoids. Methods: A retrospective study was done at AUBMC comparing patients who underwent the hybrid procedures with those who underwent the pure THD. The patients were followed up to 5 years with a mean follow up of 6 months. Results: Our results showed that the hybrid procedure was associated with a lower recurrence rate than the pure procedure (5.7% Vs 13 %, p-value 0.155). In addition, the hybrid group has a lower rate of complications. Conclusion: The hybrid procedure comprises a novel technique for the treatment of hemorrhoids. It provides a safe alternative with lower complications rate compared to the pure procedure. Moreover, it provides a recurrence rate comparable to conventional hemorrhoidectomy with decreased postoperative pain.

Abstract. Vitamin B12, a water-soluble vitamin, plays a vital role in the formation of hematopoietic stem cells and has been associated with oral mucosal diseases, mainly recurrent aphthous stomatitis (RAS). The latter is a debilitating condition, and B12 was proposed as a potential treatment given its role in regenerating oral mucosal tissue. There is conflicting evidence that B12 deficiency causes RAS. Five of the seven randomized controlled trials reviewed used the inactive form of B12 (cyanocobalamin) as intervention, while the other two used the active form (methylcobalamin). Of the latter two, buccal discs (500 μg B12) showed significant improvement and reduced perceived pain in 77% of the subjects, and submucosal injections showed a significant difference in pain, starting from the second day. Moreover, three studies administered vitamin B12 sublingually with different dosages, which revealed that the higher dose (1000 μg) achieved a significant reduction in outbreaks, number, and duration of ulcers, especially after six months. Multivitamins showed no difference in new RAS episodes and duration. Injectable B12 was compared with the oral form, and nearly 50% of the injection group reported a desired response by the eighth week. An ointment form (500 μg) showed a significant reduction in pain levels after two days of treatment. Based on the available literature, we suggest that a daily dose of 1000 μg of vitamin B12 sublingually for six months can be used to treat RAS. Nevertheless, this conclusion should be considered tentative due to the lack of high quality, large scale studies.

Hepatocellular carcinoma (HCC) constitutes most of primary liver cancers. HCC invading the gastrointestinal tract (GIT) is considered a rare entity with limited reports in the literature. Management can either be palliative or curative such as transarterial chemoembolization (TACE) followed by definitive resection. Here, we present a case of direct HCC invasion of the GIT that was managed by surgical resection.A 74-year-old male with a history of a liver mass, found to have HCC. Admitted for medical optimization prior to definitive resection, however his stay was complicated by hemorrhagic shock, with imaging findings of hemoperitoneum suggestive of spontaneous rupture of the mass. TACE was done to stabilize the patient prior to resection. Patient was taken immediately to the operating room for definitive resection.Most cases of direct HCC invasion into the GI tract present mainly with GI bleed. Some patients, present with abdominal pain without any warning signs of an occult GI bleed. Thus, absence of an occult GI bleeding does not exclude a GIT invasion. Management options are several, but in advanced stages, management is not limited to palliation.GIT invasion is a rare complication of HCC reported in scarcity in the literature. Most cases present with GI bleeding but with some rare cases, they present with more generalized symptoms like abdominal pain, weight loss or fatigue. Despite having a poor prognosis, complete surgical resection of the tumor may be a reassuring and life prolonging treatment option for these patients.

Squamous cell carcinoma (SCC) of the colon is an extremely rare pathologic entity, accounting for less than 1 % of all colorectal cancer cases. They tend to be very aggressive with poor outcomes and treatment strategies are still controversial due to the paucity of data available to guide management.A case of a cecal mass with metastatic liver lesions. Initially diagnosed as an adenocarcinoma, the patient underwent resection with metastasectomy. Despite achieving negative surgical margins and undergoing adjuvant chemotherapy, the patient relapsed and presented with a new mass in the descending colon. The patient underwent resection with subsequent follow-up revealing distant metastasis. The patient passed away soon after.Primary colorectal SCC has similar presentation to adenocarcinoma of the colon. Unfortunately, it usually presents at a late stage. Diagnosis of colorectal SCC requires histologic confirmation of SCC plus exclusion of possible causes. Management is predominantly definitive radical resection followed by adjuvant chemotherapy and radiotherapy. Surgical margins should be at least 5 cm, preferably 10 cm. Lymph node yield greater than 20 was associated with improved survival. Studies assessing the prognosis of primary colorectal SCC following chemo-radiotherapy have not been done.Surgery remains the most vital important step in the management of colonic SCC. The role of chemotherapy and/or radiation remains questionable. Depending on the aggressiveness of this disease the need for further frequent.

Neonatal circumcision is one of the most frequently performed procedures in male infants; it is also particularly painful. In a previous trial, we showed that the combination of Eutectic Mixture of Local Anesthetics (EMLA) + Sucrose + Ring Block (RB) was significantly effective in reducing pain during circumcision.In this study, we added music as an adjunct aiming to further reduce the pain scores.This was a double-blinded randomized controlled trial comparing EMLA + Sucrose + RB (Control) to EMLA + Sucrose + RB + Music (Intervention). The trial setting was the normal nursery of a university teaching hospital. One hundred and three healthy newborn males were randomized to each of the intervention and control groups. Babies were videotaped (face and torso) during the procedure for assessment of pain by two blinded and independent reviewers. The primary outcome measure was the NIPS score; secondary outcomes included heart rate, oxygen saturation and crying time.The NIPS score of the intervention group (EMLA + Sucrose + RB + Music [2.6 ± 1.6]) was significantly higher than that of the control group (EMLA + sucrose + RB [1.4 ± 0.9]) (p = 0.00). Inter-rater reliability was high (κ .89). The intervention group registered significantly higher mean heart rate (142 bpm) and increased mean crying time (5.44 s) compared to the control group (135 bpm and 1.63s, respectively) (p = 0.01) and (p = 0.00). No adverse events were noted. Delivery music medicine by playing it from an iPad in the procedure room did not reduce pain during circumcision.There is overwhelming evidence in the literature describing the effectiveness of music on pain management especially in the NICU. However, our results did not align with the general trend; not only did music medicine fail to enhance analgesia but it might have had the opposite effect, further agitating the infants, as indicated by the significantly increased heart rate, crying time and NIPS scores of the participants in the intervention group. Limitations of our study include the fact that this is a single center study and the method of delivering music via iPads instead of noise-canceling headphone.Our results showed that music, delivered in this manner, may have increased agitation. We affirm the fact that the combination of EMLA + Sucrose + RB is highly effective for managing pain during circumcision and further reduction of already low scores might not be possible.Registry Name: ClinicalTrials.gov; Registration number: NCT04252313; link: https://clinicaltrials.gov/ct2/show/NCT04252313.