Iranian Journal of Colorectal Research
Year:2013 | Volume:1 | Issue:2|Papers Count:12

Context: Minimally invasive procedures are used for treatment of nonresponsive hemorrhoids to conservative therapy. These OPD (Out-Patient Department) procedures are effective to eradicate the hemorrhoid symptoms with minimal postoperative pain and complications. Evidence Acquisition: In this review, data base of PubMed, and MEDLINE were searched with time limitation (2002- 2012). Recent articles in English journals were reviewed to evaluate and compare these minimally invasive procedures including Rubber band ligation (RBL), Infrared coagulation (IRC), Direct current Electrotherapy (DCE), and Sclerotherapy.Results: Upon the articles, 881 were treated with RBL, 454 with IRC, 1203 with DCE, and 2372 with sclerotherapy. Postoperative pain, which is a common complication of hemorrhoidectomy, was 3-25% in RBL, 2.13-4.3% in DCE, and 1.8-7% in sclerotherapy. Pain was mild to moderate and rarely needed analgesic. Postoperative rectal bleeding was seen in 1.26-32.4% of patients treated with RBL. Recurrence of preoperative symptoms was 1.9-39% for RBL, 6.9-21% for sclerotherapy, and 2.9-3% for DCE. Postoperative complications were minor in all procedures and for sclerotherapy it was seen in 6.9-21% of patients. Success rate was 69.4-96.4% in RBL, 80% in IRC, 89.3-99.7% in sclerotherapy, and 98.2% in DCE. Patient's satisfaction was 98% for DCE versus 99% for RBL and IRC. Operation time for each tag of hemorrhoid was 4.5-10 minutes for DCE, regarding different amplitudes of currency and degrees of hemorrhoid, and 13 minutes for sclerotherapy and not reported for other methods.Conclusions: Minimally invasive procedures are used depending on surgeon's experience and preference. These modalities are comparable from different aspects. The cost of treatment and availability of equipment may affect the choice of modality. All of these techniques could be used in patients resulting in maximum success rate and minimum complications.

Background: Malignant neoplasms of the anal canal are rare accounting for approximately 4% of all colorectal malignancies.Objectives: The present study aimed to report the clinicopathological characteristics and treatment outcomes of 41 cases with malignant neoplasms of the anal canal.Patients and Methods: Between 1999 and 2012, 41 consecutive patients were diagnosed with primary malignant neoplasm of the anal canal which were treated and followed up at Namazi hospital. Only primary malignant tumors arising from the anal canal were included. Patients with secondary anal canal involvement from rectal or perianal skin cancers and metastatic tumors were excluded.Results: There were 22 women and 19 men, age ranging from 33 to 83 years, with a median age of 57 years at diagnosis. Sixteen patients (39%) had localized disease, 21 (51%) had regional disease, and 4 (10%) had metastatic disease at diagnosis. Squamous cell carcinoma (61%) was the most frequent histologic subtype, followed by adenocarcinoma (27%), malignant melanoma (10%), and gastrointestinal stromal tumor (2%). After a median follow-up of 51 (11-169) months for surviving patients, 22 patients were alive and without disease, three were alive with disease, and 19 patients died due to the disease. Histological subtype (P=001), and stage of disease (P=0.002) were prognostic factors for overall survival. The 5-year local control, disease-free, and overall survival rates for all patients were 63.9%, 53%, and 59.4% respectively.Conclusions: This study indicated that squamous cell carcinoma, adenocarcinoma, and malignant melanoma are the most frequent malignant neoplasms in the anal canal. Histological subtype and disease stage are the most important prognostic factors for overall survival in this region.

Background: Chronic functional constipation is an epidemic problem in children that has effects on the growth status.Objectives: The aim of this study is to evaluate the growth parameters in children with chronic functional constipation and compare them with healthy individuals.Patients and Methods: One hundred children with chronic functional constipation (defined as Rome III criteria) referred to Pediatric Gastroenterology Clinic enrolled in this study. Control group was consisted of 100 children who referred for well-child visits, without constipation. Weight, height, body mass index (BMI) and Z-score weight, Z-score height and Z-score BMI was calculated for each patient and control group.Results: Both case and control groups were consisted of the same age (P=0.725) and gender (P=0.777) individuals. The BMI (P<0.0001) and BMI Z-scores (P<0.0001) of constipated children was significantly higher than the control group. Also, weight (P=0.004) and weight Z-scores (P<0.0001) were significantly higher in the study group. There was no significant difference in height between two groups (P=0.1), but constipated children had higher height Z-scores than control group (P=0.027). The rate of obesity (define as BMI Z-score>2) in children with chronic constipation was 40% that was significantly higher than normal control group (11%) (P<0.0001).Conclusion: We found a higher obesity rate and also higher BMI and weight Z-scores in functionally constipated children compared with healthy control group. The reasons for the association between obesity and constipation are not clear and multifactor including diet, activity level, or hormonal influences, are involved that required additional studies.

Background: In western countries with high prevalence of colorectal cancers, colonic polyps are usually adenomatous. There are few studies from Iran regarding to the predominant type of polyps in colorectal area.Objectives: We conducted this retrospective study to evaluate the predominant colorectal polyps in our center as the largest referral center of the South region of Iran.Material and Methods: We retrospectively analyzed pathology reports of colonoscopies during five years (2005 - 2011). Histologic reports and demographic findings were recorded and compared with published studies in the literatures of other countries from different geographic regions of the world.Results: During these years, 990 patients with colorectal polyps were refered to the center. The most common types of polyps were adenomatous (603), followed by hyperplastic (300), juvenile (80), inflammatory (5) and Peutz-Jeghers (2). The most common site of polyp was rectosigmoid.Discussion: The type and distribution of colorectal polyps in Iran is very similar to western countries.

Background: Rubber band ligation is one of the most worldwide used treatments of hemorrhoids because of its effectiveness and low complication rate. Hemorrhoidectomy is the procedure of choice for treatment of grade four hemorrhoids which is a painful method for a relatively benign disease. There are a few studies available analyzing the effectiveness of RBL as an initial treatment for grade four symptomatic internal hemorrhoids.Objective: This study aimed to analyze the efficacy of the staging rubber band ligation in treatment of grade four hemorrhoids and comparing to hemorrhoidectomy.Patients and Methods: A prospective randomized clinical trial was performed on all patients diagnosed with grade four symptomatic internal hemorrhoids from August 2011 to March 2013. Sixty four patients with grade four hemorrhoids were divided into two groups and underwent hemorrhoidectomy (H group) and rubber band ligation (R group).These patients were compared for any complications and recurrence in a six month period.Results: Pain existed in 100% of the H group and 67.7% of the R group in the first visit one week post operation (P<0.05). There was a statistically significant difference between the two groups regarding the days off work. Patients’ satisfaction and recurrence were similar in both groups after a period of six months.Conclusions: This study showed that staging rubber band ligation is effective for treating grade four hemorrhoids. Few complication and low recurrence rate were noted which enable us to recommend this modality as the procedure of choice for the management of selected patients with grade four symptomatic hemorrhoids.

Background: Pouchitis is a non-specific inflammation of the ileal reservoir and the most frequent complication that patients experience in long time periods. Diagnosis should be made on the basis of clinical, endoscopic, and histological aspects. Prediction of pouchitis is an important issue for the physician.Objectives: Identifying the predictive factors of pouchitis and their importance is the study's objective.Patients and Methods: In the present study, two classifier techniques namely decision trees method and logistic regression analysis are used to help the physician for prediction of pouchitis in ulcerative colitis (UC) patients. These patients are submitted to a specific surgery. The ability of these two methods in prediction is achieved by comparison of the accuracy of the correct predictions (the minimum error rate) and the interpretability and simplification of the results for clinical experts.Results: The accuracy rate in prediction is 0.6 for logistic regression method and 0.45 for decision tree algorithm. In addition, the mean squared error is lower for logistic regression (0.41 versus 0.48). However, the area under the ROC is more for decision tree than logistic regression (0.52 and 0.45 respectively).Conclusions: The results are not in favor of none of these two methods. However, the simplicity of decision tree for clinical experts and theoretical assumptions of logistic regression method make the choice clear. But more sample size may be needed to choose the best model with more confident.

Introduction: Pneumatosis intestinalis is usually considered as a benign condition. Here we report the association of this condition with mesenteric vein thrombosis leading to bowel gangrene which to our best knowledge is the first reported association.Case Presentation: Our patient was a 71 year old Iranian male, smoker, who was followed with diagnosis of pneumatosis intestinalis for 11 months and then developed abdominal pain which was confirmed to be due to mesenteric vein thrombosis complicated by bowel gangrene.Discussion: Although pneumatosis intestinalis is not usually a threatening condition in adults, new onset of abdomen in these patients should prompt for complications such as mesenteric vein thrombosis.

Dear Editor: This study from Shiraz is an important contribution to our understanding of the epidemiology of inflammatory bowel disease. It also offers an opportunity to investigate those environmental factors that are operational in the increase of incidence that has been seen in a number of countries. The epidemiology of IBD in Shiraz shows the classical features of a condition that first emerges in urban areas with the dominant condition initially ulcerative colitis. With time there is a move towards equality of the two conditions and a disappearance of the urban/rural divide (1). We have no understanding as to why this happens. However, with the sophisticated techniques now available to both epidemiologists and laboratory scientists it is possible that Shiraz and other areas of Iran could provide the answer. One exciting difference reported in this paper is the absence of a significant role for tobacco use. What does this mean and will a more clear role emerge as the disease incidence increases.

Dear Editor: We have read with interest the paper "Epidemiology of Inflammatory Bowel Diseases (IBD) in Iran" (1) by Dr. Taghavi’ AR et.al and would like to make few comments on this study. According to the first published literature from Fars (Shiraz) 44 years ago the authors claimed that there is no IBD in Iran (2). The first two reports of IBD in Iran which were designed to look for all cases of IBD [both ulcerative colitis (UC) and Crohn's disease (CD)] came 28 years ago from Tehran and 27 years ago from Shiraz. In both surveys the authors could only find UC and they both confirmed that they couldn't find even a single case of CD (3, 4). The first CD case was reported 13 years ago and now CD incidence is increasing and became close to the incidence of UC (5, 6). This epidemiologic pattern is similar to what happened in western countries during the first two decades after the emergence of IBD in Western hemisphere that is UC appeared first, followed by CD 15–20 years later and today CD is almost as common as UC. The most important causes of increasing IBD prevalence are life style changes, better hygiene, vaccination and cold chain theory rather than availability of diagnostic tools (7).

Dear Editor: Variety of mesh materials are available, for treatment of ventral hernia repair, that can be selected by surgeons. Three main types of prosthetic mesh are used for repair of abdominal hernias (1-4).These types are: 1- Synthetic mesh, such as polypropylene (pp) or poly ester with vigorous tissue ingrowth and high tensile strength.2- Biologic mesh is a collagen based human, borine or porcine scaffold (4, 5). This type of mesh is used in the setting of contaminated or infected surgical incisions, and can be implanted intra or extra-peritoneal position.3- Composite, or barrier–coated is a dual sided prosthetic having a visceral surface that repels tissue in growth and parietal side to primate a strong repair (4). The visceral side decreases adhesive formation. Synthetic mesh such as polyester are appropriate durable materials for extra peritoneal placement (4-6). And if we used intraperitonealy could develop sever adhesions to the bowel and causes enterocutaneous fistula (2, 7). This phenomena is confirmed by many studies. Even mesh related fistula or their complications have seen in these patients who were treated using composite dual sided prosthetic meshes (2, 3).

Dear Editor: Refering to the letter entitled "Caution in Usage of Synthetic Mesh in Repair of Incisional Hernia" (1) I should say that as mentioned, mesh is used to repair defects. Higher cost of "Biologic" Mesh, less consistency and more probability of formation of seroma in using "micro porous" mesh lead to better acceptance for prolene as a macro porous compared to mentioned types. However, the weak point for this type of mesh is higher chance of adhesion to adjacent organs like small bowel. In our study used omentum as a layer beneath mesh to reduce the probability of adhesion. Thus we did not experience such problem (2).

Dear Editor: It is never easy to conduct a randomised double blind control trial in pregnancy and so the importance of this report cannot be over-emphasised (1). Support for this view comes from the fact that 724 of 3136 (23%) of women invited to take part in the study declined to do so. However the outcome has been to demonstrate clearly that the addition of psyllium to the diet in the third trimester can effectively reduce the painful rectal complications of pregnancy. In the treated group 10 patients (1%) had a fissure or haemorrhoids compared to 138 (13%) in the placebo group (2). Such a benefit should be offered to all pregnant women in their last trimester. In addition there should be long term follow-up of these cases to assess whether this benefit extends to include a reduction in the rates of rectal and vaginal prolapse.