Vincent de Parades

Introduction: Third- and fourth-degree hemorrhoids often require surgery due to prolapse, bleeding and discomfort. Among the available procedures, there is no consensus on which surgical technique offers better results. This systematic review with meta-analysis aims to compare harmonic scalpel hemorrhoidectomy (HSH) versus stapled hemorrhoidopexy (SH). Methods: A search was conducted in the PubMed, Scopus, and Cochrane Library databases. Inclusion criteria were (a) randomized controlled trials, (b) comparing HSH and SH, (c) in patients with grade III/IV hemorrhoids, and (d) reporting at least one outcome of interest. Statistical analyses were performed in Review Manager 5.4.1 and RStudio, using a random-effects model to calculate the risk ratio and mean differences with 95% confidence intervals (CIs). Results: We included six randomized controlled trials with a total of 375 patients. HSH was associated with a lower recurrence compared to SH. However, there were no significant differences in bleeding, fecal incontinence, operative time, hospital stay, and urinary retention. SH group was associated with less postoperative severe pain and overall pain. Conclusion: HSH and SH are comparable in the treatment of grade III/IV hemorrhoids, analyzing postoperative bleeding, fecal incontinence, operative time, hospital stay, and urinary retention. However, SH presented less severe and overall pain, showing better results in the short term and HSH presented lower recurrence, highlighting as a better outcome in the long term.

Purpose: Minimally invasive techniques are increasingly applied in the management of pilonidal disease. While laser therapy is well established, radiofrequency (RF) represents a newer alternative with theoretical advantages. However, no prospective data have yet been published on its use. This study aimed to assess the safety, efficacy, and patient satisfaction associated with RF treatment for infected pilonidal sinus.Methods: We conducted a prospective, single-center pilot study including consecutive patients treated with RF between March and December 2023. The procedure was performed under spinal or general anesthesia in an outpatient setting using a radial RF probe (25 W, 4 MHz) following mechanical debridement. Patients were followed up at 15 days and at 1, 3, and 6 months. The primary endpoint was safety; secondary endpoints included healing rate, predictors of failure, postoperative pain, return to activities, and patient satisfaction.Results: Forty-four patients were enrolled (median age, 25.5 years; 31 men, 70.5%), of whom 38.6% had undergone previous surgery. The median operative time was 12 minutes. No major complications occurred, and minor early events were reported in 6.8% of cases. Complete healing at 6 months was achieved in 77.3% of patients. Failure and recurrence rates were 13.6% and 9.1%, respectively. A history of prior surgery significantly increased the risk of failure (odds ratio, 0.2; P=0.005). The median peak pain score was 2 out of 10, with a median duration of 2 days. Overall, 33 patients (75.0%) were very satisfied, and 40 (90.9%) stated they would undergo the procedure again or recommend it to others.Conclusion: RF appears to be a safe, minimally invasive outpatient treatment option for pilonidal disease, demonstrating promising efficacy, minimal postoperative pain, and high patient satisfaction.Trial registration: ClinicalTrials.gov identifier: NCT05855733.

Background: High-resolution anoscopy (HRA) is the gold standard for anal cancer screening, but its interpretation is challenging and operator-dependent. Artificial intelligence (AI) may increase diagnostic yield, but most studies have focused on differentiating low-grade and high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively) in still frames, with no clinical application reported. Methods: We describe the first real-time use of deep learning, demonstrated in three patients undergoing HRA for anal cancer screening, at a high-volume American referral center. When an area suggestive of HSIL appeared, a YOLO-based object detection model generated a bounding box. Results: The model detected only histologically confirmed HSIL and did not activate when no lesions or only LSIL were present. Conclusions: This report suggests that real-time AI-enhanced HRA is feasible and may improve lesion detection and differentiation, potentially representing a significant step forward in this demanding field, although multicentric validation studies are still needed.

Background: Although urinary retention (UR) is one of the most frequent complications after proctological surgery, most studies identifying risk factors were conducted before the development of current good practice guidelines. Objective: This study aimed to update the list of risk factors for UR occurring within 14 days after hemorrhoid surgery and to develop a predictive algorithm. Design: A retrospective observational study based on computerized medical records. Patient and Methods: All patients who underwent hemorrhoid surgery between 2018 and 2023 in a single hospital in Paris. Main Outcome Measures: All occurrences of UR within 14 days after surgery. Sample Size: A total of 4233 interventions were included. Results: The frequency of UR was 4.4% (n = 185). Among these, 674 (16%) were minimally invasive procedures. Spinal anesthesia was used in 513 operations (12.5%), and 2605 operations (63.7%) were performed under pudendal nerve block. The following risk factors were identified: male sex (odds ratio [OR]: 1.6; 95% confidence interval [CI] [1.0–2.5]); high prostatic risk, defined as benign prostatic hyperplasia or a history of prostate surgery (OR: 4.3; 95% CI [2.1–8.8]); and the use of certain techniques—tripedicular hemorrhoidectomy (OR: 4.0; 95% CI [1.9–8.5]), Tripedicular hemorrhoidectomy with fissulectomy (OR: 3.4; 95% CI [1.2–9.2]), and ligation of the hemorrhoidal arteries under Doppler control with mucopexy (OR: 4.5; 95% CI [1.9–10.7]). The perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs) was protective (OR: 0.6; 95% CI [0.4–0.9]). The use of a pudendal nerve block or spinal anesthesia had no effect on the risk of UR. The predictive model yielded an area under the curve of 0.71 (95%CI: 0.63–0.80). Conclusion: Certain surgical techniques were associated with a higher risk of UR. Conversely, the perioperative administration of NSAIDs was protective. The type of anesthesia did not affect the risk of UR. Limitations: Single-center, retrospective design. Conflict of interest: VdP reports conflicts of interest with A. Legrand, Biolitec, FCare Systems, and THD lab. The other authors declare no conflicts of interest.

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Perineal suppuration encompasses a broad spectrum of pathologies involving the anatomically complex perineal region. While anal fistula, with or without abscess, is the most frequent cause, infections may also originate from the skin, accessory urinary or genital glands, pelvic and perineal implants, or supralevator digestive structures. Clinical presentations range from benign acute episodes to severe life-threatening conditions or chronic relapsing infections. Diagnosis is often challenging due to overlapping symptoms and variable anatomical involvement. Imaging plays a pivotal role in delineating the extent and origin of disease, particularly in distinguishing anal from extra-anal sources, an essential step for appropriate management. Ultrasonography (US) and Magnetic Resonance Imaging (MRI) are well suited for evaluating anal fistulas; MRI is preferred for chronic, recurrent, or deep-seated infections, particularly those of cutaneous origin or associated with implant infection, while Computed tomography (CT) is favored for supralevator digestive involvement and Fournier’s gangrene. A detailed understanding of perineal anatomy and its imaging correlates is crucial for accurate diagnosis and treatment planning. This pictorial essay illustrates the imaging features of perineal suppurations from diverse etiologies, emphasizing the diagnostic value of cross-sectional imaging and the central role of radiology in clinical decision-making.

Introduction: Perianal Crohn's disease (CD) remains challenging to treat despite the increasing number of advanced therapies. Advanced dual‐targeted therapy has emerged as a new treatment option in CD, but no data are available for perianal CD. The aim of this study was to evaluate the effectiveness and safety of advanced dual‐targeted therapy for anoperineal fistulas (APFs) in CD patients.Materials and Methods: We prospectively included all consecutive patients receiving an advanced dual‐targeted therapy for APFs from August 2019 to December 2023 in a single tertiary perianal CD centre. The primary outcome was clinical effectiveness. Secondary outcomes were patients' treatment perception, radiological effectiveness, luminal disease effectiveness, impact on extra‐intestinal manifestations, and safety. Factors associated with complete clinical remission of APFs were identified using logistic regression.Results: A total of 33 patients were included. The most frequently used advanced dual‐targeted therapy was a combination of infliximab and ustekinumab (75.8%). After a median follow‐up of 27.4 months, 48.5% and 97.0% of patients were in complete clinical remission and reported a perceived improvement, respectively. Complete radiological remission was achieved in 24.2% of the patients. A concomitant improvement in luminal intestinal involvement was observed in 46.1% of cases, and in extra‐digestive manifestations in 45.8% of cases. Treatment tolerance was considered good or very good in 90.9% of cases. Associated anal ulcers and long‐term exposure to antibiotics were associated with a lower likelihood of complete clinical remission for fistulas.Conclusion: These findings suggest that advanced dual‐targeted therapy is a valid option with a good safety profile for the treatment of refractory APFs. Larger studies are required to identify the most effective combination.

Background: The primary opening of the cryptoglandular fistula-in-ano is generally assumed to be present at the dentate line as the cryptoglandular glands open there. However, no study has ever systematically studied the location of the primary opening. Methods: All fistula-in-ano patients operated-on over two years were screened and those who were never earlier operated on were included. Magnetic Resonance Imaging (MRI) was done on all patients. The primary fistula opening was localized on the MRI and corroborated with the operative findings. The primary opening was categorized at three levels - at the dentate line, above the dentate line, and below the dentate line. Results: 744 anal fistula patients were operated on over two years and 379 patients, who had never been operated on before, were included in the study. 35 patients were excluded (the primary opening could not be localized). In 344 patients (finally analyzed), the primary opening was at the dentate line in 223 patients (64.8%), above the dentate line in 79 (22.9%), and below the dentate line in 42 (12.2%) patients. The primary opening was located above the dentate line in significantly higher numbers in complex fistulas than in simple fistulas (73/102 in complex vs 6/242 in simple fistulas, p< 0.00001). Conclusion: Unlike commonly presumed, the primary opening is located at the dentate line in only two-thirds (64.8%) anal fistulas. In 22.9% it was located above the dentate line and in 12.2%, below the dentate line. This is the first study in which the level of primary opening has been systematically analyzed.