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Thank you for that really excellent talk. Um It is a real honor to introduce Professor Brown, especially as a pelvic floor representative. Professor Brown is a past president of a CPG BA founding member of the Pelvic Floor Society and is a leading voice in the fields of IBD and proctology. We look forward to hearing proctology hacks. Thank you very much indeed. Yeah. II li originally invited me to give a talk on Fischer a know, but I'm not an expert in fissure. So I negotiated with her and it struck me that over the years uh trainees in er surgery that come through Sheffield have learnt haven't got the same skills necessarily, haven't had the same opportunities in pro that the older members of the audience have. Uh And you know, I've, I used to run an independent list by myself as a registrar. And then 20 years' worth of being a consultant means that I've made every mistake in the book. So I thought I could actually give you some tips and tricks on how to do proctology. And this is what I thought I'd cover P sinus disease, not really proctology, but I've listed amongst the things that I would talk about a bit about anal fissure, a bit about hemorrhoids. And then I realized I've bitten off more than I could chew. So there is no way that I can cover fure any, but I'm delighted to do it next year if you want to invite me back. So, uh pineal disease, this is a mixture of anecdote plus uh evidence base when I can find it. There is a bit of evidence base about pineal disease because we did the pit stop study recently. Thank you to anybody that was involved in that. And that gave us a snapshot really of what goes on in pilar disease in the UK at the moment. And these are all the procedures that are being done quite a lot of them. And that's consistent with the literature. But two procedures I want to point out to you that are being done in about 20% of cases that the connoisseurs of Pinar disease would say were obsolete. And that is just simply cutting the disease out and leaving it open or trying to close it in the midline. And the reason that these procedures are obsolete is that they go wrong, er, they cause big problem problems for both the surgeon. And most importantly, the patient who has many, many months of uh um inconvenience because of uh necessary wound healing. And actually, if you look at the data from pitstop, they don't do very well. Either the middle column, the one in the red, about a 40% chance that that treatment will fail. Actually, overall, it's pretty bad for pineal disease in the UK, 20% of patients have treatment failure at six months. So we're not really doing it very well. And if you're gonna do it best of all, or you wanna avoid treatment failure. If that's what the patient wants, then uh an asymmetric closure seems to be the best, but even then 10% recurrence rate. So we can improve this. So bit of anecdote. Now, what operation should be done? It all depends upon the disease severity so that the, the patient on the left, you shouldn't really be doing an asymmetric closure there living or a single pit, you're gonna make the surgery worse than the disease itself. Uh If you simply cut it out, so do something minimal. The same can be said of the one in the middle. You've just got three pits there. You can just simply do a very, a minimally invasive procedure. And you could argue, er, er, for the patient on, on the far left of your screen who's got a uh an extension, uh uh a lateral extension, they could get away with a minimally invasive procedure. So these are the three top minimal invasive procedures in the UK at the moment. It picking pretty simple. All you need is one of these biopsy, uh um er, er, core biopsy sets and you simply, er, excise the pit and scrape out the underlying cavity and that's it. Anybody can do that. Now, John's in the audience. So he would say that after you've done this, you should put a bit of glue in there. Always a bit of a skeptic about this. Is it really worth the 300 quid? It costs for that to seal glue. But actually, if you look at the er pit stop data, you can reduce their reco er recovery rate from 10 days to four days. Is that worth a 300 quid? Probably, maybe. Uh I tend to favor the Bascom S one technique as John, er Wild has already alluded to, er, he should have carried on with this rather than doing all that fancy stuff that he does there. You make a lateral incision after you've done the pits, er, excision and you just, you can see where the hairs are and you can scrape them out with confidence. I'm not sure you can with the other two techniques. Uh when it comes to complex disease, it's a bit more tricky. You're not gonna get away, get away with pick, picking on the left hand s slide. Er, you're gonna need to do something more extensive and the same is true for the middle one where you've got that sort of quite large pit. Uh You do sort of pit picking there, you're gonna make a hole that's as big as if you excise it and then the patients on the far left, the ones with recurrent disease, they're in mixed bags. Sometimes you get away with minimum invasive procedures perhaps with this one you can. But most of the time you can't. So you need something a little bit bigger. And the most popular intervention is an asymmetric closure of some sort. There's a, a Bascom Cleft closure illustrated in those slides there, but you may want to be doing flat procedures. So I think the important thing is we're going to do this more aggressive surgery is to do it right? Because I don't think we do, even though we think we're doing a KODA or a cleft closure, I'm not sure we're doing it right. Necessarily. This is an operation that has been done, right? Because the wound you've got at the end is away from the midline only, just away actually. And I would say that I would prefer it to be about a centimeter or two away. Uh This is a procedure where they've had apparently a, a Cary Ais. Uh fortunately it's healed, but you can see that the wound when you finish is in the midline. So if you're doing this operation, you think you're doing it right? And you find that the er overall closure is in the midline, you're not doing it right. And you should learn how to do it properly. And I learned how to do Koeki off this video. Actually. By Peter Willsi Worth looking at. Uh it's, it's a very good explanation of how you should do it. So this is my algorithm for patients with Pinard disease. I think you've got to have two operations. You've got to know how to do two operations and do them, right. A minimally invasive procedure of some sort and a more maximally invasive procedure. So with minimal disease, you do a pit picking or glue or eps. If you've got the money to do that or Bascom one, if you've got a lateral extension, I tend to favor Bascom one. But John I'm sure would favor glue if you've got multiple pits in the midline. Once you've excised them all, you've made a big hole. So actually, you're probably best doing an asymmetric closure. Now, for bilateral disease, you need to do a flap. If you don't know how to do a flap, just find somebody that does or send to you a friendly plastic surgeon and then recurrent disease is a mixed bag. So that's it about pineal disease. I'm whizzing through as fast as I can. I'm aware of time onto anal fissure. Now, for, for me, the important thing about anal fissure is getting the diagnosis, right? Cos we share lists, we share the day case list and sometimes patients are listed for Botox or something for their um anal fissure and actually they haven't got an anal fissure. So this is an example of a patient who doesn't have an idiopathic anal fissure. It's chronic irritation. These patients don't need an operation. They just need some steroid cream and perianal hygiene advice. Here's another patient who doesn't have an idiopathic fissure. They've got Perianal Crohn's disease, send him down the line of treatment for Perianal Crohn's. And here's an elderly patient with cardiac disease who doesn't have an idiopathic anal fissure. They have a nicorandil associated fissure just changed their cardiac medication. You don't see this so frequently now, but it seemed to be rife about 1020 years ago. So there is some evidence here. It's pretty poor evidence, but there are some guidelines. Katie Cross has recently updated these guidelines and I'm sure you're all familiar with the pathway of treatment, acute fissure treat conservatively chronic, start with topical treatment. GTN gives you a headache, dilTIAZem, difficult to get hold of by GPS, certainly, but doesn't tend to give you a headache just as an aside, some other designer drugs for the anus. There have been a few things that have tried and trialed. L Arginine was a promising one because that's a precursor to GTN. Unfortunately, trials so far suggest it doesn't work. There's some other medications including Minoxidil which has some really good side effects for some of us, unfortunately doesn't work. And another one with a good side effect is Viagra should work. Been trialed. Unfortunately, not so far, been shown to work. Something that's promising though, if you ever want to do a bit of research is clove oil. Some small trials have suggested it works well cheap as chips. If it seems to work, anybody interested in doing a trial, I think this would be a winner. What about Botox for the anus? Does it work? Uh, don't, don't know how it works. I'm a simple surgeon. I thought the Botox relaxes striated muscle and you want to relax smooth muscle. So, really don't know how it works and somebody clever needs to explain it to me. What dose do you use? Uh The literature varies between 2.5 units. That's probably too low and 100 units. That's probably too much in my book. Uh Nobody knows where to put it. I tend to put it either side of the fissure, but I think you can basically put it anywhere you want. What about lateral sutures? I think lateral is a great operation. It's got a bit of bad press, but there aren't many operations that you can guarantee a sort of 95% success rate. But the big fear for everybody is that it causes incontinence. So we tend to shy away from that in these days of defensive medicine and do a tailored sphincterotomy cut, the fissure, cut the, the sphincter to the level of the fissure. Uh This will lead to an increased recurrence rate compared with cutting it down to the dentate line, but certainly reduces er, incontinence. Um I think incontinence is rare. Um, you tend to very wear, wear away from it in women. But all of this data, all of these studies were done on men and women at the time. But II would tend to reserve a lateral sphincterotomy for men. I would tend to use it actually ahead of Botox. I think a man with a big sphincter who's got lots of symptoms, it works really well and the instance of incontinence is rare, I wouldn't do it in women. Uh Moving to the low pressure fish is an interesting group. I think if you're not a pelvic floor surgeon, you've got an easy get out with these, just send it to somebody who is, if you are a pelvic floor surgeon, then they could cause you trouble biofeedback. It's a safe thing to do. The Dutch have shown in a study recently that it works for some of these patients who've got this disorder defecation leading to the fissure neuromodulation is safe but expensive. If they've got an internal interception, you might want to consider a rectopexy, but you're into tiger country there. And I really like the Peroneal Support toilet when I was in Singapore. This was really raved about. So this is a perineal support toilet. Apparently you sit at the back of the toilet seat when you're pooing and it supports your perineum. Never really taken off in the UK. Not quite sure why. Maybe it's a cultural thing. We don't like sitting on the back of the toilet moving swiftly on to hemorrhoids, er, evidence base here. Uh There's lots and lots of guidelines out there but I think still the best guidelines is the ES EP guidelines and anybody who's read it will be familiar with their treatment algorithm based on the degree of hemorrhoids according to the Gouger Scale, which isn't perfect, but it's certainly how we've done all of the studies so far. One thing in common with all grades of hemorrhoids is that you start with conservative management. So most patients that come to your clinic are just worried that they've got cancer if you can exclude that. Actually, most of the time they are very happy. Certainly give him some uh lifestyle advice. Uh, tell him to eat more fiber, don't strain on the toilet, but there are some patients who will continue to want some further treatment. Now, I've, uh, this is where shared decision making comes in to find out what that patient wants and what they're prepared to go through. Do they want an operation that's gonna sort them out that might cause pain for six weeks or do they want something that is not necessarily gonna be so effective but doesn't cause so much pain. I've got a colleague who will band and band and band again and they think that patients will always get better. I'm not sure that that's true. This is a study that's quite old now, but I think it's quite intuitive. Uh, so you can see that they, er, looked at a big coal of patients, uh, and put them through 123 or more banding sessions. And if you look at the one band session, uh, your half life, 50% of the patients will, within six months. If you do two bands, 50% will recur within about 12 months and three or more bands, you can keep them going to 18 to 24 months. So some patients might like that. I certainly would. I'd be happy to come back every 18 to 24 months to have a further banding session. Um I've got another colleague who says, if you've got to operate on a patient, you should only do a hemorrhoidectomy. Nothing else works. Uh But I uh put this to you. This was a, a very, very non scientific survey. I did. I asked 15 consultant surgeons, would you ever have a hemorrhoidectomy? Guess what the result was? 93% a a categorical? No. So I think you've gotta bear that in mind if you're gonna offer a hemorrhoidectomy for somebody if you do do it. Uh This is evidence based given some laxatives, preoperatively, one of the oldest randomized controlled trials that I'm aware of anyway, uh is when I was a medical student, seven days of lactulose before operation definitely increases the pain afterwards. Do it as a day case? Not quite sure that would, the way that would work better. Um, probably out of sight out of mind, I guess. Um, one thing that is very, very prominent in that is dia excision, don't ligate the pedicle. There's absolutely no need to do that. Just use the dia be a bit more thorough about it and that will reduce your pain quite substantially. Now, if you were in a hospital, uh that can afford it, uh somewhere down south, then you, you might use the ligasure, put loads of local anesthetic in it doesn't matter if you do a pedal nerve block or a local anesthetic, give them some metroNIDAZOLE for 3 to 5 days afterwards. And the last thing about evidence based practice that I don't follow is GTN that will reduce the pain, but I tend to find it irritates the wound. So I have dropped that one. What about other options? This gives me an opportunity to plug the Hubble trial. I've been doing it for eight years now. This was a trial, hemorrhoidal artery ligation versus rubber band ligation. I think the important thing to take away from here is that hemorrhoid larger ligation, the recurrence rate is high. It's 30% and that's a lot higher than the Italians would lead you to believe. And it obviously costs more than rubber band ligation. I still do it in patients that want an operation that don't want a hemorrhoidectomy, stable hemorrhoidopexy. That's almost gone out of day. I'm not sure that anybody here would necessarily have confidence about how to do it. And I guess it's fallen out of favor because of the high recurrence rate. But it's not as high as hemorrhoidal art ligation interestingly, but it's also the complications that can occur. The urgency, more serious complications, which actually are very, very rare. I still do this. I'm in a very select group of patients and here's an example of one, I don't know what else would sort this patient out circumferential hemorrhoids that are huge. And, and for me, this is AAA stable hemorrhoidectomy will be the only thing that will work for them. What about newer techniques? Still? Raffaello is the new kid on the block. Can't tell you much about this, but I can in about 12 months time when the Orion trial will eventually finish. So again, another reason to invite me back and as I say, fish, invite me back next year. Thank you very much.