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A long time before they actually report the symptoms. So uh it is a huge burden. So what we want to do is to overlay of what, what the condition, different class of do also. So it's not hard and different treatment strategies and what you're going to choose a very simple blood kind of uh uh strategy might say that. So we pick up the form and his legs come up. So until the we're trying to connect. OK. That is a year. It's been, it should be now inside the Yeah, thanks. Yeah. It OK. OK. So I got to define production. So it's um of the of the person. So it's more than stopping to collapse if it's depending on how, which degree it is for self causing symptoms, for the patient sometimes down there. And the contribution to the anal tone is much more than anyone else. So if we do something to them quite dramatically shrinking the hemorrhoidal complexes when they are not symptomatic may affect the other side of the symptom complex. So it is from the super rectal artery and middle rectal veins, we're going to see some pictures which show how they are. So what, what, what, what is this, what, what, what is this cause of the heal uh tissues to present itself symptomatically or prolapsing outside? There, there, there are suspensory ligaments very nicely scripted described and pictured in the Giger text with the newer version written by uh Nigel. It's two volumes, just two volumes, I think some 5000 pages. It's like this much or all, all topics. So the topic on the, the chapter on hemorrhoids, nice line diagrams showing the suspen suspensory ligaments which which when Gola prolapse down and then I love the internal component and the mucosal element to props outside the as the external component obviously habitually, uh we strain on the toilet to what extent we strain to evacuate. Depends on your personal condition and underlying ra factors. Habitual strainers have traditionally a higher chance of getting mucus or prolapse and prolapse hemorrhoids. Uh It's a vicious cycle. We always tell the patient it is a vicious cycle. You get constipation, you strain, you get hemorrhoidal congestion, they prolapse, they get more symptomatic, they uh and and they, they will address this underlying cause. So there's more straining, more constipation, more pain, they don't go to the toilet and then this this cycle has to break. So we're going to talk about that. And there's one of the important competence in hemorroidal management is conservative measures like a kind of one word conservative measures. But according to literature can address 40% of the symptoms, if you just address the conservative measures to the um to a relevant degree. Well, as you can see there, ok. Uh hemorrhoidal cushions, the internal internal hemorrhoids there, the external plexus uh classically you can see them in certain early hemorrhoids when you can't be visible outside, when you pop the proctoscope and you get a bulge there and a and a kind of bluish discoloration of the mucosa and they are interconnected obviously. And at some stage, they emerge into the whole thing coming out presenting as an internal external hemorrhoid, common symptoms, bleeding, prolapse, discharge and itching. Sometimes many patients present with just discharge and itching. Uh And if they get thrombosed, e especially the external component, they present with thrombosed external piles which stretches the skin and it's very painful, very painful. And coincidentally, there are conditions which uh p simulate pretend to be hemorrhoids, but they are not. We just biopsied. The lady on a Sunday list, an extra list. I saw her last Wednesday GP for hemorrhoids. One look said this is anal cancer. It's not hemorrhoid, it's uh booked uh for an eu a gentle anesthetic biopsy. It was a classical anal cancer with a hemorrhoid sitting next to it treated for good part of 18 months with topical applications. So it won't be really, really be aware you it will, it will catch someone. Uh otherwise if we are not looking for it. So this is the classical gold classification. There are, there are, there are a code of classifications and I think it was touched by uh uh Costus similis who did a meta analysis from uh uh with, with the persis published 56 years ago of all the eral treatments. And when they compare er treatment, you need a common classification and we don't have one and this is the uh in practice classification which we use. So grade one hemorrhoids bleed, but you can't see them. Grade two hemorrhoids bleed and prolapse but reduced spontaneously. Grade two hemorrhoids prolapse and need manual reduction and grateful uh stay out all the time. You can't get it back in. So what there is a school of thought says that this classification is based on what the patients are telling you. So not your finding, it's not your eliciting a sign or symptom. So it is it is done to that extent. You can speak to someone and you can grade the hemorrhoid if you know what I mean. So based why, why do we have the gradation? Because based on the gradation, we are going to classify the treatment opportunities we can provide to the patients. So I think we need to come back to this slide in the end to kind of get an idea once we go through all the things. But basically, the algorithm will ent taking history, physical examination, grading them. And then based on what the grade is, you offer the treatment options. And if you just eyeball that screen, you can see that there's basic treatment and, and which is the conservative measures across the boat followed by for the lower grade hemorrhoids of rubber band ligation, which is a reasonable option along with sclerotherapy or as an alternative. And on the other side, you have uh a a pexy kind of offers and excisional hemorrhoidectomy. So this is a, this is a broad classification. It is very clear and it will help you outline your strategy to the patient in the clinic and in the exam to the examiner quite clearly and justify why it is. But I think we should come back to this later once we go through the different option, but it gives you a flavor of the different types of treatment you can offer. Lovely. This is what it looks like. Uh when, when you do retroflexion in the anus, as you can see, it is a, it's congested in, in internal piles and what to look outside, you can imagine. So basic treatment. So this is what we can combine it as conservative measures. And in my opinion, and when what I've read from the literature, this is going back several years can address 40% of the symptoms. It's not going to cure the piles, but it's going to address 40% of the symptoms and it's going to improve the outcome of any treatment they're going to offer, whether they are going to offer rubber band ligation, radiofrequency treatment, uh humid Opex, uh or humid omy if they don't address this. Uh in my opinion, and I think others will agree that it reduces the efficacy of the other treatment that we have to nail to the patient before we start. And all the information leaflets should, should contain that as the basic information they try easy to say, difficult to follow. Uh weight loss, exercise, alter fiber, alter fiber. So some patients, not all patients need a high fiber diet. There are some patients we see in a very complex situation, having IBS type symptoms, hypersensitivity, same things heal bleeding. If you give them high fiber diet, they will not comply. So you, you, you if there's something else I can help with. No, if uh so, so you ask them to modify their diet and you can give fiber supplements, increase dietary content in uh the in in the diet. Add it on with laxatives and toilet training. Even before they go for formal uh gi physiology lab, you can, you can tell them to use a step stool high to s to simulate the squatting kind of mechanism to vertically align the rectal channel and then evacuate because that that is the closest simulate to squatting. Uh you can't squat on the western toilet, it's dangerous uh and laxatives and topical therapies. So in the audition clinic for uh he symptomatic hemorrhoids. So Emma will you treat asymptomatic hemorrhoids? No, why, um, because you are doing something with something that's not causing any other risks. Symptoms get worse when there's no symptoms initially. Yeah. So there's no need to treat there. There's no need to offer procedural treatment. But we can tell them about the basic treatment strategies as, as a bottom line to, to kind of advice, lifestyle changes, weight, uh, regulation of bowel habit, dietary modification as a, as a package deal, which will help their overall. Yes. So the all the the answer could be yes but no, but I will advise them of the of the lifestyle changes which which which helps them overall holistically. So rubber band ligation is a time tested uh uh method of treating hemorrhoids. Uh I remember going back several years uh uh using the Baron's Gun stainless tail uh proctoscope with a metal uh gun applicator, you to load the gun attached to the suction and then fire it with a spring mechanism. It looked daunting. Actually, there was a patient next to me like clank metal metalwork, clanking uh while doing it now, it is fantastic. The auto loading guns uh love them making fire in 10 seconds. As long as it's in the right spot. Patients happy if it's in the wrong spot. No one is happy. It, it, it kind of completely decimates the clinic after that. And you should remember that uh the the the perception of the dentate line, it should be quite clear when you do a proctoscope of where it is and you have to place the rubber bands well above the dentate line, not just above the dentate line, you're not bending the rectosigmoid. I'm not telling you the band, the rectosigmoid junction. But if you keep it too close to the dentate line and apply suction, it pulls the mucus in and if it's on the verge of the dentate line, then they still get pain because of the dragging sensation there. So we advise to go half a centimeter above and half a centimeter is half a centimeter. It should be the same for all of you and for me. So it's not that I think that's half a centimeter and then bang on it close to the line because it, it can cause excruciating pain. And really, I don't want someone to ban my piles on the dentate line and then go for an e way to snip that band out. It just happens about once every two years uh that someone is so painful that they, we have to do it. What happens to the rubber bands on the, on the, on, on the piles they shrink, they call ischemic necrosis of that, of that uh of that uh mucosal uh knuckle, which is, which is squeezing and falls off. We have seen it fall off when they stand in the clinic. So obviously, it's not constricting enough and we've seen it uh fall off after five days seven days, they don't look for it, but there, there's a bout of bleeding which occurs during that. And all information, leaflets and advice, pre bending. Advice is to watch for the bleeding, nominal bleeding except if it's hosing out and if they unwell, come to the nearest A&E should be the default advice. You give patients injection sclerotherapy. Uh It was very common when I was training, we used to inject anyone who comes and opens their mouth in their co in the colorectal clinic, complaining of BS they go out after getting in injected with uh oi oily phenol uh in almond oil. Uh when it is done in the right plane is a very therapeutic satisfying procedure. Submucousal injection above the dentate line, they get no pain and uh it can be done for patients on anticoagulation. Uh and you can use the proctoscope to kind of give compression for uh for, for a few seconds to a minute to kind of seal that injection site. Have you seen the inje the, the syringe or the size of that needle? You've done it. Yeah. So it is quite a big syringe and because it's thick uh volume, it has a, it is. So what do you call that thing? Which uh it's, it's loaded on to air. So to a to a to a, to a, to an applicator so that when you apply pressure, you don't pass point or anything, you can smoothly inject into it So uh we still, we still do it. But II admit that it's gone off the, in our practice that common because of uh lack of guidance. Basically, you need to have the kit, you need to have the uh the para to apply it, you need to have the time to do it. And then to for the sake of convenience, banding has taken precedence over injection, sclerotherapy. Yeah, because you mentioned the risk, is there any evidence about with people on? The only problem is how long do you stop the anticoagulation? So if a patient comes to a flexible sigmoidoscopy list stopped uh the clopidogrel for seven days or Apixaban for three days, then you can bang it. But then if they start the anticoagulation or the antiplatelet on the same day or the next day when the band is going to fall off, they'll be fully anticoagulated. So there's a higher risk of secondary hemorrhage. So we, we tell them to stop the Apixaban or whatever for, for that 10 day period. Yeah. At, at least in our practice any comments, Phil The. So the uh when we banned a patient who's on cyclogram. Oh, a Apixaban. So, and we, when do you ask them to restart it after the banding? Absolutely. No. Mm Because the bleeding risk is rather than, than the. So you, you preferentially choose that. That is very much debate and no one know the right. That's thought to be the residual implications. So if you bend, if you band it, a patient with anticoagulation antiplatelet, you have to tell them not to take it for that longer. And if they are for a high risk anticoagulation condition like lupus antibody or whatnot, you know, there is a high risk and low risk condition, then they may need uh uh bridging because you don't want to really stop, you know, apixaban for so long and then clot some metal valve or uh or whatnot. I don't know what they're gonna have. What indication they have is so varied now. So for ease of for clarity, just divide it to low grade, high grade uh high, low risk, high risk indication for classification. All high risks should be discussed with hematology. So you have a secondary mind uh looking at it advising. So o oo otherwise it's very difficult to get keep uh bleeding complication for a simple condition for he's refusing to move on. Maybe he's asking me to stop. Now you inject the sclerotherapy into the, into the. So the the the the site of sclerotherapy is again above the dentate line in the submucosal cushion of the internal pile. So if we make it a picture, we'll show and what's the success rate of bending? Discuss with the patient? Yeah, anywhere between 40 to 80% for you here. Mhm OK. You can see a a pro external pile. It's working now. Thank you. So, processing external pile, if it's seen outside like that uh for the grade three and grade four, which it is a very sizeable external component, you can still bend, but there is a, there's a lower response rate but can be used as part of the treatment strategy to move towards uh more in more invasive treatment strategies. Uh That helps the patient adjust to the basic treatment strategies, diet, fluids, fiber exercise and everything. And also gives them time to for the ex if it's a large extra, come to shrink it. So that if you do an operation, it's a much less extensive procedure. Hemorrhoidectomy is the gold standard. 94%. Plus I think in uh Costas is uh comparison of uh the meta, the meta analysis for because they're excising the bile. So the the the the symptoms should be that much better. So they, but comes with a come, comes with a uh higher time of period of work, period, more pain score, POSTOP and less compliance with the patient. So that's why some patients are terrified of external hemorr, they Google, they speak to their friend in the pub and they, and they come, they're already pre preconditioned about what they're going to hear when you tell them hemorrhoidectomy. So that's why alternatives have been uh have been discovered and suggested hemorrhoidopexy uh is, is an operation to as it's a pexy operation, it's not exist, it is to plicate the mucus uh w which uh has the blood vessel, feeding the pile. So if you plicate it, you're cutting it off and then it tucks the prolapsing component in and also cuts off the blood supply to shrink it. So that is the ethos behind the contribution to treating the symptoms. It can be done, duplicated which we do here regularly. Uh And was the basis of the halo trial, we can do it without the Doppler in the clock face. Do you have any evidence about it? Do you have, can I can, I can, I, is it justified? Yes. Yes, definitely. Yes. So, um, what, where, where will you target you physically see the piles. If there, if it's at, uh, uh, 973 and two o'clock, then you can apply the s there and put less uh intense plexus stitches between those. So, if you put six stitches around the clock face, then there will be symptomatic improvement. But if you have a Doppler guided instrument, then it just feeds the te tells you where the arteries are going and then to do and to do it technically. Is it, is it, uh mandatory? Yes. Yes. If you have the kit, you use it. If you, if it doesn't work or if you can't get it, then you can use humeral Opex on its own stale humeral was, uh, was discovered described several years ago to, to, to treat circumferential hemorrhoids. So the circumferential prolapsing hemorrhoids, we see every now and then you know, you can't do accessional because we can't excise the whole, the whole circumferential component. Why stenosis? Yeah, they just contract into a, into anal stenosis. We can band, it is not banding is not a uh II II. It, it, it doesn't give uh appreciable therapeutic effect. So, but it is a, it is a, it is a very technical procedure. You need to know certain steps which you have to follow through the letter on the on, on the, on the recommendation and it it, when it works, it works very well. But if there is a complication, it is rarely uh soul destroying for the patient, especially in a rectovaginal fistula or uh in some male patients, prosthetic uh injury, prostatitis. So we have done several stable hex in the past with very good symptomatic improvement. But because of widespread use without governance, my feeling is that it has lost its uh it is placed in the treatment of viles because it has been really tightly controlled. Do you still use staple humera pexy film? Uh I've never used. Ok. So here we do, we do use it here once in so many months for circumfer piles. And we have nominated one surgeon who can deal with the legal issues if they have it later. So we send the patients to Professor Brown to, to, to, to, to have it, but it has its own indication. So in your, in your, in your daily life, if someone comes like can you do a stable opex for me? You say no and you send to Professor Brown. OK. So the reasons why I have the alternatives is because uh the better pain thresh, be better pain outcome. Uh earlier return to work and less complications with a reasonable efficacy. Not reaching that of the hum ectomy though for just press the button or something to move it on. I think it's it's good. Lost its sync. Can I do this? Mhm Yeah. Two. So we spoke about this. Uh a success rate is 90%. Uh You can, you can, you can use, traditionally, most of us use the open malignant moment, hematoid pedicle heid toy as far as possible. I do take still take out so to I take a trans transfixation stitch at the, at the base of the pedicle. Uh But I do, I'm aware and I've also done completely that semierect toy without, without a uh without using a transfixation stitch. Uh It is a personal preference. You can do either whichever is safe and acceptable and especially for the very large ones with a uh a redundant skin left behind. After you remove the pile, we close the skin uh in line with what was described by Ferguson. The Ferguson erect toy just completely closed. Sometimes if there's a wider mucosal component removed, it's not possible to close all the mucosal comes the skin, you can close. There's a picture, a nice picture which uh which, which we can talk about that. And then Jordan did one yesterday with me, which we closed the external and left the mucosal element open because it's too wide. There's a really huge base in the, in the, in the, in, in the pedicle. And the key issue is to maintain adequate skin bridges, to prevent stenosis and to encourage epithelialization around. Yes. So what Jordan did yesterday more or like looks the same. So that humoral component, I'm not quite sure, but I think this might be the patient you saw earlier has been operated on, they removed the hemorrhoid. So you can see the uh the skin uh defect after the after excision of the hemorrhoids, the pedicle will be somewhere inside there and you can, you can close this with we repeat or normal white subcuticular to to increase the uh to, to kind of optimize the recovery period. You can use li ligasure, which a which is AAA refined version of dither to seal the skin. What what I've noticed it if you just use the ligature, find a big pile, stick, the ligature in it will be skin will be sealed at the time of the operation. They go home and invariably break down and then heal with secondary intention because several patients have come back. So uh there are several methods to use the leg issue to use the you to kind of seal the skin and uh give adequate hemostasis to the pedicle, but it has to be used judiciously uh to excites the hemorrhoid. And if it's done in the right way, the pain, postoperative pain is better. If it's not done in the right way, they do get quite excruciating pain because the skin gives way and then granulates with a lot of uh POSTOP pain. So, nonexistent techniques, we discussed uh Humera Opex. You can use Doppler, uh you can use the Doppler later this afternoon uh on, on, on the models and stable erex we have spoken uh about is basically you put a purse string in the submucosal plane, apply the there, there are some videos on youtube, you, you, you, you deploy the anvil with a long stem uh proximal to the bus string, tie the bus string, uh dock the gun and then fire it. The patient has to be really relaxed because you need to open daily tennis, put a big gun in on fire complications. Uh POSTOP pain, minor contents impairment is, is, is expected. And what we can explain as fecal leakage, urinary retention mainly in men fecal impaction because of the POSTOP pain. They just tighten their bottoms. Don't go refuse to uh go to the toilet and come as there is one of the common causes of re a commission and a and contributing to anal fissure, post humor, bleeding and fissures. We have seen some uh we've seen it happen before requiring readmission. Botox injection, hopefully not. But the other long term circulate could be fistula and stenosis incontinence and intersphincter sepsis if you entered the wrong plane. And obviously you have not gone into the technique of an open hemorrhoidectomy, but you should identify the internal sphincter, uh sweep it away and, and uh and then a apply the ligate uh or uh any kind of he hemostatic mechanism for the pedicle well away from it and use as minimal diatom as possible if possible. No diatom on the sphincter because it contributes to pain. The Hubble uh was was a uh run by Professor Brown from here several years ago and compared a rubber band ligation with uh hum humeral artery ligation for grade two and three piles. Uh recurrence rate after one year was higher for rubber band ligation as as supposed to humeral artery ligation. But in the patients who had more than one application of a sitting of rubber and ligation, the the the the the kind of difference even shrunk at a much lower cost. Uh So the the take home message was that if you use the rubber band ligation properly, more than once you can, uh you can, you can simulate a similar kind of uh postoperative outcome. The ethos trial compares stable hemor with he uh obviously stable hemopexin. Uh yes, more complex to do more operating time, more cost uh but had greater recurrence as well and it is a technical exercise. So it's very difficult to quality control, uh procedural R CT S. So everyone doing this procedure has to do it in exactly the same way if you have to get ee equivalence of the clinical skill and that contributes to an effect to an extent, I think in my opinion, so a reasonable approach is basic treatment for all that is the bottom line. So you drum it in even though if, even if you're not doing any intervention, RR rubber band ligation for uh uh grade two, grade one and two piles who are symptomatic erex for grade two to higher. And if there's an external component presenting, then uh consent consider exist hemorr toy. So uh to reduce the incidence of poster pain, uh we can use ligo sure if you use, use it judiciously plenty of local infiltration. Uh We use a uh at least I use a parental block all the time for all all hemorrhoidectomies or any kind of anal surgery. Almost all of them have. No, it's a, it's a parenteral block. So there are no anal canal sensation in, in the recovery in the day surgery unit. They're sitting, you've done three particle erect toy, they're sitting comfortably before the local result. Leave the hospital. Yeah. Yeah. So leave the hospital. So and then it's, it's uh and then for it's good for the patient and the and the surgeon because they will have. So tell them that start taking the analgesic. Well, before so that things were off, we give them dilTIAZem cream, uh, analgesic laxatives, metroNIDAZOLE, which has been shown in the trial to reduce POSTOP pain. So, uh, use it as a blanket for all anal surgery unless you're allergic to it. Uh, I, I've not used lateral anal sphincterotomy for dealing with postoperative pain myself to reduce postoperative pain but have used uh, dilTIAZem and uh, occasionally Botox in, in patients having severe anal spasm. What can we do with that? So we find patients and uh and spinal injuries, all kind of neurological problems. Ok. Two minutes. Um ok, because there's a fish as well. So some, some something like this stable hemo is out of out, out of, out of normal practice that we can't use. So just take it out of the equation unless you know, Professor Brown, uh you can exercise uh the biggest companies and bring them back for. You can excise biggest components. PC, the components they are not removed to shrink them or rubber band like them. So it is a multi proned approach to deal with them. So in summary, uh classify the hum humera check for high risk factors, deal with the uh confounding factors and the basic treatment and choose a treatment depending on the configuration of the piles. Farag told me that I have two minutes to finish. Fisher. Very common, very common condition in the community, uh treated, treated with all sorts of uh medications uh can be acute or chronic, less than six weeks or not. And in my, in my definition, if this is, if the spasm uh pain, unable to defic and unable to examine uh that, that kind of, even, even in, even in a chronic fissure, you can get an acute episode where you get a new recurrence on a scar or in a different site due to due to straining. Then you, you get this really, really painful patient who was difficult to satisfied. Most of them are uh due to a straining and they're most commonly seen in the posterior segment. Why Christi? Yeah. So the art the arterial architecture of the vascular architecture of the anal canal, there's a paucity of uh vessels in that six o'clock station. Don't ask me why. And that apparently contributes to less blood supply, less healing capacity and predilection of fissures in that area. If you get a fissure at say 11 o'clock or 12 o'clock, then you should think out of the box uh recurrent fissure. I think out of the box is an inflammatory bowel disease, proctitis, uh STD various other things. Uh ano receptive uh intercourse practice. All these have to be considered as the, as a reason for atypical fissures. The classic six o'clock Fisher is chronic or acute. Ok. Just call me presents with anal pain, passing broken glasses. Uh painful bleeding is a classical presentation of a fissure and usually associated with constipation or straining. You look at it, you see it, you can find it. So many of the fish have a sentinel tag in front of them, which is a little skin tag at the base. Uh If it's acute, then he'll need a, uh examination on the general anesthetic or spinal with a view to do something to uh like a Botox injection, even first line and to rule out other significant differentials what's going on there. This, this should have been blanked out. Yeah, like my patient, II took a biopsy. It was very clear that it wasn't a fissure. It would, it wouldn't be a non healing fissures, indurated base biopsy. And for anywhere, any part of the body fissure is an ulcer, non healing, old age intubated base. It's telling you please biopsy me very similar appearance to anal cancer in most of the things and they can have a concomitant anal fissure uh as well with, with a, with an anal cancer. So the basic treatment recommendations are very similar to what we tell what you say for hemorrhoids with a higher emphasis on stool, softness and laxatives and avoiding straining. Especially we have uh pelvic floor issues contributing to a defecate problem which makes them high risk for have a fissure. And if you do a treatment, it won't heal because the underlying cause is not addressed. So E SCP guidelines, uh acute Fisher conservative measures, uh laxatives, avoid straining dilTIAZem cream or GTN if it's chronic and, and the and the topic measures haven't worked. You go to Botox injection. Uh if Botox doesn't work, consider other treatment options like lateral spiny. In postpartum, female patients where fissure is sometimes common. And in male, some male patients where who had anal canal surgery is good to do a preoperative assessment of the anal sphincter function. The way you do it is to get endoanal scan, anorectal physiology. And if they are very painful, you cannot do it without an anesthetic. And in some patients, uh especially in less than 16 because it is a nearby children's hospital, they call us to do some proctology there. You can't see a probe and measure pressure in a child around the G A and to what extent that affects the sphincter pressures is debatable. But at least we have a baseline value to compare. If it's a high pressure sphincter, a high high pressure sphincter contributing to fissure, then a lateral sphincterotomy is a really good treatment strategy done properly, 90% plus healing rate. And if it's a low pressure chronic fissure advancement flap, which Phil will take you through later. So, topical therapy, GTN and dilTIAZem are the common ones usually applied twice a day for two months. GTN is a nitric oxide contributor. DilTIAZem is a calcium channel blocker. They act locally, they act locally. So it's just a, a spending two minutes to tell the patient how to apply on the anal verge, uh twice a day and top it up if they've gone to the toilet and wiped it off is a good thing to do because compliance is an issue who will enjoy applying cream in their bottom when they're out working in the construction site or something, you know. So compliance can be an issue. And as we have discussed in a, in a fissure which is written and not healing. Think out of the box, a biopsy, something else contributing, exclude Crohn's inflammation, bowel disease proctitis. So uh the, the, the, the com comparing the sphincterotomy was the sphincter preserving treatment strategies. Uh 11 thing to remember is to use the sp sphincterotomy. You can use it in a male patient earlier than using in a female patient or uh a category who are more prone to complications from it, water toxin. Uh A I don't know what's the difference between A and A B but that's what it says on the tin whenever we use it is, is, is, is, is a, is a very good, it was a very good uh tool in your Armamentarium to use uh 20 to 50 units. It says uh I sometimes use a bit more, bit more, you know, uh fill it up, draw the whole 100 units out and then give maybe 40 40 un 80. Uh II did start with 20 20 years ago and slowly it's increased to 80 now. Uh And for the recurrent, the second doses of Botox, we give for some patients. We give 100 no cross that yet. 60 to 60 to 75% success rate. Uh where you give it in the, the sphincter plane where it, it can be juxta Fer or a three and nine by default, I give it at three and nine because it's opposite ends and it, it, it, I, II presume that it'll give a global effect on the, on the, on the sphincter complex. But you can use it juxta fissure, which means on either side of the fissure, you can send them for trans transitory temporary incontinence to flatus and liquid stool. Uh And sometimes it can be, you can combine with the fissurectomy for chronic fissure, the fish cured. I just good question. Uh Good question. So in the examination of uh when you do an examination under anesthetic, uh when you feel the anal canal with, with a moist finger, you should be able to feel two ridges in the anal wedge. The internal ridge is the internal sphincter. The external ridge is the external sphincter. If you can't delineate it, put a proctoscope in and open it. When you open the body, you, you, you're stretching the sphincter. So it should, you should be able to feel the ridge. So the plane between the plane between the two bridges is the intersphincter plan. Why do you uh contribution to uh anal sphincter to internal sphincter? Uh is what is one of the treatment strategies or one of the kind of workshops we do in another kind of pro decision to anal sphincter tone. Indole winter contributes to the resting tone and the external sphincter contributes to the the squeeze John the contribution, if you just give it to the internal sphincter, and if there's no paralytic effect on the external sphincter, the judgment is that the net reduction in to would be less. So you you you're just compartmentalizing the effect of the Botox to one, one anatomical compartment. So I don't think I I'm not aware of a of a randomized controlled trial comparing. Do you know there's no data Fisher guideline? It's quite useful in this and it indicates that nobody knows where it should go. Theoretically. Botox will only work on. We should probably be in the external, internal center. Probably shouldn't be doing very much people put it in the space and I hope that it will work somewhere. I think that's a very reasonable approach. Thank you. Maybe, maybe you should, you should design a trial. Yeah, radio ectomy is for uh uh uh combine it with Botox. What if it's failed the first line therapies or if it's a ra rarely painful hypertonic sphincter with a um with, with, with, with a fresh ulcer. So there are some indications in acute fissure and there are some indications in a chronic fissure and you always use it second line after you tried the 1st, 1st line methods. So there, there, there is what you don't want to create is a new ulcer which is known healing. So you can't use it without something to reduce the anal anal pressure or secondary, which is uu use as an adjunct. If you know what I mean. That's why II in some of the fissurectomy, it's better to do an advancement flap with it in, in, in no more tensive fissures because we remove it, you cause an ulcer. You leave it expected to heal. And the fact that it's not healing itself is because of some underlying condition, predisposing to that fissure not healing. So address the underlying cause if it's still not healing, combine the primary treatment strategy with fasciectomy. So mucocutaneous a advancement flap. Uh I just, I personally don't use, use a anal cutaneous flap. I think the host flap you're gonna see for uh anal fissure is really nice, simple, straightforward technique. Once you know the geometry of the flap and just slide it in and close it. Uh healing rate 40 to 80%. I would say 40 to 80% so that the patients are aware that you know, half the times it may not heal. Uh and because you're not touching the sphincter complex uh un unlikely to affect continence. So physical summary uh a good history exclude the con confounding factors. Try lifestyle measures, topical applications. Second line Botox. If Botox doesn't work, go for the in, in, in invasive methods like sphincterotomy and advancement flap in some male patients, you can skip Botox, go to straight to lateral sphincterotomy if they are compliant, understand the uh consequences and want a better healing rate. How much have I overrun? Two? Thank you very much. I have to take the microphone. Thank you. No, thank you. Thank you very much indeed. So we are just gonna trim this next talk a bit. So I apologies if I rush through some of the slides. After that, we go in and do the first practical, which is er, e eu A um A at HD and er, we'll do sphincterotomy as well. Then we have a quick coffee and then back in here another, another and the next kind of set. How are you doing there? Fara can you find it? Yeah, they probably are so something I forgot to say because I didn't have the slides and so it didn't occur to me is that these um presentations have all been created from existing presentations. And so that means there are multiple authors. I have not written all of these and, er, those authors have very kindly agreed to have those slides used. So you will recognize some of these slides from other people and I will try and point out where are, where we're drifting from one person to another. Um, er, and this section um is from Jenny Granger who was planning to come today, but unfortunately, couldn't in the end. There should be four people here talking to you, but it's just me and Harry. So you're gonna get a lot of me today. I'm sorry about that. Normally there's more people um Jenny Granger and the other one is Tamsin Cumming, who you're probably aware of. He's a brilliant, brilliant a in surgeon. So, so these slides are mostly belonging to those two with some tinkering. So we'll start off talking about pruritus A and I uh which simply mean itchy bum as you will all know and it is super duper common, more commonly affects men than women because men are dirtier features than women's I suspect uh and usually present in middle age. Um there is a really key um er er concept to think about with pruritus, which is the itch scratch cycle and you will all be aware of this scratch cycle. You will all have been in it at least once in your life where something is itching. So you scratch it and then it itches some more. So you scratch it again and the scratching feels glorious, but it leads to a further period of itching and whatever the primary cause, whatever the cause of the pruritus, this will mean it will perpetuate. So there is always a conversation to be had with a patient right at the beginning about the concept of the itch scratch cycle and everyone's aware of it, right? Everyone's mom says leave it alone, that's happened to everybody. And that's, that's what you have to say. Um the etiology with pruritus is really, really important. And that's because of all the secondary um causes that you can see here. So, um sometimes um uh pruritus is functional in nature. It's often related to fecal contamination. Um but it can also be the secondary to um particular problems such as skin conditions, infections, systemic illness and so on. And we'll talk about a number of those things around a quarter of the time a cause is never found. And then all you can give is really detailed, valuable lifestyle advice. And wherever you end up working, there needs to be an information sheet or a website or something that you can point people to to take away the need for having very, very boring, repetitive conversations with people. They will need to adopt a particular set of set of lifestyle changes which you need to get across to them. So have some kind of uh mechanism for giving that information to them. So the fecal contamination thing is actually really important. And a a now retired surgeon called Tim Aur in London used to say that you should get a bit of damp, cotton wool and wipe it across the perineum of anyone with pruritus and show it to them because quite often it will be brown stained with stool, right, which is occult fecal contamination probably aerosolized when they're passing wind, but perhaps just through poor hygiene practices, they get stool on the skin and it drives irritation and itching. So quite a lot of, quite a lot of uh the solution here is simply to have people clean their bums appropriately properly. Um There's a, there's a, a big component here which seems to be related to loose stool and soiling and, and very many people who have idiopathic pruritus will have a high incidence of loose stools. They're not the kind of people who get constipated and they are the kind of people who have a little bit of marking in their underwear at the end of the day. So there is really something here about fecal loss and contamination and the perianal skin seems particularly to be affected by fecal irritation. If you got stool and put it on your arm, it wouldn't cause itching in the same way that it does around the anus, which seems an element of poor design there. We are such as the way now the key with pruritus or a key with pruritus as with piles you heard about earlier is to make sure that you're not seeing another condition presenting through a, a benign, relatively benign uh um er symptoms. And so you must always be thinking about whether or not there's an underlying disease which might be a malignancy. So around half of patients with pruritus will have a, an anorectal cause and a quarter of those patients will have a malignancy. The data suggest II suspect the answer is that it's rarer than that. But anyway, it's a, it's a substantial minority of patients who present with pruritus that will have an important cause. And even those who don't have a cancer, you know, if you know the cause, you've got a much better chance of treating the pruritus. And you've, you can see this long list of things which you will all be able to recite in any case. there's a bunch of different infections. I think this is really hard as a proctologist, we don't see these things very often. I think they're hard enough to pick up. You know, when you get a text message from your niece, from your uh your uh you know, some in law who send you a picture of their niece who's got a rash on their arm. You know, I know what the fuck that is. How would I am I? So it's even harder for us, you know, looking at the anus and trying to work this out. But these are the kinds of things you need to be thinking about the skin stuff, the parasitic stuff. And if someone's got a bunch of kids really think very carefully about worms, you can deworm a whole family fairly easily and cheaply and it can be quite a useful thing if you're thinking about pruritus, particularly if the kids have got itchy bums as well. But also think very carefully about S TI S and we've got a section on S TI S in it. So I'm not gonna dig into it now. ST isa really important thing that we do not think about enough. There's all the dermatological conditions which you may or may not recognize. It's obviously helpful if they've got further patches of that condition elsewhere, that obviously makes life a lot more straightforward. Um But it, it looks weird not inflamed, but in some way, path pathological then think about involving a dermatologist. I think there is no shame at all in getting a dermatologist to just do a kind of screening review of these patients to see if they think there's something that might be going on. Remember, lichen sclerosis. So if you see these white atrophic patches that's associated with cancer and some of the lesions that we'll talk about a bit later on, which are either malignant or premalignant also present with um pruritus. So also have no hesitation in taking biopsies, bunch of systemic illnesses which can cause it. I, I'm not sure how they do it. I don't know, I don't know what that mechanism is. Maybe the pruritus is er, driving those things. But anyway, apparently that is the case. And then, then A b there's a bunch of drugs, including some of the ones that we use. So you're gonna be thinking about the itch itself, their bowel habit and any precipitating factors which might be, but also things like food, their medical history, the drugs they're on crucially their sexual history. And then this concept of travel, which just might be driving pinworms or some weird thing that they've picked up. So you have a good old hunt and the examination is really about looking carefully for evidence of any of those other causes that you've seen as well as trying to assess the perineal skin itself. And then obviously digital rectal examination with proctoscopy and sigmoidoscopy. If you want to, there's a bunch of investigations that you might do. I don't do this. I don't think that's my job. I don't think I will do it. Well, I think I'm much more likely to produce an equivocal response if I take a scraping or a biopsy of some skin lesion. Dermatologists are great at that stuff. We should let them do it in my view, but n it shouldn't be the case that no one does it. So either do it or refer for it if you think there's plaques or lesions that need assessment. Um And this area swabs and cultures probably we should be doing more than we do in the proctology clinic. It's not something I do very often at all. And again, I worry that I might bugger it up and you can always send them down to the gum clinic, but it is something again that needs to be done either by you or by them. If, if the patient's history is sufficient and if you don't get any further than an eu A, it is important to make sure there's no underlying cause that you've missed. It's also worth thinking about stopping the various lotions and patients that they will have started to take either on their own cognizance or because of their GP, um, who's given them advice. Er, it may be that it's worth stopping them. On the other hand, sometimes lotions or barrier creams and so on can be very helpful and it may be that they do a bit of trial and error to find the correct combination of things that works for them. Uh, we'll talk about treatment a bit more in a second now, in fact, so it may be that we're treating a skin condition or an infection. I think there's a really nice piece here about um, defecation. So, improving patients defecation, either through bulking their stool or through thinking about things like biofeedback to make, to make, uh, um, to improve their emptying and make sure that they don't see and leak so much afterwards. Those are some really useful pieces of work. And quite often when you find someone with pruritus, they may well have O DS symptoms of O DS. And so things like biofeedback, defecating, proctography and so on might be a really helpful thing that will help, not just the pruritus, but a lot of people just don't poo very well and it causes them a lot of misery and this might just be the tip of the iceberg that, that they're demonstrating to, uh, demonstrating it with, I think about things like skin tags. We all bulk at the idea of taking off small skin tags. You should cope with it. No one's looking at your anus, but in fact, they can cause trouble with, um, cleaning and that might be a cause of pruritus. So in that situation, it may be worth doing it. Uh, the lifestyle advice thing is really key and every colorectal clinic in my view needs something like this that you can hand out to patients to get them to do the various things. This is actually an, an example of that you guys know Shahab Ki. So that's his piece that he submitted. And it's a really nice thing that you can just use to give advice. Er, and then for the cleaning, the difficulty is that you sometimes push people over into this kind of polished anus principle and then things don't get better, they get if anything worse. And so they need careful calm instruction on what to do here and things like a barrier cream before they open their bowels can be very effective. Uh take out of your diet, all of these things and then see if you have anxiety or depression at the end of all of that, you may well. Um but of course, you know, with the, it, it, it can be helpful and so it is worth discussing these things with patients but they will never take all of those things out of their diet. Topical steroids have been used with some short term improvement but rarely with really long term benefit. Um, and doesn't seem in studies to be any better than simply good hygiene. People eat Rius quite a hardcore drug. Um, and again, it works when it's working, you know, when you're using it but doesn't seem to have a long term beneficial effect, treat the cause. And then there's capsaicin, there's one that is chili pepper. Yeah, it's the stuff that makes chilies hot. So you can put that on your bum and your, your uh itching isn't so much of a thing for you anymore, Kel SRE. But it does seem to be, it does seem to be somewhat effective. So there is an, there is an argument for this and there's probably a kind of gait effect. Do you remember the Gate theory thing? There's probably some kind of gait effect which means it is vaguely beneficial. And then there's anal tattooing if nothing else has worked, which you can do and does seem to have quite AAA long term benefit, but it has some risks associated with it. But these are the kinds of options that you might go to. I've never done this. I mean, it's very difficult to imagine anyone ever actually doing this, but it is occasionally necessary. Have you ever done that, Harry, you ever done annual tattooing? For pruritus. Not yet at some point in your career. No, you're quite right. Yeah. Good. So, there you go. Um, think about the other causes. It is a debilitating very miserable condition. It makes people very, very unhappy. So it is absolutely worth treating. Have a, have a conversation about lifestyle advice that you can trip off your tongue and for the exam and also for when you're in clinic but, but mainly treat the underlying course. Ok. S TI S very briefly, uh, you're aware of the various S ti s and the symptoms that they can cause. And we're gonna talk about prox mainly here and sexually a proctitis, probably very important. The new diagnosis of proctitis that we see in the IBD MDT, we ought to be thinking about whether it might be S ti related, particularly if it's someone who a man who has sex with men, particularly if they've got HIV, for example, but actually in anyone who has anal intercourse, er, and of course, it's important to recognize that not everyone will, will report an intercourse even if you ask them nicely. Um L GV, lymphogranuloma varium, which is one of the chlamydia. Um, uh, chlamydial diseases is probably the one that's most important and is on the rise, particularly men who sex men. So that's well worth thinking about, um, in particular in that group. Um, we won't linger on this, but chlamydia is important can be passed through anal sex. But but bear in mind that also it sometimes uh yy, you don't have to have penetrative anal intercourse to get chlamydial proxys. It can just be local to the area through touching and rubbing and so on. And then L GV, really important chlamydial version and we really must think about it carefully in men and women. Um although it is much less likely to present in women or, or heterosexual people, er, diagnosed with a rectal swab and treated relatively straightforwardly actually with Doxycycline, which is another reason why it's so valuable to pick up. Um and then gonorrhea um after chlamydia, the second most common cause of S ti prox itis, um the same kind of symptoms of pain and discharge and bleeding and tenesmus that you get with any proctitis. Again, a straightforward test and a straightforward treatment. So really nice to pick these up if you occasionally do cos you can really make people better. I'm not gonna focus on HSV just for the purposes of time, but you will know what herpes simplex looks like with the vesicles and it looks the same around the anus. And then monkeypox, definitely worth thinking about ox. Monkeypox was considered pejorative. The name is ox. Now that is how we talk about it. Um And it's well worth thinking about in men who have sex with men, particularly if they have these lesions. These are the monkeypox, the MPX lesions that you'll all be aware of in concept has anyone seen any MPX? Did it make its way this far north to be fair? We didn't see it very much in London either. II have never seen anyone with it. It's just something to be aware of. Um, and the, the principal, I think the principal way to DD um differentiate it from others is the presence of those lesions on the skin. And the fact that if you try and do proctoscopy, they'll punch you cos it's really painful when you put anything in their bum. Uh, uh, treatment is mostly supportive. Um It is important to talk about sex when you're thinking about um, pruritus or proctitis, any of these anal conditions because it might be driving disease. It's also important to talk about sex in the context of all anal rectal disease and surgery because it might not be the driver of disease. But it may be that your intervention will alter their sex life. That's a brilliant and in my view, independently, effective argument against staple hemorrhoidopexy staples in the anus is just terrible bad thing and you can make an argument for it if you're gonna save someone's life and prevent them having a stama like in a cancer operation. Very hard to make the argument about putting staples in someone's anus if you could do the same job with sutures in my view. Uh So the next time you think about putting staples in someone's anus, just wonder to yourself whether someone's penis or finger is gonna be in that anus later and might get scratched or torn as a result of your staples and whether you are fundamentally altering someone's sex life for the rest of their life by the nature of your operation. Hai A I just a couple of words and now we're on to Tamsin Cumming and some of her beautiful, beautiful picture about a in. So this is high resolution anoscopy which she does at er, and for us at Saint Mark's oh um with er acetic acid vinegar and you can see beautifully clearly how she can spot HSIL ah which is what we now think about, talk about with a in two and three as it, um how beautifully she can see that and therefore treat it. So this is a different world. Do you guys do, do, do you have a um hra wherever you work is the thing, do you still do quadrantic biopsies? That's what I would do if I didn't have Tamsen coming to refer to. So if you guys, you, you know everyone's always on the lookout for their USP, that's gonna make them attractive as a consultant. No one's doing this, everyone's going to do it every hospital, right? This is a wave. You could jump right on that wave right now. You can learn this technique and it is a thing that you can do that no one else does and you can take it to your new job and everyone will be after it, it's gonna be increasingly important. Screening is likely to come along with this and so on. So there's gonna be money and therefore for jobs. So I would pay great attention to this if I were you. Anyway. Uh, it is valuable. Um, um, because you can use treatment of those lesions to prevent cancer. We'll come to that later on. The cancers are all driven pretty much completely by HPV. And you'll be aware of HPV 16 and 18 being the main drivers, particularly HPV 16 in the er, in the context of anal cancer. And it tends to come late a long, long, long after exposure by comparison with cervical cancer. Um, the anus harbors HPV in people who are exposed to it forever and that's perhaps one of the reasons that you see the incidence of this problem of HPV driven cancer increasing in age and I'll show you a graph about that later on. But it is worth bearing in mind that HPV carriage is extraordinarily common in men who have sex with men, particularly if they um also are immunosuppressed with HIV or indeed other immunosuppressive conditions. You don't have to have anal sex to get HPV. And therefore a in type changes in your anus. And um you'll be aware that women who have HPV, infection or cervical neoplastic changes are more likely to have a, in type changes. In addition, without necessarily ever having anal intercourse the perineum is now harboring that infection and it can work its way around. And there are ideas about, about how women I'm not going to mans explain how women should wipe their bums. But you can you take the uh the point about front to back versus stabbing. Um But it is certainly true that anal intercourse increases the risk of a in HPV carriage and a in. And there's this nice piece of work in renal transplant, patient, transplant patients who are obviously immunosuppressed, which showed that the additional addition of anal intercourse alongside that im immunosuppression, non HIV, immunosuppression increase the rate of high risk HPV carriage within the anus. So the so anal sex definitely delivers um HPV, but you don't have to have anal intercourse in order to get HPV into your anus. So this is um the graph I was mentioning. So this line represents the incidence of colorectal cancer, right, which we screen for as you are all aware, er these dots are the incidence of uh different groups of people. And so the one over on the left there is men who have sex with men and if they are HIV positive and over 45 they are more likely to get an anal cancer than they are to get a rectal cancer. So that's I think a surprising statistic but very, very important particularly for that group of people. But it's also really worth wondering about older women who have um er, er, er, intraepithelial neoplastic lesions in the vulva, in the, um, cervix and so on. They are also at really quite a substantial risk of a, in related, uh A I NN cancers, um, er, as well. So think about these patients in addition to those ones that we're all thinking about all the time. Um, 90% of anal cancers are palpable. This is, I think really a slide that Tamsin puts in to encourage gastroenterologists to examine patients. Cos I know that you're all doing it regularly. But the disal examination really is an undervalued examination and you, you, it might take two or three minutes to do a really good digital examination such that you're having a conversation with the patient and explaining to them why you're taking so long and that you're not some kind of weirdo. Uh it, it really, it should be something that you can get a lot of detail out of. Just a quick. Yes, there is indeed anus and take your finger out again. Hra very um um increasingly used, very valuable resource. Um You can see how easy it is to identify these areas um of, of HSIL and then you can treat those with laser or with quarter. There are other treatments, things like excision, which can be damaging topical treatments which are not very effective. Ablation does seem to be the way to go and laser is cool and electrocautery is adequate. So both of those can be done. And more importantly, the anchor study has demonstrated that if you do that, if you do HRA and then treat them with a with ablation of some kind, then you can reduce the risk of anal SCC in these patients. Really substantial reduction. This is the equivalent of Polypectomy in colonoscopy, right, reducing the risk of colorectal cancer down the line. And if you've got those patients with a very high risk and you've got an intervention you can do at a screening level which reduces the risk of cancer. Well, it will not be long before we are doing this routinely. Just like we're doing routine breast screening and routine cancer screening, colorectal cancer screening, colonoscopies growth area. Uh, that's it. Um, any questions about any of that? I'm sorry for the rush, but I hope that's all clear. Watch any talk that Tams and Cumming ever gives on a in, it is fantastically educational. She's a brilliant speaker. She understands this with, in great, great depth. I commend her to you. Er, and she talks ACP about once every two or three years on a in. So you don't have to wait too long to see it. I think that's a really good point. There may well be from previous A um A CPS. So take a deep breath, jump up, head through into the other room. We're gonna do um eu A I think we'll start with T HDI. Think the T HD lady's probably champing at the bit. So we'll do eu at HD and then eu a very briefly and then we'll do a sphincterotomy and then you can have coffee. Ok. It's not a long practical question. It won't take long, well done at 11 15. Obviously, we're running unfortunately, 30 minutes of my schedule at the moment, but it's fine because whenever you're done, you can go grab your coffee downstairs and come back and then lunch at one o'clock. That's fine all day. Ok, thank you. Thank you, Jordan warned me not to touch anything.