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296 S. R. Brown
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Fig.11.3 Example of acutely thrombosed haemorrhoids with associated oedema
easy to distinguish from a thrombosed haemorrhoid. Within the first few days
of presentation, symptomatic relief can be obtained rapidly by incising the lump
under local anaesthetic and evacuating the clot. After around 72 h the pain tends
to ease, and the lump should be managed conservatively. It will usually resolve
completely.
11.5.3 Haemorrhoids in Pregnancy
Haemorrhoids are common in pregnancy due to the increase in endopelvic pressure. Around one in ten women will suffer from the condition in the last trimester
of pregnancy with one in five developing symptoms immediately after delivery
[67, 68]. Treatment is mainly conservative with dietary advice topical agents and
sitz baths to bring symptomatic relief. Often symptoms will resolve when the
endopelvic pressure reduces after delivery. An oral flavonoid called Rutoside may
be effective in reducing symptoms according to a Cochrane review but cannot be
recommended until further studies are able to confirm safety [69].
11.5.4 Anticoagulants
Current guidelines suggest any patient undergoing interventions for haemorrhoids
should have appropriate cessation of anticoagulants before the intervention. This
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Fig.11.4 Example of a
perianal haematoma. The
swelling does not extend into
the anal canal
of course reduces the potential for immediate bleeding but, if secondary or later
haemorrhage is to be avoided the cessation should continue for around two weeks.
This is often not practical or safe. There are some procedures that have a theoretically higher risk of late haemorrhage. Rubber band ligation is one such intervention
where the mechanism of action is such that the banded pile sloughs off at around
5–10 days and an ulcer is formed. This is when bleeding is most likely to occur
[70]. It makes sense therefore to not undertake this procedure if the patient is
anticoagulated and protracted cessation of anticoagulants is not feasible. Other procedures such as injection sclerotherapy and haemorrhoidal artery ligation appear to
have a lower risk of bleeding, even when anticoagulants are continued [58, 71]. It
is the authors practice to favour injection sclerotherapy for those patients on anticoagulants where outpatient treatment is indicated, with cessation of anticoagulants
only during the perioperative period for those undergoing surgical intervention.
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11.5.5 Immunocompromised
Data are limited on the risks of haemorrhoidal interventions in immunocompromised patients. Both outpatient and in patient procedures appear to be safe but
should be performed only with careful consideration [16]. Antibiotic prophylaxis
is advisable.
11.5.6 Haemorrhoids in Inflammatory Bowel Disease
There is little data on the incidence of haemorrhoidal disease in patients with
inflammatory bowel disease. However, there is no reason to believe it is any
less than in the general population and may be more if the IBD is associated
with increased bowel frequency and protracted time on the toilet. Symptoms
may be underestimated due to causation being attributed to the underlying IBD
rather than the haemorrhoids. If, after careful consideration, treatment is indicated,
non-excisional techniques are recommended (e.g. haemorrhoidal artery ligation)
[72].
11.6 Conclusion and an Evidence-Based Algorithm
of Care
Numerous guidelines have been produced in the last ten years providing an
evidence-based algorithm of care. Despite the same evidence base, these guidelines differ markedly in some situations, possibly reflecting the values, preferences,
acceptability, and affordability within the country of origin [73]. Nevertheless,
some definitive universal guidance can be determined.
A consistent theme in the management is shared decision making. The views
of the patient are paramount. If they are simply seeking reassurance that there
is nothing sinister causing their symptoms, after exclusion of such, advice about
diet and lifestyle is as far as treatment need extend to. For those that wish for
intervention, a tailored approach is appropriate, again considering the wishes of
the patient. Grade I haemorrhoids do not need surgical intervention. If available,
micronised flavonoids may be justified.
For Grade II haemorrhoids outpatient treatment, usually in the form of rubber
band ligation, is the gold standard. The intervention is cheap, easy to use with a
low complication profile. Repeat banding for those with a partial response about
6 weeks later is cost effective and preferred by many patients. Others may prefer a more definitive intervention. These patients along with those with Grade
3 haemorrhoids should be given the choice of surgical intervention. The current
interventions with the most evidence include haemorrhoidectomy and haemorrhoidal artery ligation. Careful counselling is required to determine if the patient
is prepared to trade efficacy (e.g. after haemorrhoidectomy) for a procedure that
is less effective but has more rapid recovery (e.g. haemorrhoidal artery ligation).
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If haemorrhoidectomy is carried out, it should include all adjuncts that enhance
recovery (preoperative laxatives, avoidance of intraoperative ligation of the pedicle, postoperative metronidazole) with the procedure preferably done as a day case
and comprising a careful anaesthetic regime including local infiltration or pudendal nerve block. A stapled haemorrhoidectomy could be an alternative procedure
for this group but, given the complication profile and the inferior efficacy, should
probably only be reserved for those cases of circumferential prolapse where other
techniques are challenging. For Grade IV haemorrhoids and those who are concerned about a substantial external component, a haemorrhoidectomy is usually
the only alternative.
There are areas where further evidence is required. Injection sclerotherapy for
those on anticoagulants is theoretically a safer outpatient treatment but the use of
alternative sclerosants requires investigation. Radiofrequency ablation is promising as an alternative treatment for grade II and perhaps III haemorrhoids. The
theoretical reduced heat damage to surrounding tissues may allow a ‘walk in
walk out’ local anaesthetic approach with less post-operative pain than other techniques. This makes it potentially cost effective despite the cost of the equipment.
The need for Doppler guidance for haemorrhoidal artery ligation also needs further investigation. Dropping the Doppler would make the intervention very cost
effective.
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72.
Microbiome Manipulation
https://t.me/med1917
in Coloproctology
Nicholas R. Suss and Benjamin D. Shogan
Abstract
Microbiome manipulation has garnered increasing interest in coloproctology for
its potential therapeutic benefits in various colorectal diseases. This abstract provides a succinct overview of the current landscape of microbiome manipulation
in coloproctology, highlighting emerging strategies and their clinical implications. It discusses approaches such as probiotics, prebiotics, faecal microbiota
transplantation, and dietary interventions, emphasizing their role in modulating the gut microbiota and impacting disease pathogenesis. Furthermore, the
abstract explores the potential applications of microbiome manipulation in conditions such as inflammatory bowel disease, colorectal cancer, and functional
bowel disorders, underscoring the need for further research to elucidate their
efficacy and safety profiles in clinical practice.
12
Keywords
Gut microbiome•Microbiome manipulation•Colorectal cancer
Inflammatory bowel disease•Fiber
Key Points
•
The human gut microbiota represents a complex and dynamic ecosystem that plays
an important role in maintaining physiologic homeostasis within the intestinal
tract and beyond.
•
The role and breadth of diversity of the complex microbiota environment as it
relates to human health is a rapidly evolving field.
N. R. Suss · B. D. Shogan (B)
Department of Surgery, Division of Colon and Rectal Surgery, University of Chicago Medicine,
Chicago, IL, USA
e-mail: bshogan@bsd.uchicago.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_12
•
303
304 N. R. Suss and B. D. Shogan
https://t.me/med1917
•
Changes in intestinal microbial composition impact on the risk of developing
colorectal cancer, inflammatory bowel disease, anastomotic leak, and surgical
site infections.
•
Compositional change in the gut microbiome have been observed following surgery, bowel preparation, dietary modification, and faecal microbiota
transplantation (FMT).
•
Recent research has identified several mechanisms by which the complex
microbial microenvironment of the lower GI tract may be manipulated.
12.1 Introduction
The human gastrointestinal (GI) tract is home to nearly ten trillion diverse symbionts, including approximately 50 bacterial phyla comprised of around 100–1000
different species of bacteria. Within a single human GI tract 150–170 different
bacterial species typically reside, who live symbiotically within their human host
[1]. Collectively, these microorganisms are referred to as the intestinal microbiota. While the human GI tract provides the microbiota with ample nutrients
to thrive, these organisms have a responsibility to maintain homeostasis by performing various immunologic, metabolic, and structural functions. For example,
microbial metabolism of intestinal nutrients promotes the structural and protective
integrity of the epithelial mucosal barrier [2]. Additionally, these organisms are
responsible for harnessing 10–30% of energy from the intestinal contents through
their role in nutrient metabolism and contribute to the digestion of dietary fibers
to produce short-chain fatty acids (SCFAs) [1]. The intestinal microbiota has also
been attributed to strengthening the host-immune cell response by enhancing the
immune response of key immune-regulated cells such as lymphocytes, plasma
cells, and regulatory T cells [3, 4].
With perturbations in the GI microbiota being implicated in the aetiology of
various GI pathologies [5–12], it follows that intentional manipulation of the
microbiome may serve as a target for the treatment of many of these diseases. This
chapter will explore the impact of intentional manipulation of the gut microbiome
and its impact on IBD, anastomotic healing, and the development, metastasis, and
recurrence of CRC.
12.2 Brief Overview of the Role of Gut Microbiome
The human GI tract is home to several trillion microbial cells, consisting of nearly
50 bacterial phyla and approximately 100–1000 bacterial species, that interact
closely with the host native cells [1]. With relatively recent advances in scientific
technology, 16S rRNA sequencing and metagenomics have allowed researchers
to better characterize the microbes that inhabit the gastrointestinal tract. Research
that analyzed faecal samples from 1200 people in the U.S., China, and Europe,
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has led to the development of an integrated gene catalogue of the human faecal microbial metagenome, with nearly 10 million microbial genes found across
analyzed samples [13]. Billions of years of coevolution has resulted in functional
interdependency between host and microbial cellular processes by which the various metabolic products encoded by the microbiota’s genome interact closely with
key host regulatory processes [14].
Taken together, this complex microbial ecosystem plays a significant role in
maintaining homeostasis through involvement in several physiologic processes,
including host-immune response and nutrient metabolism. The intestinal mucosal
immune system consists of three layers of protection: Peyer’s patches, the lamina propria, and the epithelia. The relationship of the gut environment with the
microbiome is one of symbiosis: the human gut provides nutrients for the intestinal microbiota, which in turn digest carbohydrates and synthesize vitamins that
help promote the integrity of the epithelial mucosal barrier [2]. Studies comparing immune function between specific pathogen free (SPF) animals and germ-free
(GF) animals, found that GF animals produced fewer intraepithelial lymphocytes
and IgA-secreting plasma cells in the lamina propria, as well as fewer regulatory
T cells, thereby impairing the host’s immune response [3, 4]. Further studies that
assessed Angiogenin-4 (Ang4), a microbicidal protein produced by Paneth cells in
the intestinal epithelium, found that these proteins are secreted into the gut lumen
to protect against microbes. Studies using quantitative mRNA measurements done
in real-time to measure Ang4 levels in conventional mice versus GF mice found
that it was significantly lower in GF mice compared to conventional mice, suggesting impaired immune functionality in GF mice [15]. Taken together, studies
on GF mice demonstrate the vital role that the intestinal microbiome plays in the
successful development of the host’s mucosal immunity.
The intestinal microbiota also plays a significant role in nutrient metabolism and
harnesses approximately 10–30% of energy from intestinal contents, while the rest
is excreted in faeces. Colonic microbiota are involved in dietary fiber digestion,
leading to the production of SCFAs, such as acetate, propionate, and butyrate [1].
Butyrate in particular has been identified to play an important role in regulating
the host immune response by downregulating inflammatory responses, in addition
to serving as a key energy source for colonocytes. Butyrate has also been found
to induce apoptosis of colon cancer cells and activate intestinal gluconeogenesis
[16]. Additionally, the intestinal microbiota contributes to bile acid metabolism,
producing various signaling and metabolic molecules that influence important host
pathways [17].
Given the significant role that the gut microbiome plays on the functionality
of the host immune response and nutrient metabolism, it stands to reason that gut
microbiota dysbiosis may have profound ramifications on human health.
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