Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication. The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE. These guidelines are inclusive and not prescriptive. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Transanal hemorrhoidal dearterialization appears to be a potential treatment option for second-degree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

Stapled hemorrhoidopexy is a safe technique for the treatment of hemorrhoids but carries a significantly higher incidence of recurrences and additional operations compared with CH. It is the patient's choice whether to accept a higher recurrence rate to take advantage of the short-term benefits of SH.

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The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

IntroductionThe aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy (SH) for the treatment of second- and third-degree haemorrhoids.MethodsPatients with second- or third-degree haemorrhoids who failed conservative treatment were randomly allocated to THD or SH. Preoperative and postoperative symptoms, postoperative pain, time until return to normal activities, complications, patient satisfaction and recurrence rates were all assessed prospectively. Patients were followed up at 2, 8 months and when the study was completed.ResultsTwenty-eight patients (43% third degree) underwent THD and 24 (38% third degree) underwent SH. There were no significant differences in terms of postoperative pain, expected pain and analgesia requirements, but more THD patients returned to work within 4 days (P < 0.05). One THD patient developed a sub-mucosal haematoma after surgery, one SH patient occlusion of the rectal lumen and two rectal bleeding. At 8-month follow-up, two SH patients complained of faecal urgency. At 38-month follow-up (range 33–48 months), all short-term complications resolved. Patient satisfaction (“excellent/good outcome”, THD 89 vs. SH 87%) and recurrence rate (THD 14 vs. SH 13%) were similar in the two groups.ConclusionsShort-term results although similar seem to suggest SH may result in increased morbidity while return to work is quicker after THD. Medium-term results demonstrate that THD and SH have similar effectiveness.

Crohn's involvement of the Vulva is unfamiliar and difficult to treat. The aim is to review the presentation, clinical course and different treatments of Vulva Crohn's disease (CD). We have reviewed the literature without language barrier from 1966 to 2009 through Pubmed with the following words: vulva and CD, vulvitis and CD, genital CD. We included articles that had Crohn's involvement of the vulva arising from a distant site (metastatic) or arising from a Crohn's fistula from the perineum and/or anorectum. We excluded CD of other gynaecological organs. One hundred thirty six abstracts were identified and related articles reviewed. Fifty-five cases of CD of the vulva were included in the final anlaysis of this review. Vulva involvement is rare and gives long-term discomfort. A combined medical therapy (metronidazole with prednisolone) appears to be the most effective treatment. The surgical approach should be reserved for non-responding cases. CD is often unrecognized cause of vulva pain and difficult to diagnose. However if diagnosed and adequately treated it usually responds to conservative therapies.

Methionine adenosyltransferase 2B (MAT2B) encodes for two variant proteins V1 and V2 that promote cell growth. Using in-solution proteomics, GIT1 (G-protein-coupled receptor kinase-interacting protein 1) was identified as a potential interacting partner of MAT2B. Here we examined the functional significance of this interplay. Coimmunoprecipitation experiments examined protein interactions. Tissue expression levels of proteins were examined using immunohistochemistry and Western blotting. The expression levels of the proteins were varied using transient knockdown or overexpression to observe the effect of alterations in each protein on the entire complex. Direct interaction among the individual proteins was further verified using in vitro translated and recombinant proteins. We found both MAT2B variants interact with GIT1. Overexpression of V1, V2 or GIT1 activated MEK1, ERK, raised cyclin D1 protein level and increased growth, while the opposite occurred when V1, V2 or GIT1 was knocked down. MAT2B and GIT1 require each other to activate MEK1/ERK and increase growth. MAT2B directly interacts with MEK1, GIT1 and ERK2. Expression level of V1, V2 or GIT1 directly influenced recruitment of GIT1 or MAT2B and ERK2 to MEK1, respectively. In pull down assays, MAT2B directly promoted binding of GIT1 and ERK2 to MEK1. MAT2B and GIT1 interact and are overexpressed in most human liver and colon cancer specimens. Increased expression of V1, V2 or GIT1 promoted growth in an orthotopic liver cancer model; while increased expression of either V1 or V2 with GIT1 further enhanced growth and lung metastasis. Conclusion MAT2B and GIT1 form a scaffold, which recruits and activates MEK and ERK to promote growth and tumorigenesis. This novel MAT2B/GIT1 complex may provide a potential therapeutic gateway in human liver and colon cancer.