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Hemorrhoids or piles are swelling inside rectum or around the anus, lower parts of your digestive system, containing engorged blood vessels. (Veins) Mostly asymptomatic but when symptoms occur they include: 1. bleeding after passing a stool – the blood is usually bright red 2. itchy bottom 3. a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool 4. a mucus discharge after passing a stool 5. soreness, redness and swelling around your anus These lumps are usually painless unless there blood supply is severely compromised Causes Although cause is unclear, but there is association of in blood pressure in vessels in and around the anus, when the pressure increases it cause the vessels to swell and inflamed. Most important cause of such high pressure is prolong constipation. Long term diarrhea can also increase the chances of getting hemorrhoid. Other risk factors includes 1. obesity 2. age – with advancing age body supporting tissue gets weaker resulting in hemorrhoids 3. Pregnancy – pregnancy its self exert pressure on the pelvic blood vessels thus causing them to engorge and inflamed resulting in piles 4. Family history 5. Strenuous exercises like weight lifting etc 6. persistent cough or repeated vomiting 7. prolonged sitting position Prevention of hemorrhoids Hall mark of the preventing hemorrhoids is to reduce the risk factor causing it for example pregnancy related hemorrhoid mostly gets resolved after delivery. Life style modification also reduces stress on the vessels and prevents hemorrhoids. These includes These can include: 1. increase the fiber content of food by using fruits, vegetables, whole grain rice whole wheat pasta and bread pulses beans nuts and oats 2. drinking plenty of fluids but avoiding caffeine and alcohol 3. avoid resisting the urge to defecate as it makes stool hard and then inturns exert pressure during passage through anus 4. avoiding medication causing constipation like painkillers containing codeine 5. losing weight 6. regular exercise These measures reduce the risk of having hemorrhoids treatment options are discussed below in case of severe or complicated cases. Diagnosis: Based completely on history and clinical examination. History includes inquiry about symptoms mentioned above and bowl habits and stool consistency. Examination is of two types 1. Digital Rectal Examination (DRE): using finger to feel any abnormalities in the anal canal or rectum. 2. proctoscopy: a proctoscope is a thin hollow tube with light at the end to visualize the entire anal canal. Types of hemorrhoids : Depending on location: 1. Internal hemorrhoids: in the upper 2/3 of the anal canal usually painless 2. External hemorrhoids : in the lower 1/3 of the anal canal near anus … usually painful Depending on size and severity: 1. First degree: small inside swelling of the anal lining not visible from outside 2. Second degree: slightly large swelling that come out on straining (usually defecting) and goes back it self 3. Third degree: one or more swelling that hand down from anus and can be pushed back manually(reducible) 4. Fourth degree: large lumps that can’t be pushed back ( irreducible).

An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus. Anal fissures are quite common, with around 1 in every 10 people affected at some point in their life. They affect both sexes equally and people of all ages can get them. But children and young adults between 10 and 30 years of age are more likely to get anal fissures.[5] Anal fissure symptoms The most common symptoms of anal fissures are: • Sharp excruciating burning pain on defecation. • Minute bleeding resulting in bright red spot on feces and toilet paper Most people delay treatment because of embracement resulting in complications but a timely visit to a GP results in early recovery on conservative management. Diagnosing anal fissures Anal fissure are solely diagnose on clinical history and examination. History includes inquiry about sign and symptoms as well as bowl habits and inquiry about general health. Examination is done slightly separating the buttocks and ulcer can be visualized around anal rim under proper illumination. Digital rectal examination procedure in which your doctor will insert a gloved finger in the anus to examine in inside of the anal canal and rectum. However it is avoided because of excruciating pain that patient experience an deserve only of complicated cases and preferably done under local anesthesia to reduce pain during examination What causes anal fissures? Anal fissures are caused by damage to the anal canal lining resulting in tear and painful ulcer development most cases are caused by long standing constipation. As constipated person passes hard compact stool it can damage the anal canal lining. Other possible causes of anal fissures include: • persistent diarrhea • inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis ( long standing inflammatory conditions of the bowel) • pregnancy and childbirth • occasionally, a sexually transmitted infection (STI), such as syphilis or herpes, which can infect and damage the anal canal • having unusually tight anal sphincter muscles, which can increase the tension in your anal canal, making it more susceptible to tearing In many cases, no clear cause can be identified.

Atrial Fibrillation is the most common abnormal fast heart rate (tachyarrythmia). It is more common as we get older, affecting 10% of people over the age of 75years but does affect younger people also. There are a number of ways it can cause problems from breathlessness to a feeling of palpitations all the way to causing a stroke or a blood clot lodging in arteries of the leg. It is treatable with medication and also by a number of procedures including AF ablation therapy. Tablet therapy has been shown to reduce the risk of developing a stroke from AF.

Reconstruction surgeries are of two type arthroscopic and open reconstruction depending on orthopedic surgeon’s choice and extent of injury. Time of surgery is debatable topic. Surgery immediately after injury has been associated with increased fibrous tissue leading to loss of motion (arthofibrosis) after surgery (1). According to some surgeon surgery should be delayed until swelling goes down, gain range of motion in knee and can strongly contract (flex) front of thigh muscle (quadriceps)(1). In adults age is not a factor in surgery though overall condition of body may be. People with medical conditions may consider non surgical treatment option because surgery carries greater risk. These include use of painkillers and anti inflammatory medications and bracing for 1 to 2 weeks with ice, elevation and programmed physiotherapy. A new non surgical treatment option is Platelet rich plasma injection, in this procedure blood of the patient is taken platelets are separated by centrifuge and injected I the injured tissue to augment healing. It is useful in both acute and chronic soft tissues injuries. Choice completely depends upon patient choice and level of activity patient having after surgery (2). Many orthopedic surgeons use arthroscopic surgery rather than open surgery for ACL injuries because: 1. It is easy to see and work on the knee structures. 2. It uses smaller incisions than open surgery. 3. It can be done at the same time as diagnostic arthroscopy (using arthroscopy to find out about the injury or damage to the knee). 4. It may have fewer risks than open surgery (3). During arthroscopic ACL reconstruction, the surgeon makes several small incisions—usually two or three—around the knee. Sterile saline (salt) solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the doctor to see the knee structures more clearly. The surgeon inserts an arthroscope into one of the other incisions. A camera at the end of the arthroscope transmits pictures from inside the knee to a TV monitor in the operating room. Surgical drills are inserted through other small incisions. The surgeon drills small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored. If you are using your own tissue, the surgeon will make another incision in the knee and take the graft (replacement tissue). The graft is pulled through the tunnels that were drilled in the upper and lower leg bones. The surgeon secures the graft with hardware such as screws or staples and will close the incisions with stitches or tape. The knee is bandaged, and you are taken to the recovery room for 2 to 3 hours.3 Physical rehabilitation after ACL surgery may take several months to a year. The length of time until you can return to normal activities or sports is different for every person. It takes most people at least 6 months to return to activity after surgery (4). ACL reconstructive surgery remains the gold standard for repairing this common knee injury. The AAOS reports that about 82 to 90 percent of ACL reconstruction surgeries yield excellent results and full knee stability. ACL reconstruction surgery is generally safe. Complications that may arise from surgery or during rehabilitation (rehab) and recovery include following (6, 7). 0.75% (104) of the consecutive patient cohort had a wound complication recorded (5). • Problems related to the surgery itself. These are uncommon but may include:  Numbness in the surgical scar area.  Infection in the surgical incisions. 0.25% (35) underwent a further procedure to wash out the infected knee joint (5).  Damage to structures, nerves, or blood vessels around and in the knee.  Blood clots in the leg. DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively with on 90 days(5)  The usual risks of anesthesia.  There were no in-hospital deaths(5) • Problems with the graft tendon (loosening, stretching, re-injury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal. • Limited range of motion, usually at the extremes. For example, you may not be able to completely straighten or bend your leg as far as the other leg. This is uncommon, and sometimes another surgery or manipulation under anesthesia can help. Rehab attempts to restore a range of motion between 0 degrees (straight) and 130 degrees (bent or flexion). It's important to be able to get your knee straight so you can walk normally. • Grating of the kneecap (crepitus) as it moves against the lower end of the thigh bone (femur), this may develop in people who did not have it before surgery. This may be painful and may limit your athletic performance. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery. • Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached. • Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery. 1.36% (190) were readmitted to an orthopedic ward within 30 days (5)

Treatment of anal fistula: A fistula without symptoms found on regular check up usually requires no therapy . [3,4] In case of anorectal abscess surgery for fistula repair should not be performed (unless the fistula is superficial and the tract is obvious). In the acute phase, simple incision and drainage of the abscess are sufficient. [5] Only 7-40% of patients will develop a fistula. Recurrent anal sepsis and fistula formation are twofold higher after an abscess in patients younger than 40 years and are almost threefold higher in non diabetics. Preoperative considerations include the following: • Rectal irrigation with enemas should be performed on the morning of the operation • Anesthesia can be general, local with intravenous sedation, or a regional block • Administer preoperative antibiotics Intraoperative considerations include the following: • Examine the patient under anesthesia to confirm the extent of the fistula • Identifying the internal opening (inside the anus) to prevent recurrence is imperative • A local anesthetic block at the end of the procedure provides postoperative analgesia Fistulotomy: The laying-open technique (fistulotomy) is useful for 85-95% of primary fistulas (ie, submucosal, intersphincteric, and low transsphincteric). [6, 7, 8, 9] The most common type of surgery for anal fistulas is a fistulotomy. This involves cutting along the whole length of the fistula to open it up so it heals as a flat scar.A fistulotomy is the most effective treatment for many anal fistulas, although it's usually only suitable for fistulas that don't pass through much of the sphincter muscles, as the risk of incontinence is lowest in these cases. If your surgeon has to cut a small portion of anal sphincter muscle during the procedure, they will make every attempt to reduce the risk of incontinence.In cases where the risk of incontinence is considered too high, one of the procedures below may be recommended instead. Seton techniques: If your fistula passes through a significant portion of anal sphincter muscle, your surgeon may initially recommend inserting a seton. A seton is a piece of surgical thread that is left in the fistula for several weeks to keep it open. This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles. Loose setons allow fistulas to drain, but don't cure them. To cure a fistula, tighter setons may be used to cut through the fistula slowly. This may require several procedures that your surgeon can discuss with you. Seton Placement: A seton can be placed alone, combined with fistulotomy, or in a staged fashion. This technique is useful in patients with the following conditions [10, 11, 12] : • Complex fistulas (ie, high transsphincteric, suprasphincteric, extrasphincteric) or multiple fistulas • Recurrent fistulas after previous fistulotomy • Anterior fistulas in female patients • Poor preoperative sphincter pressures • Patients with Crohn disease or patients who are immunosuppressed Single-stage seton (cutting): Pass the seton through the fistula tract around the deep external sphincter after opening the skin, subcutaneous tissue, internal sphincter muscle, and subcutaneous external sphincter muscle. The seton is tightened down and secured with a separate silk tie. With time, fibrosis occurs above the seton as it gradually cuts through the sphincter muscles and essentially exteriorizes the tract. The seton is tightened on subsequent office visits until it is pulled through over 6-8 weeks. A cutting seton can also be used without associated fistulotomy. Recurrence and incontinence are important factors to consider when this technique is employed. The success rates for cutting setons range from 82-100%; however, long-term incontinence rates can exceed 30%. [13,14, 15] Two-stage seton (draining/fibrosing): Pass the seton around the deep portion of the external sphincter after opening the skin, subcutaneous tissue, internal sphincter muscle, and subcutaneous external sphincter muscle. Unlike the cutting seton, the seton is left loose to drain the intersphincteric space and to promote fibrosis in the deep sphincter muscle. Once the superficial wound is healed completely (2-3 months later), the seton-bound sphincter muscle is divided. Two studies (74 patients combined) supported the two-stage approach with a 0-nylon seton. Once wound healing is complete, the seton is removed without division of the remaining encircled deep external sphincter muscle. The researchers reported eradication of the fistula tract in 60-78% of cases. Mucosal Advancement Flap: A mucosal advancement flap is reserved for use in patients with chronic high fistula but is indicated for the same disease process as seton use. [1,16, 17] Advantages include a one-stage procedure with no additional sphincter damage. A disadvantage is poor success in patients with Crohn disease or acute infection. This procedure involves total fistulectomy, with removal of the primary and secondary tracts and completes excision of the internal opening. A rectal mucomuscular flap with a wide proximal base (two times the apex width) is raised. The internal muscle defect is closed with an absorbable suture, and the flap is sewn down over the internal opening so that its suture line does not overlap the muscular repair. Plugs and Adhesives: Advances in biotechnology have led to the development of many new tissue adhesives and biomaterials formed as fistula plugs. By their less-invasive nature, these therapies lead to decreased postoperative morbidity and risk of incontinence, but long-term data are lacking for eradication of disease, especially in complex fistulas, which carry high recurrence rates. [18, 19, 17] Reported series exist of fibrin glue treatment of fistula-in-ano, with 1-year follow-up showing recurrence rates approaching 40-80%. [20, 21,22] The Surgisis fistula plug has also had mixed long-term results in direct clinical trials. [23, 24, 25] Early success rates have been reported for newer materials, such as acellular dermal matrix and the bioabsorbable Gore Bio-A fistula plug, in low fistulas and good animal model data. [26] Assessment of long-term success rates with plug techniques for complex disease will be based on further data from randomized trials. In a randomized, controlled study designed to evaluate the efficacy and safety of the anal fistula plug in patients with fistulizing anoperineal Crohn disease, Senéjoux et al did not find the plug to be superior to seton removal for achieving fistual closure, regardless of whether the fistula was simple or complex. [27] A combined sphincter-sparing repair that includes both an anal fistula plug and a rectal advancement flap has been proposed for the treatment of transsphincteric fistula-in-ano. [28] LIFT Procedure: Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-sparing procedure for complex transsphincteric fistulas first described in 2007. It is performed by accessing the intersphincteric plane with the goal of performing a secure closure of the internal opening and by removing the infected cryptoglandular tissue. [29] The intersphincteric tract is identified and isolated by performing meticulous dissection through the intersphincteric plane after making a small incision overlying the probe connecting the external and internal openings. Once isolated, the intersphincteric tract is hooked with a small right-angle clamp, and the tract is ligated close to the internal sphincter and then divided distal to the point of ligation. Hydrogen peroxide is injected through the external opening to confirm the division of the correct tract. The external opening and the remnant fistulous tract are curetted to the level of the proximity of the external sphincter complex. Finally, the intersphincteric incision is loosely reapproximated with an absorbable suture. The curettaged wound is left opened for dressing.[29,30,31] Because of its relative novelty, LIFT has not been extensively researched. In a randomized trial of 39 patients with complex fistula-in-ano who had failed previous procedures and were treated with LIFT technique, success rates were comparable to those seen with the anorectal advancement flap technique. [32] The probability of recurrence at 19 months was 8% for the LIFT technique versus 7% for the anorectal advancement flap. Time to return to work was shorter in the LIFT group (1 vs 2 wk), but there was no difference in incontinence scores. [32] Further randomized surgical trials are needed to determine whether this technique is a viable—or, possibly, a better—alternative to the other previously mentioned procedures for the treatment of fistula-in-ano. Diversion: In rare cases, the creation of a diverting stoma may be indicated to facilitate the treatment of a complex persistent fistula-in-ano. The most common indications include, but are not limited to, patients with perineal necrotizing fasciitis, severe anorectal Crohn disease, reoperative rectovaginal fistulas, and radiation-induced fistulas. Fecal diversion alone is effective in these select patients to control sepsis and symptoms; however, long-term success rates after reanastomosis are low because of recurrence from the underlying disease. Thus, this approach should be avoided unless the underlying fistula-in-ano disease process is repaired or has healed completely, which is unlikely. Postoperative Care: After the operation, most patients can be treated in an ambulatory setting with discharge instructions and close follow-up care. Sitz baths, analgesics, and stool-bulking agents (eg, bran and psyllium products) are used in follow-up care. Complications: Early postoperative complications may include the following: • Urinary retention • Bleeding • Fecal impaction • Thrombosed hemorrhoids Delayed postoperative complications may include the following: • Recurrence • Incontinence (stool) • Anal stenosis - The healing process causes fibrosis of the anal canal; bulking agents for stool help to prevent narrowing • Delayed wound healing - Complete healing occurs by 12 weeks unless an underlying disease process is present (ie, recurrence, Crohn disease) Postoperative rates of recurrence and incontinence vary according to the procedure performed, as follows: • Standard fistulotomy - The reported rate of recurrence is 0-18%, and the rate of any stool incontinence is 3-7% • Seton use - The reported rate of recurrence is 0-17%, and the rate of any incontinence of stool is 0-17% • Mucosal advancement flap - The reported rate of recurrence is 1-17%, and the rate of any incontinence of stool is 6-8% [16] Long-Term Monitoring: Frequent office visits within the first few weeks help to ensure proper healing and wound care. It is important to ensure that the internal wound does not close prematurely, causing a recurrent fistula. Digital examination findings can help distinguish early fibrosis. Wound healing usually occurs within 6 weeks.

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