Hemorrhoidal disease is a common anorectal condition that may require treatment when bleeding, prolapse or persistent symptoms fail to respond to conservative or office-based therapy. Radiofrequency ablation (RFA) has emerged as a minimally invasive, tissue-sparing technique for symptomatic internal hemorrhoids, based on controlled delivery of high-frequency energy into hemorrhoidal tissue. The resulting thermal effect induces coagulative necrosis, fibrosis, mucosal fixation and progressive reduction in hemorrhoidal volume, without excisional removal of anoderm or rectal mucosa. This narrative review summarizes the mechanism, technical principles, clinical advantages, comparative evidence and remaining uncertainties surrounding RFA, with particular attention to the Rafaelo procedure and related radiofrequency-based approaches. Current evidence suggests that RFA may reduce postoperative pain, analgesic requirements, wound-related morbidity, hospital stay and time to return to normal activity compared with conventional hemorrhoidectomy, while maintaining acceptable short- and mid-term symptom control in selected patients, especially those with grade II-III internal hemorrhoids. However, available studies remain heterogeneous in design, technique, patient selection, outcome definitions and follow-up duration. The relationship between modern probe-based RFA and earlier radiofrequency-based approaches, including Ellman surface coagulation, Celon bipolar radiofrequency-induced thermotherapy and radiofrequency-assisted hemorrhoidectomy, remains insufficiently standardized in the literature. Further randomized trials, standardized outcome reporting, long-term recurrence data and cost-effectiveness analyses are required to define the optimal indications and therapeutic position of RFA.

Objective: To investigate the risk factors of long-term (>3 months) severe anastomotic complications after rectal cancer surgery. Methods: A case-control study was employed, with the following inclusion criteria for cases: (1) age between 18 and 80 years; (2) history of radical surgery for rectal cancer; (3) tumor located ≤10 cm from the anal verge; (4) occurrence of long-term (>3 months) severe anastomotic complications (e.g., refractory local infection or intestinal obstruction) requiring transverse colostomy; (5) complete clinical data. Exclusion criteria: (1) transverse colostomy due to local recurrence or extensive peritoneal metastasis; (2) transverse colostomy due to non-anastomotic complications(e.g., radiation enteritis, fecal incontinence, anal pain); (3) extensive liver or lung metastasis; (4) loss to follow-up. This study defined long-term severe anastomotic complications as complications requiring readmission for transverse colostomy, including anastomotic leakage, sinus tract formation, anastomotic stenosis, and intestinal obstruction. According to the above criteria, a retrospective collection was conducted on 107 patients who underwent transverse colostomy after rectal cancer surgery at Shanghai Changhai Hospital from May 2014 to June 2024 due to long-term severe anastomotic complications (severe anastomotic complications group). 737 patients who underwent radical surgery for rectal cancer at the same hospital from January 2019 to December 2019 were selected from the clinical database as the control group. The inclusion criteria for the control group are as follows: (1) age between 18 and 80 years; (2) history of radical surgery for rectal cancer in our hospital; (3)tumor located ≤10 cm from the anal verge; (4) complete clinical data. No transverse colostomy, recurrence, metastasis, death, or loss to follow-up were included. The observation indicators of this study were risk factors associated with long-term severe anastomotic complications. The variables analyzed included: gender, age, carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), body mass index (BMI), preoperative hemoglobin, preoperative albumin, tumor distance from the anal verge, stoma construction status, postoperative tumor T stage, postoperative tumor N stage, maximum tumor diameter, KRAS mutation, NRAS mutation, BRAF mutation, neoadjuvant chemoradiotherapy status, adjuvant chemoradiotherapy status, and perirectal fat space (PFS). Preoperative images with fat quantification sequences of the rectum were acquired via the Picture Archiving and Communication System (PACS), followed by quantification of perirectal fat areas at superior and inferior tumor margins using ImageJ software. Results: Among 107 rectal cancer patients undergoing transverse colostomy for long-term severe anastomotic complications, 85 were male (79.4%) and 22 female (20.6%), with BMI (22.3±3.1) kg/m[2]. Twenty-nine patients (27.1%) had no radiotherapy exposure, while 78 (72.9%) received radiotherapy, including 31 (39.7%) preoperatively and 47 (60.3%) postoperatively. The long-term severe anastomotic complications comprised two categories:(1) fistulas in 47 cases (43.9%): including anastomotic, rectovaginal, rectourethral, and rectovesical fistulas; (2) anastomotic stenosis in 60 cases (56.1%). Univariate analysis demonstrated significantly higher proportions of male patients, advanced age, postoperative T/N stages, and radiotherapy history, but lower BMI in the severe anastomotic complications group versus controls (all P<0.05). Multivariate analysis identified male sex (OR=2.435, 95%CI:1.333-4.447, P=0.004), advanced age (OR=1.035, 95%CI:1.010-1.060, P=0.005), T4 stage (OR=14.634, 95%CI:2.096-102.187, P=0.007), N2 stage (OR=2.014, 95%CI:1.043-3.888, P=0.037), low BMI (OR=1.175, 95%CI:1.080-1.278, P<0.001), and radiotherapy (OR=9.759, 95%CI:5.517-17.264, P<0.001) as independent risk factors. Propensity score matching was further performed in patients receiving radiotherapy, with PFS measurements at both superior and inferior tumor margins. Matched cohorts comprised 78 patients each. Univariate analysis revealed higher male proportion but lower BMI, superior PFS, and inferior PFS in the severe anastomotic complications group (all P<0.05). Multivariate analysis confirmed male sex (OR=2.756, 95%CI:1.130-6.720, P=0.026), low BMI (OR=1.169, 95%CI:1.033-1.324, P=0.013), and reduced inferior PFS (OR=1.021, 95%CI:1.001-1.042, P=0.041) as independent predictors. Conclusion: Radiotherapy significantly contributes to long-term severe anastomotic complications. Male patients exhibiting low BMI and diminished PFS at inferior tumor margins demonstrate the highest risk profile.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare multisystem paraneoplastic disorder. The syndrome presents unique perioperative challenges, including sclerotic bone changes that may preclude conventional neuraxial techniques. The ultrasound-guided sacral erector spinae plane (SESP) block represents a novel interfacial plane block that offers an alternative approach for sacral region analgesia. We describe a 58-year-old man with POEMS syndrome who presented with an acute perianal abscess requiring surgical drainage. The patient exhibited multiple high-risk features: sacrococcygeal sclerosis preventing identification of the sacral hiatus, severe hyperkalemia (6.54 mmol/L), stage 3 chronic kidney disease, pericardial effusion, and previous ischemic stroke. These comorbidities rendered traditional caudal epidural block contraindicated and general anesthesia high risk. Under ultrasound guidance, a single-shot SESP block was performed at the S3-S4 level using 25 mL of 0.2% ropivacaine with 25 µg dexmedetomidine. The block provided complete intraoperative analgesia (visual analog scale [VAS] score of 0) and effective postoperative pain control (VAS score <2 for 24 hours), facilitating successful surgery and discharge on postoperative day 1. This case demonstrates that the SESP block is a feasible and effective alternative for patients with complex conditions such as POEMS syndrome, where neuraxial techniques are anatomically precluded or clinically contraindicated. Based on this experience and supporting literature, the SESP block warrants consideration as a valuable component of multimodal analgesic strategies for anorectal and pelvic floor surgery, particularly in high-risk patients with challenging anatomy or significant comorbidities.

Gastrointestinal Kaposi sarcoma is an uncommon but clinically relevant manifestation of human herpesvirus 8-associated disease in patients with human immunodeficiency virus (HIV) infection. Its diagnosis may be delayed because symptoms are often nonspecific and may overlap with other anorectal disorders, particularly in patients with condylomatous disease, fissures, proctitis, or anal malignancy. We report the case of a 25-year-old male with HIV infection on antiretroviral therapy and an undetectable viral load who presented with one month of anal pain and rectal bleeding. Initial colonoscopy demonstrated multiple irregular ulcerated lesions in the distal rectum, and biopsy confirmed Kaposi sarcoma associated with human herpesvirus 8. Despite referral to Medical Oncology and initiation of chemotherapy, the patient had persistent rectal bleeding, mucus discharge, anal condyloma, and fissure. Repeat proctologic evaluation and colonoscopy revealed elevated, irregular, ulcerated circumferential lesions extending from the anal canal to 10 cm proximally, with increased submucosal vascular pattern. Persistent gastrointestinal Kaposi sarcoma with suspicious anorectal tumoral involvement was identified, and the patient was referred for multidisciplinary oncologic management. This case highlights the diagnostic challenge of anorectal Kaposi sarcoma in patients with HIV infection, especially when symptoms overlap with benign anorectal disease or synchronous malignancy. Early endoscopic evaluation, biopsy, and immunohistochemistry are essential for timely diagnosis and appropriate multidisciplinary treatment.

Squamous cell carcinoma (SCC) of the anal canal is an uncommon malignancy with increasing incidence, particularly among people living with human immunodeficiency virus (HIV). In rural populations, limited access to specialized screening and fragmented care contribute to delayed diagnosis and advanced-stage presentation. A 58-year-old male patient with a 25-year history of HIV presented with one month of persistent rectal pain, intermittent bleeding, and mass sensation. Physical examination revealed a 5 × 6 cm ulcerated lesion near the anal margin. The patient reported inconsistent adherence to antiretroviral therapy due to transportation barriers and had no prior anorectal screening. Colonoscopy was performed, during which rectal retroflexion revealed an irregular, ulcerated, exophytic lesion with friability and infiltrative features. Biopsies and subsequent examination under anesthesia confirmed anal SCC. Staging demonstrated regional lymph node involvement without distant metastases, consistent with stage IIIA (T3N1M0). The patient was referred to colorectal surgery, radiation oncology, and medical oncology for further treatment. Ultimately, this case highlights how transportation barriers, inconsistent care access, and reliance on multiple geographically separated providers contributed to delayed diagnosis. In resource-limited settings, the lack of high-resolution anoscopy restricts early detection. Although not a primary screening tool, colonoscopy with careful anorectal evaluation may allow for opportunistic detection of malignancy in high-risk individuals. This case underscores the need for improved care integration and expanded access to screening resources among rural communities.

Background and Aims: This study investigates the feasibility of performing anorectal surgery in neonates in a prone position via epidural anesthesia and sedation without an instrumented airway. Methods: Twenty infants, scheduled for surgery for anorectal malformations, were included in this study. The primary endpoint was the success of the anesthesia method without invasive airway manipulation after skin incision, and secondary endpoints were defined as the need for additional opioids or sedation drugs during the perioperative period. The study was approved by the Ethics Committee of the Medical University of Vienna (ref. 1133/2017-approval date 24 August 2017), and was registered in the German Clinical Trial Register (DRKS ID: DRKS00012683, approval date 15 July 2019, updated 30 July 2020). Results: The primary outcome parameter could be achieved in 95% of the cases, and 85% of the cases could be managed without additional opioids (secondary outcome parameter). Only one infant (5%) needed endotracheal intubation due to laryngospasm during prone positioning. Conclusions: Surgery for infantile anorectal malformations in a prone position is possible with epidural anesthesia and sedation without an instrumented airway.

Effective postoperative pain management after hemorrhoidectomy remains a significant clinical challenge, largely due to the scarcity of safe and effective non-opioid analgesics. Zhi-Lou-Xun-Xi decoction (J5) is a traditional Chinese formula that has been used clinically for decades, yet its active components and mechanism of action remain unclear.

Background Anorectal surgeries are commonly performed as ambulatory procedures requiring effective perineal anesthesia, hemodynamic stability, adequate postoperative pain control, and early mobilization to facilitate same-day discharge. Saddle block provides dense sacral anesthesia but is often associated with sympathetic blockade, hypotension, motor impairment, and urinary retention. Ultrasound-guided caudal epidural block (USG-CEB) has emerged as a reliable alternative that allows selective sacral nerve root blockade with potentially improved recovery characteristics. However, direct comparative evidence between USG-CEB and saddle block in adult anorectal surgeries remains limited. Aim and objectives To compare USG-CEB with saddle block in adult patients undergoing elective anorectal surgery. The primary objectives were to evaluate time to mobilization and time to first rescue analgesia. Secondary objectives included assessment of onset of sensory blockade, intraoperative hemodynamic changes, time to voiding, requirement for supplemental local infiltration, and patient satisfaction. Materials and methods This prospective randomized controlled study included 59 adult patients scheduled for elective anorectal surgery. The trial was registered in the Clinical Trials Registry of India (CTRI/2020/01/022896) and also obtained approval from the Institutional Ethics Committee (approval number: VMMC/ANESTH/2019/01). Patients were randomized into two groups: Group C (USG-CEB) and Group S (saddle block). Ultrasound-guided blocks were performed using a high-frequency linear probe (L13-3Ns, 3-13 MHz). Rescue analgesia was administered when the visual analogue scale (VAS) score was ≥four, using intravenous tramadol 50 mg, repeatable every eight hours as required. Postoperative assessments were conducted by a blinded observer. Data were analyzed using appropriate statistical methods. Continuous variables were expressed as mean ± standard deviation and compared using the independent t-test. Categorical variables were analyzed using the chi-square test. Effect sizes (Cohen's d) and 95% confidence intervals were calculated for primary and key secondary outcomes. A p-value <0.05 was considered statistically significant. Results Patients in the USG-CEB group demonstrated significantly earlier mobilization (5.82 ± 0.71 h vs. 6.95 ± 0.60 h, p<0.001) and earlier time to voiding (4.95 ± 0.73 h vs. 6.82 ± 0.71 h, p<0.001) compared to the saddle block group. Time to first rescue analgesia was longer in the USG-CEB group (5.00 ± 0.95 h vs. 4.45 ± 0.74 h, p=0.021). However, sensory onset was faster in the saddle block group (9.83 ± 1.42 min vs. 12.86 ± 1.84 min, p<0.001). Hemodynamic parameters were more stable in the USG-CEB group. Conclusion USG-CEB is an effective alternative to saddle block for anorectal surgery, offering a favorable recovery profile characterized by earlier mobilization, earlier voiding, and stable hemodynamics. However, these advantages should be weighed against a slower onset of anesthesia and the need for supplemental analgesia in some patients. The clinical significance of these findings may vary across practice settings, and anesthetic technique should be individualized.