Antibiotics and early post operative complications of closed hemorrhoidectomy: a retrospective matched pair study.

OBJECTIVE: The purpose of the present study was to compare early post-operative complications and length of hospital stay of hemorrhoidectomy patients between those who had and had not received metronidazole perioperatively. RESEARCH DESIGN: Retrospective, matched pair case-control study. MATERIAL AND METHOD: Medical records of all hemorrhoidal patients hospitalized between January 2000 and December 2005 were reviewed. Hemorrhoidectomy patients who had and had not received metronidazole perioperatively during this period were matched based on demographic data. Demographic data including bodyweight and number of hemorrhoidectomies of both groups were collected. Length of hospital stay and immediate post-operative complications (bleeding, urinary retention, and wound dehiscence at 2nd and 4th week), the total dosages of pethidine, acetaminophen, and NSAIDs were analyzed and compared by the McNemar and the Wilcoxon Signed Rank Test. RESULTS: Of 1,184 patients who completed the follow-up protocol, 88 patients (male: female = 31:57) who had received metronidazole could be matched by gender, age, NSAIDs used, number of hemorrhoids resected and operation in the same period with 88 patients (male:female = 31:57) who had not. There were six (6.8%) and seven (8%) patients with urinary retention in the metronidazole group and non-antibiotic group respectively. One patient in each group (1.1%) experienced bleeding that ceased spontaneously. The length of hospital stay was 1.14 +/- 0.35 (ranged 1-2) and 1.11 +/- 0.35 (ranged 1-3) days in the metronidazole and the non-antibiotic group respectively, showing no significant difference (p = 0.683). There was no significant difference in the total dosages of pethidine given postoperatively, which was 1.06 +/- 0.83 and 1.03 +/- 0.78 mg/kg in the metronidazole and the non-antibiotic group respectively (p = 0.747). At the 2nd week, there were two wound dehiscences (2.25%) in each group. At the 4th week, no more new wound dehiscence was detected and all were completely healed without stricture. CONCLUSION: There was no benefit of metronidazole on closed hemorrhoidectomy with respect to post-operative complications, length of hospital stay, and total analgesics used.

Outcome of familial adenomatous polyposis: a retrospective study.

BACKGROUND: Familial adenomatous polyposis (FAP) is characterized by the presence of numerous colorectal adenomatous polyps that progress to colorectal cancer if left untreated. Following colorectal cancer, periampullary cancer and aggressive desmoid tumor are also the common causes of death. The purpose of the present study was to describe the clinical course of FAP patients. MATERIAL AND METHOD: The authors conducted a retrospective study of 31 FAP patients who were treated at King Chulalongkorn Memorial Hospital (KCMH) between March 2000 and March 2006. Demographic data, family history, symptoms, extracolonic manifestations, operative procedures, pathologic findings, and postoperative results were collected. RESULTS: Two patients were excludedfrom the present study. The average age of the 29 patients was 33.48 years with the sex ratio (male/female) of 0.93. Seventeen of the 29 patients (58.6%) had a family history of FAP Sixteen of 29 patients were discovered with colorectal cancer with a mean age of34.56 years. Mucous bloody stool was the most common presenting symptom and most of the patients with this symptom (11/13) already had colorectal cancer Gastroduodenal polyps and desmoid tumor were common extracolonic manifestations. The most common operative procedure was restorative proctocolectomy with ileal J pouch (RPC). Wound infection and gut obstruction were the frequent complications. Functional outcomes of patients with RPC were good. The mean age ofpatients with colon cancer was older than the mean age ofpatients without colon cancer However, there was no significant difference between the two groups. The sex ratio and family history of FAP were not statistically different. No significant differences were found in surgical procedures and postoperative complications. On the follow up period, two patients in the later group died of desmoid tumor and pancreatic cancer while seven patients in the former group died of metastatic colon cancer and one with desmoid tumor CONCLUSION: The proportion ofpatients who were discovered with colorectal cancer in the present study was high with young age onset of cancer Moreover, patients in this group had poorer outcome compared to the group of patients without colorectal cancer; of which, metastatic colorectal cancer was the major cause of death. This result may be due to aggressiveness and advanced stage of disease at the first diagnosis.

Closed lateral internal sphincterotomy using endoshere cut scissors.

BACKGROUND: Internal sphincterotomy remains the gold standard for treatment of chronic anal fissure but it is associated with immediate wound bleeding and hematoma, which is usually corrected by a pressure dressing for half an hour. OBJECTIVE: This procedure was the initial study to decrease intra-operative and immediate postoperative wound bleeding, hematoma, and duration of pressure by using Endoshere cut scissors for closed lateral internal sphincterotomy. MATERIAL AND METHOD: Closed lateral internal sphincterotomy was performed on patients with chronic anal fissures by using Endoshere cut scissors in standard technique. The Fansler's proctoscope (diameter 1.5 cm) was inserted into the anal canal to permit adequate exposure of the anal fissure after local anesthetized with 0.5% xylocaine with adrenaline 1-2 cc. at left lateral region. The intersphincteric groove was identified, and then the small stab incision was made on the lateral side. The surgeon used the forceps to expose the internal sphincter then sphincterotomy was carried out with Endoshere cut scissors. After the operation was finished, no pressure dressing was applied to the sphincterotomy wound. RESULTS: Closed lateral internal sphincterotomy was performed on 10 patients by using Endoshere cut scissors. The present results showed that no intra-operative and immediate postoperative wound bleeding, hematoma occurred. No pressure dressing was required. CONCLUSION: The authors' early results showed that Endoshere cut scissors are usefulfor closed lateral internal sphincterotomy. There was no intra-operative and immediate postoperative wound bleeding and hematoma. The pressure dressing is unnecessary. The long term results should be further studied in a randomized control trial.

Closed vs ligasure hemorrhoidectomy: a prospective, randomized clinical trial.

OBJECTIVE: To compare the operative time, postoperative complications, and analgesic requirement between closed hemorrhoidectomy and Ligasure hemorrhoidectomy. MATERIAL AND METHOD: The study was conducted in a prospectively randomized controlled fashion. Forty-seven patients with grade 3 or 4 hemorrhoids plus external component or skin tag were operated on by either hemorrhoidectomy with Ligasure (24 patients) or closed hemorrhoidectomy (23 patients). One patient in each group was lost to follow up. The operative time, postoperative verbal numeric pain score, analgesic requirement, bleeding, and wound dehiscence between the two groups were compared Unpaired t-tests, Mann-Whitney U tests, or Fisher's Exact tests were used where appropriate. RESULTS: Demographic and clinical data between two groups were comparable. Operative time for the Ligasure hemorrhoidectomy was significantly shorter than the closed hemorrhoidectomy group (21.70 +/- 11.76 vs 35.68 +/- 14.25 min, p < 0. 001), while the number of resected hemorrhoids in the study group were 2.91 versus 2.18 in the control group. However, there were no differences in post-operative pain score, analgesic requirement, bleeding, or wound dehiscence between the two groups. CONCLUSION: Ligasure hemorrhoidectomy is superior to closed hemorrhoidectomy in terms of reducing the operative time without affecting postoperative complications.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

The new laparoscopic proctocolectomy training (in soft cadaver).

OBJECTIVES: The purpose of the present study was to evaluate the quality of preservation (tissue plane, named vessels identification, consistency of colon and rectum), quality of performing procedures, difficulties and problems and finally the satisfaction of surgeons in laparoscopic proctocolectomy in soft cadaver. SETTING: Colorectal Division, Department of Surgery and Surgical Training Center Department of Anatomy, Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study MATERIAL AND METHOD: 10 soft cadavers were scheduled for laparoscopic proctocolectomy. The procedures (colon-rectum mobilization and named vessels identification) were performed by 14 experienced surgeons (8 colorectal surgeons) and assisted by surgical residents. The quality of preservation, successfulness and the satisfaction in performing the procedures were recorded using questionnaires for evaluation. RESULTS: The preservation was very good in every aspect especially tissue plane between colon, mesocolon and retroperitoneum which was clearly dissected, same asfasciapropria of rectum. The named vessels and the tissue consistency were very well preserved and tolerated to laparoscopic equipment handling. The surgeons were satisfied with the tissue handling and dissections. There were two difficulties, the first was air leakage but simply corrected with purse string suture and the second was unflavored smell which was not concerned. Laparoscopic proctocolectomy could be completely performed in soft cadaver. CONCLUSION: Laparoscopic proctocolectomy could be performed in soft cadavers with great satisfaction. Repeated practice is possible, so the surgeons can gain their experiences outside the operating theatre. This success may shorten the learning curve and may be the new era in cadaver-based training.

Laparoscopic versus open surgery for rectosigmoid and rectal cancer.

OBJECTIVES: The aim of this study was to evaluate feasibility and safety of laparoscopic surgery for rectosigmoid cancer and rectal cancer. MATERIAL AND METHOD: Twenty four patients who underwent laparoscopic surgery for rectosigmoid cancer or rectal cancer were retrospectively evaluated. Results were compared with those of 25 patients who had open surgery at the same period. The procedures of both groups were anterior resection, low anterior resection, coloanal anastomosis, abdominoperineal resection and subtotal colectomy. RESULTS: The mean operative time was significantly increased in the laparoscopic group. However, this group showed faster recovery of bowel function. There were no differences in the distal margin and yield of harvested lymph nodes of resected specimens. Although anastomotic leakage was comparable between 2 groups, surgical wound infection was significantly higher in open surgery group. CONCLUSION: Laparoscopic surgery for rectosigmoid cancer and rectal cancer is feasible and can be performed safely with comparable oncological clearance.