Long-term manometric study of anal sphincter function after hemorrhoidectomy.

BACKGROUND AND AIM: Data on maximum resting pressure (MRP) and maximum squeeze pressure (MSP) changes after hemorrhoidectomy are not univocal and follow-up of patients undergoing surgery is mostly short-lived. The aim of this study was to prospectively examine during 1-year follow-up the long-term manometric results of MRP, MSP, and ultra slow wave activity (USWA) within a set of patients undergoing Milligan-Morgan hemorrhoidectomy as compared to healthy controls. MATERIALS AND METHODS: Twenty patients with hemorrhoids of third and fourth degree were enrolled and anorectal manometry was performed preoperatively, on the 5th day, and after 1, 6, and 12 months after surgery. RESULTS: On the 5th and 30th day after hemorrhoidectomy, USWA was slightly increased as compared to preoperative status. Six and 12 months after surgery, patients with USWA were significantly less in comparison to preoperative assessment without differences with healthy subjects. After surgery, MSP values were not significantly different to baseline values. On the 5th postoperative day after hemorrhoidectomy, MRP was significantly greater than baseline preoperative values. Thirty days after surgery, MRP values were similar to those detected preoperatively, but still significantly increased as compared to healthy subjects. After 6 and 12 months, MRP values were significantly lower than those detected during preoperative phase and comparable to healthy subjects. CONCLUSIONS: Our data support that Milligan-Morgan hemorrhoidectomy induces a complete resolution of typical manometric alterations of disease and that the excision of anal cushions is responsible only for mild and transient alteration of anal continence.

Botulinum toxin vs. topical glyceryl trinitrate ointment for pain control in patients undergoing hemorrhoidectomy: a randomized trial.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound healing and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mmHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

A case of squamocellular uterine cervix carcinoma metastatic to the skin with enterocutaneous fistula.

Metastases to the skin complicated by enterocutaneous fistula are a rare event in gynecological malignancies. We present the case of a 70-year-old woman with uterine cervix carcinoma metastatic to the skin and treated with surgery and radiotherapy. The last relapse to the skin was complicated by the formation of an enterocutaneous fistula. This low-output fistula was treated with surgery and adequate supportive care. The treatment of enterocutaneous fistulas may be either invasive (surgical resection, surgical repair with corrective procedures or with myocutaneous flaps, colonic and/or urinary diversion, endoscopic treatments with metallic stents) or conservative (skin care and local disinfection, pouching of secretions, control of nutrition and electrolytes, TPN, antisecretory treatment with scopolamine or octreotide, and control of psychological conditions). Enterocutaneous fistulas associated with skin metastases are not commonly reported in the literature and may be successfully treated with surgery and supportive care in patients with good performance status and no evidence of further metastatic disease.

Cytokines and growth factors in wound drainage fluid from patients undergoing incisional hernia repair.

Knowing the dynamics of growth factor and cytokine secretion within the site of a surgical operation is important, as they play a crucial role in the pathophysiology of wound healing and are a target for modifying the repair response. The aim of this study was to evaluate the production of several cytokines and growth factors in the drainage wound fluid from patients undergoing incisional hernia repair: namely, interleukin (IL)-6, IL-10, IL-1alpha, IL-1 ra, interferon-gamma, vascular endothelial growth factors and basic fibroblast growth factor. Ten female patients with abdominal midline incisional hernia undergoing surgical repair were included in this study. In all cases, a closed-suction drain was inserted in the wound below the fascia and removed on postoperative day 4. Wound fluid was collected on postoperative days 1-4 and the amount was recorded each time. Growth factors and cytokines production was evaluated as the whole amount produced over a 24-hour period. In all patients, the amount of drain fluid from surgical wounds was more copious the first day after surgery, it decreased significantly afterward. The presence of all cytokines was highest on postoperative day 1, decreasing over the following days. More specifically, the production of IL-1 ra, IL-6, IL-1alpha, and IL-10 on postoperative day 1 fell sharply on postoperative days 3 and 4, whereas, after an initial reduction, interferon-gamma showed an increase from day 2 onward. Vascular endothelial-derived growth factor production increased progressively after the operation reaching statistical significance only on day 4. As for basic fibroblast growth factor, it showed an opposite pattern: it was higher on postoperative day 1 decreasing thereafter. This analysis of cytokine and growth factor production in the drain fluid will lead us to a better evaluation of the events that follow a surgical wound and to a better understanding of the healing process.

Modifications in the production of cytokines and growth factors in drainage fluids following mesh implantation after incisional hernia repair.

BACKGROUND: The aim of this study was to evaluate changes in the production of some cytokines (interleukins [ILs]-6, -10, -1, and -1ra), vascular endothelial growth factor, and beta-fibroblast growth factor after polypropylene mesh implantation. METHODS: Twenty female patients were divided into 2 groups. In 1 group, hernia repair was performed with conventional sutures (CR), whereas in the other group polypropylene mesh (MR) was used. Growth factors and cytokines production was analyzed in wound drain fluids based on the amount produced during 24 hours. RESULTS: IL-1 increased substantially in MR patients on postoperative days 1 and 2. IL1-ra and IL-10 production was always significantly higher in CR patients. IL-6 production did not show any considerable difference between the 2 groups. Vascular endothelial growth factor production was significantly higher in the MR than the CR group at all time points, whereas beta-fibroblast growth factor production was higher in the MR than the CR group only on postoperative day 1. COMMENTS: Our data suggest that different surgical procedures induce various levels of inflammation and that implantation of prostheses significantly stimulates the inflammatory response.

Serum VEGF and b-FGF profiles after tension-free or conventional hernioplasty.

BACKGROUND: Angiogenesis is strongly influenced by vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF), whose production is also regulated by interferon (IFN)-gamma and interleukin (IL)-10. The aim of this study was to evaluate the modifications of serum VEGF, b-FGF, IFN-gamma and IL-10 levels in patients with inguinal hernia undergoing hernioplasty with the Lichtenstein technique (LH) using polypropylene mesh or with Bassini open conventional inguinal hernia repair (BH). MATERIALS AND METHODS: Randomly, 16 patients underwent BH, and 16 were treated with the LH technique using polypropylene mesh. Blood samples were collected 24 h prior to surgery and then 6, 24, 48 and 168 h postoperatively. The serum concentrations of VEGF, b-FGF, IFN-gamma and IL-10 were evaluated. RESULTS: In BH patients, a peak of VEGF synthesis at 6 h with a normalization of this parameter 24 h after surgery has been observed. In the same subjects, b-FGF synthesis increased after surgery reaching significant levels 48 h later. On the contrary, in LH patients, a decrease in the serum VEGF and b-FGF concentrations was detected after surgery and their increase afterwards. IL-10 was increased in both groups 6 h after operation and declined to preoperative levels 24 h afterwards. IFN-gamma enhanced in LH patients 6 h after surgery, whereas no modifications were detected in BH subjects. CONCLUSIONS: This preliminary study shows that VEGF and b-FGF modifications, associated with alterations of cytokine secretion, are detectable in human undergoing hernioplasty, and suggests that they could somehow influence in the wound-healing process.

[Efficacy of topical use of 0.2% glyceryl trinitrate in reducing post-haemorrhoidectomy pain and improving wound healing]. / L'efficacia del trinitrato di glicerina allo 0.2% per uso topico nel ridurre il dolore post-emorroidectomia e favorire la guarigione delle ferite.

The aim of the study was to evaluate whether topical application of 0.2% glyceryl trinitrate ointment could reduce post-haemorrhoidectomy healing time and pain both at rest and during defecation. Thirty patients with grade III and IV haemorrhoids were included in the study and divided into two groups. All patients underwent Milligan-Morgan haemorrhoidectomy, and anorectal manometry was performed before surgery and after 5 and 30 days. In one group a placebo ointment was applied to the perianal wounds, while in the other group a 0.2% glyceryl trinitrate ointment was used. Maximum resting pressure was reduced in the glyceryl trinitrate group and increased in the placebo group after 5 days. Postoperative pain both at rest and during defecation, and the time to healing and return to normal activity were significantly reduced in the glyceryl trinitrate group, whilst analgesic consumption was similar. An elevated incidence of headache was observed In the glyceryl trinitrate group. Topical application of glyceryl trinitrate was effective in reducing postoperative pain and healing time, but the substantial incidence of side effects may limit its extensive use.

Acute inflammatory response after inguinal and incisional hernia repair with implantation of polypropylene mesh of different size.

BACKGROUND: The purpose of this study was to assess the modifications of interleukin (IL)-6, C-reactive protein (CRP), leukocytes and fibrinogen after implantation of polypropylene mesh. METHODS: Thirty-six patients were included in this study and divided into two groups. To the first group were allocated patients affected by inguinal hernia and undergoing conventional repair (subgroup Ia) or hernioplasty with 40-cm(2) polypropylene mesh (subgroup Ib). To the second group were allocated patients affected by incisional hernia and undergoing conventional repair (subgroup IIa) or incisional hernia repair with 400-cm(2) polypropylene mesh (subgroup IIb). Peripheral venous blood samples were collected 24 h before surgery and then 6, 24, 48 and 168 h postoperatively. RESULTS: We present evidence that serum levels of IL-6, CRP, leukocytes and fibrinogen were significantly increased postoperatively in all subgroups compared with their baseline values. In particular, the production of inflammatory mediators was higher in subgroups Ib vs Ia and IIb vs IIa. Comparing the entities of the inflammatory responses among various groups we found that it was clear that they were similar in subgroups Ib and IIa, and that the highest were in subgroup IIb and the lowest in subgroup Ia. CONCLUSION: The data show that conventional inguinal and incisional hernia repair induces an inflammatory response, which is smaller than that observed if both operations are carried out with polypropylene meshes. Furthermore, the results suggest that a larger mesh is associated with a higher production of inflammation mediators.

Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.