Doppler-guided hemorrhoidal dearterialization with laser (HeLP): a prospective analysis of data from a multicenter trial.

BACKGROUND: Doppler-guided hemorrhoidal laser procedure (HeLP) is a new minimally invasive technique to treat symptomatic hemorrhoids. The aim of this multicenter study was to prospectively assess clinical results and patients' satisfaction in patients treated with HeLP. METHODS: Indications for HeLP included patients with symptomatic hemorrhoids resistant to medical therapy, with low-grade prolapse. Clinical efficacy was evaluated assessing resolution of symptoms and patient satisfaction. Frequency of bleeding and frequency of acute hemorrhoid-related symptoms were given a score of 0 to 4 (where 4 = more than 3 episodes/week) and 0 to 3 (where 3 = more than 5 episodes/year), respectively. Quality of life, pain at rest, and pain with evacuation were scored using a visual analogue scale (VAS) of 0 to 10. Intra- and postoperative complications were recorded. Potential predictive factors for failure were assessed. RESULTS: Two hundred and eighty-four patients (183 males, 101 females) with a mean age of 47.5 years were included in the study. At 6-month follow-up, symptoms had completely resolved in 257/284 (90.5%) and 275/284 (96.8%) patients were satisfied with the results. An analysis of a subgroup of 144 patients followed up for a minimum of 12 months revealed a resolution of symptoms in 130/144 (90.3%) and satisfaction in 139/144 (96.5%). There was a statistically significant improvement of the bleeding score (from 2.4 ± 1.07 to 0.36 ± 0.49; p < 0.0001), acute symptoms score (from 2.03 ± 0.16 to 0.61 ± 0.59; p < 0.0001), quality of life (from 4.63 ± 1.32 to 8.96 ± 1.35; p < 0.0001), pain at rest (from 3.0 ± 2.05 to 1.1 ± 0.99; p < 0.0006), and pain with evacuation (from 4.8 ± 1.22 to 1.7 ± 1.15; p < 0.0001). No significant changes in continence and constipation were observed. Univariate analysis failed to show factors significantly associated with failure. CONCLUSIONS: The HeLP procedure seems to be safe and effective in patients with symptomatic hemorrhoids. It is simple, minimally invasive, and relatively pain free. It can be performed in an ambulatory setting without anesthesia, and it achieves high patient satisfaction. It may, therefore, be considered a "first-line treatment" in all patients without significant hemorrhoidal prolapse in whom medical therapy has failed.

Double PPH technique for hemorrhoidal prolapse: a multicentric, prospective, and nonrandomized trial.

INTRODUCTION: Longo's technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse. MATERIALS AND METHODS: We describe the application of "Double PPH Technique" (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse. RESULTS: In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5). CONCLUSIONS: Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo's procedure for hemorrhoidal prolapse.

Double stapled haemorrhoidopexy for haemorrhoidal prolapse: indications, feasibility and safety.

AIM: Selected patients with haemorrhoidal prolapse undergoing double stapled anopexy with the procedure for prolapse and haemorrhoids (PPH03) were studied. METHOD: Between March 2007 and March 2010, 235 patients referred with haemorrhoids were included in the study. Patients with obstructed defaecation were excluded. At surgery intraoperative evaluation for double stapled anopexy was carried out based on the criteria of prolapse occupying half or more of the anal circumference and redundant prolapsed tissue determined by the circular anal dilator. Patients fulfilling these criteria were submitted for double stapled anopexy with the PPH03 stapler. All clinical and operative data were recorded in a prospectively maintained database. RESULTS: Among the 142 patients with haemorrhoidal prolapse having surgery 91 had a single and 51 a double stapled technique. The mean operative time was 34.8 min with no major or minor intraoperative complications. Recurrence at 48 months was 1.9% and the mean satisfaction score was 8.9. CONCLUSION: The double stapled PPH03 technique in selected cases was as safe and effective as a single stapling technique with a lower incidence of recurrence over a medium-term follow-up.

[Toxic megacolon: report of 2 clinical cases and review of the literature]. / Il megacolon tossico: presentazione di 2 casi clinici e revisione della letteratura.

The authors present two cases of toxic megacolon. A proctocolectomy with ileostomy was performed in both cases. One of the two cases was detected late; the patient underwent surgery in desperate conditions and died on postoperative day one. The authors regard a prompt diagnosis as fundamental for the correct timing of the surgical approach in patients with toxic megacolon and severe acute colitis. Clinical and laboratory findings and, above all, plain films of the abdomen should be evaluated very carefully. The authors suggest total proctocolectomy with section-suture of the rectal stump at levator level and ileostomy, which makes it possible to avoid postoperative rectal haemorrhages and recurrences.

Local excision for rectal cancer.

BACKGROUND AND OBJECTIVES: The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. METHODS: From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries. RESULTS: There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76). CONCLUSIONS: LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity.

[Current trends in the treatment of rectal carcinoma]. / Attuali orientamenti in tema di trattamento del carcinoma del retto.

Authors report their personal experience about 336 cases of curative surgery for rectal cancer. They describe technical surgical details universally accepted in Literature such as sharp total mesorectal excision, the extension of lymphadenectomy with high ligature of inferior mesenteritis artery while pelvic lymphadenectomy seems to be unuseful and burdened by high morbidity; finally they underline advantages offered by a colic pouch above all for lower incidence of anastomotic leakages. As adjuvant therapy is concerned, our actual tendency is a preoperative radiochemiotherapy of which we are still evaluating long-term results. Finally we analyzed correlations between cellular genetics and colo-rectal cancer.

[Role of curative local excision in rectal cancer]. / Ruolo delle escissioni locali con intento curativo nella chirurgia del cancro del retto.

The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). 20 patients (4.1%) underwent LE, 7 males and 13 females, median age 65 years. Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2, N0, M0, grading G1 or G2, achievable location. As far as the type of LE is concerned, 13 transanal excisions (Francillon technique), 2 Mason, 2 endoscopic excisions and 3 TEM were performed. Among patients who underwent LE there was no operative mortality. 13 tumors were T1 and 7 were T2; pathologic findings included 20 adenocarcinoma, 14 G1 and 6 G2. There was no postoperative specific morbidity, while aspecific morbidity was minimal (5%). There were no local recurrences but 2 patients (10%) had secondary lesions. Five year overall survival following LE was 87.4%. Comparing T1 and T2 tumors after APR and SSR (17 T1 and 42 T2, all adenocarcinoma), operative mortality and specific morbidity were respectively 1.7% (p = 0.55) and 28% (p = 0.007). There were 5 (8.5%) local recurrences (p = 0.17) and 6 (10.2%) metastatic lesions. Five year overall survival was similar to LE (88.3%; p = 0.76). In conclusion the authors stress the importance that IE for rectal carcinoma must be performed only in selected patients provided there is correct preoperative staging. In these cases five year overall survival, local recurrence and operative mortality were similar to APR and SSR, while there was a statistically significative difference following LE in terms of specific morbidity.

[Role of CT assessment of mediastinal lymph nodes in the preoperative staging of T1 pulmonary carcinoma]. / Ruolo della valutazione TC dei linfonodi mediastinici nella stadiazione preoperatoria dei carcinomi polmonari T1.

The utility of the preoperative staging of T1 lung cancer is controversial. This is due to a lower prevalence of N2 metastases in tumors of small diameter. To assess the prevalence of N2 metastases in such tumors and the sensitivity and specificity of computed tomography in mediastinal sadiation, the authors reviewed CT scans and pathology reports of 56 patients who had undergone surgical resection of a T1 lung cancer so distributed: Adenocarcinoma 20 cases, adenosquamous carcinoma 14, Bronchioloalveolar carcinoma 7, Undifferentiated 7, Carcinoid 5, Small cells carcinoma 3. Mediastinal nodal metastases were present in 11 patients: 6 of them were correctly detected by CT scan. Some differences in terms of N2 prevalence and sensitivity were noted when the T1 were divided in two groups of diameter greater or smaller of 2 cm. Important considerations derived after dividing our patients according to the histological type. The prevalence of N2 metastases was greater in adenocarcinoma than in adenosquamous carcinoma but CT sensitivity was lower in adenocarcinoma (40% Vs 100%). The authors conclude that the prevalence of N2 metastases is high enough to request a preoperative sadiation, but the utility of CT in this purpose is limited by a low sensitivity.

[Spigelio's hernia: presentation of 2 clinical cases and review of the literature]. / L'ernia di Spigelio: presentazione di 2 casi clinici e revisione della letteratura.

The authors present two cases of Spigelian hernia. The patients underwent surgery, in one case with urgency modality. They repaired surgically both hernias, by a plastic of the abdominal wall. Neither postoperative mortality, nor morbidity have been observed. On follow-up, they didn't observe any relapse. Nevertheless the extreme rarity of the Spigelian hernia, the authors believe that this pathology must be considered among the different causes of the partial intestinal obstruction or acute abdomen. The diagnosis can be performed both by the simple clinical examination and by instrumental devices. Ultrasonography seems to be the most specific and the less invasive one. Recently laparoscopic approach has been emphasized; it allows to reach the diagnosis and to treat the hernia at the same time. However the authors remark that traditional surgery remains the most effective treatment.

The lung cancer in the elderly: the surgical approach.

The experience accumulated in a 5-year period with the surgical treatment of lung cancer in the elderly is reviewed. The cases of 171 patients treated between December 1989 and November 1994, were evaluated retrospectively, according to a selected groups of parameters. Fifty patients underwent thoracotomy, and the recorded postoperative complications were analyzed. The most important factors for predicting complications were the oxygen partial pressure in the arterial blood (PO(2)), the forced expiratory volume/1 sec (FEV(1)), the seriousness of the surgical intervention, and the duration of general anesthesia. The correct selection of patients and an adequate treatment of complications may be crucial for the success of surgical therapy of elderly patient.