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.

[Traumatic lesions of the pancreas: diagnosis and treatment]. / Le lesioni traumatiche del pancreas: diagnosi e trattamento.

The diagnosis and treatment of traumatic lesions of the pancreas are difficult. The deep anatomical location of the organ, the lack of truly accurate non-invasive diagnostic investigations and the frequent initial scarcity or absence of specific symptoms, often mean that a clinical assumption based on the dynamics of the trauma is fundamental for a rapid, correct diagnosis. The state of the main pancreatic duct is the most important element in establishing the prognosis and guiding the treatment, and should therefore be accurately defined before or during surgery. If the Wirsung duct is intact, even when radiological, clinical and laboratory signs indicate a pancreatic lesion, conservative treatment can be attempted. On the contrary, if there is evidence of a lesion of the duct, surgery is mandatory, bearing in mind that pancreatic resections involving removal of the portion of the gland distal to the lesion have a lower incidence of complications than do reconstructive and/or anastomotic procedures and are therefore to be preferred. Nevertheless, in selected cases, especially in young patients, Roux-en-Y pancreaticojejunostomy can avoid the risk of functional insufficiency, sparing large tracts of otherwise sacrificed glandular tissue. Only the more serious complex lesions of the head of the pancreas also affecting the duodenum require pancreaticoduodenectomy.