Sutureless hernioplasty with light-weight mesh and fibrin glue versus Lichtenstein procedure: a comparison of outcomes focusing on chronic postoperative pain.

PURPOSE: Groin hernia is one of the most common disease requiring surgical intervention (8-10% of the male population). Nowadays, the application of prosthetic materials (mesh) is the technique most widely used in hernia repair. Although they are simple and rapid to perform, and lower the risk of recurrence, these techniques may lead to complications. The aim of the present study is to assess the incidence and degree of chronic pain, as well as the impairment in daily life, in two procedures: (1) the "Lichtenstein technique" with polypropylene mesh fixed with non-absorbable suture, and (2) the "sutureless" technique carried out by using a partially absorbable mesh (light-weight mesh) fastened with fibrin glue. METHODS: This was a study conducted over a period of 3 years from July 2006 to July 2009. A total of 148 consecutive male patients suffering from groin hernia were divided randomly into two groups: (1) Group A: patients operated with "sutureless" technique with partially absorbable mesh and plug fastened with 1 ml haemostatic sealant; (2) Group B: patients operated with Lichtenstein technique using non-absorbable mesh and plug anchored with polypropylene suture. Follow-up took place after 7 days, and 1, 6 and 12 months and consisted of examining and questioning patients about chronic pain as well as the amount of time required to return to their normal daily activities. RESULTS: No major complications or mortality were observed in either group. In group A there was a faster return to work and daily life activities. Six patients (7.8%) in group B suffered from chronic pain, whereas no patient in group A demonstrated this feature. CONCLUSIONS: Our experience shows that the combined use of light-weight mesh and fibrin glue gives significantly better results in terms of postoperative pain and return to daily life.

Oesophageal achalasia in elderly people: results of the laparoscopic Heller-Dor myotomy.

AIMS: To assess the outcome of laparoscopic Heller-Dor myotomy for oesophageal achalasia in two groups of patients identified by age (under and over 70 years) using functional and clinical instruments. BACKGROUND: Current therapies for achalasia can't restore normal motility but can palliate dysphagia. Many other symptoms may persist difficult to quantify and to compare. In order to understand if age is a factor that influences the therapeutic outcome we tested the reliability of a specific QoL instrument for comparing outcomes of surgery for achalasia. METHODS: Functional examinations and the Gastrointestinal Quality of Life Index (GIQLI) were used before and after laparoscopic Heller-Dor myotomy. RESULTS: Starting in January 1996, 28 consecutive patients of 32 diagnosed (instrumental evidences) achalasia were operated on laparoscopically for various clinical stages of achalasia. In 78% of patients dysphagia disappeared, the incidence of gastro-oesophageal reflux was of 11%. The patients completed a GIQLI questionnaire preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 78(range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 35 months (range 18-72), the score had significantly improved to 115 (range 71-140). All the items assessing gastrointestinal symptoms and physical, social, and emotional function were significantly improved. There is no difference between the two groups identified. CONCLUSIONS: The laparoscopic Heller-Dor myotomy is an effective palliation for acalasia, the medium-term outcome is not affected by the age of the patients. The GIQLI is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL.

Influence of the surgical treatment on local recurrence of rectal cancer: a prospective study (1980-1992).

BACKGROUND AND OBJECTIVES: The incidence of locoregional recurrences (LR) following radical surgery of rectal cancer varies from 5% to 30% according to the literature. The purpose of this prospective study was to compare the outcome of the Abdomino-Perineal Excision (APE) vs. the Anterior Resection (AR) in a consecutive series of 188 patients who underwent surgery for cure from 1980 to the end of 1992 (81 APE and 107 AR), followed for 5 years, evaluating their influence on the incidence of the recurrences. METHODS: The patients were enrolled at random in the two surgical groups, provided that a radical excision of the tumour, with only two limits: the level of the lesion from the anal verge and the presence of a severe incontinence instrumentally proven. TNM, Dukes staging, grading, and tumour location were statistically evaluated. Further primary suture vs. packing of the perineal wound in APE and handsewn vs. stapled anastomosis in AR were compared in relation with the incidence of LR. RESULTS: The overall local recurrence rate was 19.2% (32/167), in details 19.7% for APE and 18.5% for AR. Similar recurrence rates were observed following both procedures, matching the patients according to the Dukes stage and different details of techniques. A slight statistically significant difference was found as far as the tumour location is concerned in the group treated with anterior resection (p = <0.05) because of the higher recurrence observed in AR performed for tumours of the lower third of the rectum in comparison with the more proximal level. CONCLUSIONS: The AA conclude that the choice of the right surgical procedure in the rectal carcinoma depends on the characteristics of the tumour and the conditions of the patients, provided that the oncologic indications were respected, because recurrence and survival rate are independent from the surgical approaches.

[Anorectal sphincter function after mechanical anterior resection in cancer of the rectum]. / La funzione sfinteriale ano-rettale dopo resezione anteriore meccanica per cancro del retto.

Out of a total of 365 operations for colo-rectal disease performed during the period 1980-1989 at the III and V Division of General Surgery of the 2nd Faculty of Medicine and Surgery of Naples, 181 (49.6%) patients had rectosigmoidal cancer: 95 (52.5%) underwent anterior resection and 86 (47.5%) Miles' operation. In 46 patients who underwent mechanical anterior resection during the period 1986-1989, pre and postoperative sphincter function was studied through a complete anamnesis, physical examination, sigmoidoscopy or colonoscopy and balloon manometry. All data were analyzed considering both the distance of the anastomosis from the anal verge and the patient age in order to stress possible relations with incontinence. The low incidence of incontinence registered after 12 months (6.5%), confirms the importance of manometry and rehabilitation, both necessary to improve the quality of life in old patients who undergo low anterior resection.

Survival and locations of recurrence following abdomino-perineal resection for rectal cancer.

Records of 134 patients treated by abdomino-perineal resection (1971-1979) were reviewed. One hundred and thirteen had curative operations. Mortality was 2.6% and morbidity was 51%. Ninety-three were evaluable and were followed for 5 to 8 years; they were evaluated for survival and pattern of recurrence. Five-year survival for Dukes' A, B, C, and D lesions was 86, 62, 31, and 0%, respectively. Thirty-seven had recurrence: Four pelvic, nine pelvic and distant, and 24 only distant lesions. The overall incidence of failures was 47%, failure rates by stage were 11% for stage A, 27% for B, 48% for C, and 70% for D. Incidence of local recurrence was significantly higher in stage C compared to stage B. Irrespective of stage, after detection of local or distant recurrence, survival did not differ. Furthermore, radiotherapy for local recurrence and chemotherapy for distant lesions did not improve survival time.

[Validity of diagnostic studies in thyroid pathology. Retrospective study]. / Validità delle indagini diagnostiche nella patologia tiroidea. Indagine retrospettiva.

In view of the growing number of examinations proposed and employed for the diagnosis of diseases of the thyroid, a retrospective evaluation was made of their validity in a series of 2500 patients (1500 operated). Attention was paid to scintiscanning, oncotropic indicators, echography, needle biopsy, thyrolymphography and thyroid hormones as aids to determining the nature of thyroid lesions and the planning of their treatment. Scintiscanning and needle biopsy proved of primary importance in determination of the nature of a lesion. Echography supplied additional, though not necessarily indispensable information. Oncotropic indicators and thyrolymphography do not appear to be useful. They do not provide data enabling a diagnostic problem to be solved, but can only help to increase any doubts that may exist. Determination of thyroid hormones is clearly indicated when planning the management of hot lesions (single, multiple or disseminated nodes), in cold lesions where thyroiditis is suspected, and in all cases where the clinical evidence suggests hypothyroidism. In euthyroid subjects requiring surgery with no objective signs of hypofunction, preoperative determinations appear to be unnecessary, where as post-operative values are of assistance in assessing the functional efficiency of the residual thyroid tissue. The conclusion to be drawn, therefore, is that diagnostic examinations should be employed in a more selective and discriminating manner.

Surgery of toxic goiter: indications and long-term results.

Treatment of hyperthyroidism is still debated, surgery in particular is conceived as the last step of a multidisciplinary approach. 130 patients were reviewed in a follow-up based on a double cell at fixed dates, after subtotal thyroidectomy for multinodular and diffuse toxic goiter. Clinical and laboratory tests (T3, T4, TSH) showed a rate of 9.1% of recurrent toxicity and 20.7% of hypothyroidism. These data confirm that surgery offers satisfactory results in the management of hyperthyroidism if indications are carefully followed. It is also shown that TSH has a predictive role in the screening of patients at risk of developing postoperative hypothyroidism.

Enhancement of colonic cancer by indomethacin treatment in dimethylhydrazine pretreated rats.

Indomethacin treatment to rats bearing dimethylhydrazine-induced colonic cancer resulted in increased mortality (p less than 0.01) and a greater incidence of metastases compared to untreated animals with the same stage of disease. It is postulated that indomethacin might have a promotional effect on the spread of autochthonous experimental colon cancer.

Effects of CO2 laser on the healing of experimental colon anastomoses.

Anastomotic leakage after colonic resection still remains a troublesome complication of major clinical significance. Systemic (nutritional status, blood viscosity) or local factors (contamination by local germs, suture technique) seems to be implicated in the healing process of the suture line. The CO2 laser as a cutting procedure in colonic resection should provide a useful tool for its accuracy and the bactericidal properties. We have tested the strength of an end-to-end anastomosis of rat colon resected by CO2 laser, scalpel and diathermy, respectively, by measuring the bursting pressures at different postoperative days. The present study shows that the use of CO2 laser resulted in a significant increase of colonic bursting pressure at the anastomotic site.