Sclerotherapy with 3% polidocanol foam for the treatment of mucocutaneous bridges and/or residual piles after open excisional hemorrhoidectomy.

Injection sclerotherapy is an effective and safe treatment in selected cases. It might be used as the first treatment for I-III degree hemorrhoidal disease (HD), but also as a bridge therapy for more severe cases not amenable to invasive treatments. However, concerning the long-term recurrence rate, open excisional hemorrhoidectomy remains the gold standard in cases of III- and IV-degree HD. In this context, it is recommended to perform the excision of no more than three piles and to preserve the muco-cutaneous bridges to avoid post-operative anal stenosis. The aim of this study is to evaluate surgical outcomes and efficacy of the combined treatment of open excisional hemorrhoidectomy and the use of ST on the remnant muco-cutaneous bridges/residual piles. This was a single-center retrospective study and a total of 18 patients with IV-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification, were enrolled between January 2023 and June 2023 and their follow-up continued until October 2023 after reaching 3 months of follow-up. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey Incontinence Score were used to assess symptoms and their impact on quality of life and continence. A total of 77.8% (14/18) of the patients were symptom-free (hemorrhoidal disease symptom score (HDSS) score = 0) after 3 months. Moreover, a statistically significant decrease in the median HDSS and short health scale for HD (SHS-HD) score was registered from 16 preoperatively (T0) to 2 at 3-month follow-up (T3). Neither post-operative bleeding nor any type of complications occurred. The use of sclerotherapy in combination with the traditional open excisional hemorrhoidectomy has shown promising results. Further structured studies are needed and greater dissemination and education of the general surgeon on the subject is necessary.

Management and surgical treatment of parathyroid carcinoma: a 6-year experience of a single centre of endocrine surgery unit.

Background: Parathyroid carcinoma (PC) affects 0.1-0.3% of the general population and represents the rarest malignant neoplasms among endocrinological diseases, comprising less than 1%. The best therapeutic treatment and management methods are still debated in the literature. The aim of this study is to evaluate the management and surgical treatment of parathyroid carcinoma after 6 years of enrolment with the Endocrine Surgery Unit of the University Hospital of Bari. Materials and methods: A retrospective observational study was carried out using a prospectively maintained database of patients affected by primary hyperparathyroidism between January 2017 and September 2022. Consecutive patients over 18 years old with a final histopathological finding of PC were included in the study. Patients with secondary or tertiary hyperparathyroidism, parathyroid hyperplasia, and parathyroid adenoma were excluded. All patients underwent follow-up every 6 months for the first 2 years, and annually thereafter. Results: In this study, 9 out of 40 patients affected by hyperparathyroidism were included; 6 (66.6%) were female and 3 (33.3%) were male patients, with a median age of 59 years (IQR 46-62). None had a family history of PC. No mortality was recorded while the incidence of recurrence was 22.2%, with a disease-free survival of 8 and 10 months. Parathyroidectomy was performed in five patients, while four patients underwent parathyroidectomy with concurrent thyroidectomy for thyroid goitre. No intraoperative complications were recorded. Open parathyroidectomy was performed with a mini-cervicotomy in seven patients, while two patients underwent robotic surgery. All patients were discharged on the second postoperative day. Conclusion: PC represents a great challenge in terms of preoperative diagnosis, management and treatment. A surgical approach represents the first best option for PC in referral endocrine surgery units. The early identification of risky patients should be the dominant goal to plan an appropriate therapy and to perform adequate en bloc surgery.

Results of sclerotherapy and mucopexy with haemorrhoidal dearterialization in II and III degree haemorrhoids. A 4 years' single centre experience.

Introduction: Haemorrhoidal disease (HD) affects a considerable portion of the adult population. The aim of this study is to confirm the safety and efficacy of the treatments and to report the long-term outcomes of Sclerotherapy (ST) and Mucopexy and Haemorrhoidal Dearterialization (MHD) performed over the last 4 years in a single tertiary centre. The secondary outcome is to evaluate the usefulness of both techniques and to demonstrate how those can be associated as a bridge to surgery. Materials and methods: Patients affected by second-third-degree haemorrhoids and undergoing ST or non-Doppler guided MHD between 2018 and 2021 were enrolled. Safety and efficacy, recurrence rate, Haemorrhoid Severity Score (HSS) and pain resulting from both techniques were evaluated. Results: Out of 259 patients, 150 underwent ST. Further, 122 (81.3%) patients were male and 28 (18.7%) were female. The mean age was 50.8 (range 34-68) years. Most of the patients (103, 68.6%) were affected by second-degree HD, while 47 (31.4%) were affected by third-degree HD. The overall success rate was 83.3%. The median pre-operative HSS score was 3 (IQR 0-4, p = 0.04) and at 2 year the median HSS was 0 (IQR 0-1, p = 0.03). No intraoperative complications and no drug-related side effects occurred. The mean follow-up for ST was 2 years (range 1-4; SD ±0.88). MHD was performed on 109 patients. In detail, 80 patients (73.4%) were male while 29 patients (26.6%) were female. The mean age in this group was 51.3 (range 31-69). Further, 72 patients (66.1%) were affected by third-degree HD and 37 (33.9%) by second-degree HD. The median HSS score was 9 (IQR 8-10, p = 0.001) preoperatively two years after treatment was 0 (IQR 0-1, p = 0.004). Major complications occurred in three patients (2.75%). The overall success rate was 93.5% (second degree 89.2% vs. third degree 95.8%). The mean follow-up for MHD was 2 years (range 1-4; SD ±0.68). Conclusions: The results confirm the usefulness of those techniques, which can be considered safe and easily repeatable procedures, with a low recurrence rate after 2 years of median follow-up.

Sclerotherapy with 3% polidocanol foam to treat second-degree haemorrhoidal disease: Three-year follow-up of a multicentre, single arm, IDEAL phase 2b trial.

BACKGROUND: Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I-II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow-up of more than 1 year. The purpose of this study was to analyse the long-term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II-degree HD. METHODS: This was an open label, single-arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS-HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score. RESULTS: The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow-up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow-up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p < 0.001) from a median preoperative value of 11 (10-13) and 18 (15-20) to 0 (0-2) and 4 (0-4), respectively. Symptom-free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo-sclerotherapy nor additional adverse events (AEs) compared to the first 12 months. CONCLUSIONS: Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate.

Short-Term Results of Sclerotherapy with 3% Polidocanol Foam for Symptomatic Second- and Third-Degree Hemorrhoidal Disease.

BACKGROUND: Hemorrhoidal disease (HD) is defined as the symptomatic enlargement and/or distal displacement of anal cushions and is one of the most common proctological diseases. Sclerotherapy (ST) with 3% polidocanol foam induces an inflammatory reaction with sclerosis of the submucosal tissue and consequent suspension of the hemorrhoidal tissue. The aim of this study was to evaluate the short-term effectiveness and safety of ST with 3% polidocanol foam for the treatment of symptomatic second- and third-degree HD. METHODS: A total of 66 patients with symptomatic second- and third-degree HD underwent a single ST session between March 2017 and July 2018. A visual analog scale score was used to assess post-operative pain and patient satisfaction. The symptoms severity and anal continence were investigated through the Hemorrhoid Severity Score (HSS) and Vaizey score, respectively, at baseline, at 4 weeks and after 1 year. RESULTS: Fifty-seven out of 66 patients were male (86.3%), and the mean age was 52 (29-75; SD ± 12) years. The mean operative time was 4.5 (2-6; SD ± 1.23) minutes. No intraoperative complications and no drug-related side effects occurred. The overall success rate was 78.8% (52/66 patients) after a single ST session and 86% after two ST sessions (57/66 patients). The mean treatment effect, obtained comparing preoperative and 12 months symptom scores in each patient, showed a median change of 8 (p < 0.001). All patients resumed their normal daily activities the day after the procedures. CONCLUSIONS: ST with 3% polidocanol foam is a safe, cost-effective and repeatable conservative treatment.

Perineal Paget's disease: A rare disorder and review of literature.

INTRODUCTION: Extramammary Paget's disease (EMPD) occurs commonly in perineum, vulva and perineal region and is considered as a complex disorder due to different clinical and histological features. PRESENTATION OF CASE: A 61 years old woman had a dermatologic evaluation for anal itch and underwent a skin biopsy with diagnostic of Paget disease in perianal region. Pelvic magnetic resonance showed a huge tumor which involved skin, derma and gluteus and she firstly refused any surgical treatment. One year later, because of increasing of the tumor and bleeding, she underwent the surgical procedure with a complete excision, resection of the skin of the anus, inguinal lymphadenectomy and left colostomy. Because of lymph nodes metastasis, a VLS Miles was sequentially performed. She started oncological follow up that showed liver, lung and pelvic metastasis. She survived for 24 months after surgery. DISCUSSION: In literature, less than 200 cases of perineal Paget's disease have been reported. EMPD in some cases has an associated adenocarcinoma, which has been associated with a worse prognosis and high mortality. Wrong diagnosis and a superficial consideration of a benign evolution should be considered as the first mistake in clinical practice. CONCLUSION: Our surgical approach is considered in literature as the best one for those cases, followed by the oncological treatment. Those patients need to be better studied and more attention should be paid to the clinical presentation.

Intragastric balloon and binge eating.

BACKGROUND: In recent years, particular attention has been paid to the effect that eating disturbances and especially binge eating can have on the outcome of surgical treatments for obesity. Endoscopic positioning of the Bioenterics intragastric balloon (BIB) is mainly used in the work-up for surgical treatment of morbid obesity. Available data show that the BIB is a valid tool for reducing weight and co-morbidity, even if only a temporary treatment in morbidly obese patients. We evaluated the results of treatment with the BIB with the patient's tendency to indulge in binge eating. METHODS: Between April 2003 and March 2006, 89 patients with morbid obesity (BMI 39-55) were enrolled in the study. Before introducing the BIB and within 3 months after removal, patients underwent a psychiatric evaluation and the following psychodiagnostic tests: SCID (Structured Clinical Interview for DSM IV), ED-SCID (Eating Disorder Module, Structured Clinical Interview) and BSQ (Binge Scale Questionnaire). All those positive for the BED criteria according to the DSM IV, and who had at least one binge eating episode per week, were considered Binge Eaters (BE). RESULTS: Of the 89 patients enrolled, 75 were eligible for evaluations (M:F = 12:63), and 27 were positive for binge eating (BE). There were no significant differences in age and preoperative BMI between the BE group and the 48 patients without BE (NBE group). The complication and failure rates with the BIB treatment were significantly higher in the BE group (P<0.01). After treatment with the BIB, both groups showed a significant reduction in BMI (P<0.01), but the NBE-group showed a significantly higher weight (BMI 5.7 +/- 2.5 kg/m2) than the BE-group (BMI 3.3 +/- 2.2 kg/m2) (P=0.03). CONCLUSION: The results of treatment with the intragastric balloon appear to be affected by binge eating pattern in morbidly obese patients, even if the presence of this behavior does not prevent a successful reduction in the BMI. Binge eating does not seem to be a contraindication for the adjuvant use of the BIB before a bariatric operation. A limitation of our study is the short period of observation, related to the period of the BIB in the gastric lumen (not more than 6 months). Further studies may show whether the association of psychiatric treatment with the BIB in patients affected by binge eating may enhance the results of the treatment.

Wandering spleen as a cause of acute abdomen: a case report.

We report a case of acute abdomen due to torsion of the long vascular pedicle of a wandering spleen, displaced in the abdominal cavity, and caused by partial infarction of the spleen. The 46-year-old patient presented to the casualty department with piercing abdominal pain, fever, vomiting, leukocytosis, thrombocytopenia, and a palpable mass in the mesogastric region. US and CT scan revealed the presence of a mass compatible with an ectopic spleen in the mesohypogastric region, featuring necrotic-haemorrhagic areas, a long, contorted vascular pedicle twisted on its axis, and an empty splenic space. We performed an emergency laparoscopic splenectomy. Conservative surgery (splenopexy) could not be done because of the severe impairment of the vascular supply to the organ. Nowadays, conservative surgery is preferred in cases without vascular impairment, especially in children, by creating an omental or synthetic pouch after fixing the organ in the splenic space.

Tachyarrhythmia due to atrial fibrillation in an intragastric balloon carrier: coincidence or consequence?

A morbidly obese patient is reported who underwent insertion of a BioEnterics Intragastric Balloon (BIB) as a pre-surgical procedure (ie. prior to restrictive gastric banding). While carrying the BIB, the patient suffered an episode of severe supraventricular tachyarrhythmia (atrial fibrillation). Although such an event is not definitely correlated to the BIB, the episode led us to modify the pre-treatment protocol, introducing dynamic Holter ECG into the work-up investigations and excluding subjects with a pathological cardiac rhythm.

Double jejunal intussusception in an adult with chronic subileus due to a giant lipoma: a case report.

We present a case of a 40-year-old male with a clinical history of intermittent intestinal occlusion, abdominal pain and moderate weight loss. Physical examination and laboratory tests were unremarkable. Diagnostic imaging including CT, MR and small-bowel barium X-rays provided evidence of a jejunal lesion of an unknown nature downstream of the ligament of Treitz. Only at surgery was it possible to identify a double intussusception due to a giant stalked polyp which the histological examination revealed to be a submucosal lipoma.

Retrobulbar metastasis from gallbladder carcinoma after laparoscopic cholecystectomy. A case report.

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor. The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.

Reliability of electrophysiologic anal tests in predicting the outcome of sacral nerve modulation for fecal incontinence.

INTRODUCTION: Sacral nerve modulation has been demonstrated to be a new efficacious treatment for fecal incontinence. The effectiveness of the procedure is preliminarily tested by means of a peripheral nerve evaluation. Integrity of the sacral neural pathway is generally believed to be a necessary condition for a good response, but no data are available to confirm whether electrophysiologic anal tests are predictive of the clinical outcome of the peripheral nerve evaluation. METHODS: Eighty-two incontinent patients underwent the peripheral nerve evaluation after full evaluation of the anorectal physiology. Univariate analysis was performed, and the positive predictive value, sensitivity, and specificity were calculated for each of the tests. RESULTS: Forty-six patients had successful results to the peripheral nerve evaluation and were subjected to permanent implant of a sacral electrostimulator. Anal sphincter electromyography had been performed in 60 patients, whereas pudendal nerve terminal motor latency had been assessed in 68 and evoked sacral potentials in 29 patients. Anal electromyography was statistically related to the outcome of the peripheral nerve evaluation ( P = 0.0004) with a positive predictive value of 81 percent, a sensitivity of 44 percent, and a specificity of 81 percent. Pudendal nerve terminal motor latency on the right side did not correlate with the outcome, but left pudendal nerve terminal motor latency was weakly correlated ( P = 0.02), although both tests had a low positive predicting value and sensitivity vs. good specificity. Evoked sacral potentials did not correlate with the outcome and had a low positive predictive value, sensitivity, and specificity. CONCLUSIONS: Simple anal sphincter electromyography can predict the outcome of the peripheral nerve evaluation with good positive predictive value and specificity in patients with fecal incontinence. Other, more expensive, electrophysiologic anal tests do not add further prognostic information.