Radiofrequency versus conventional diathermy Milligan-Morgan hemorrhoidectomy: a prospective, randomized study.

BACKGROUND: In the past decade, several new surgical tools have revived the hope for an improved technique to treat radically hemorrhoids with less postoperative pain. Among these radiofrequency (RF), excisional surgery seems to be safe, fast, and accompanied by less postoperative pain. The aim of this study was to evaluate and compare RF (ligasure TM) to conventional diathermy Milligan-Morgan hemorrhoidectomy (MMH). PATIENTS AND METHODS: Between January 2003 and July 2009, 210 symptomatic patients were randomized to undergo RF (118 patients) or diathermy MMH (92 patients). Mean follow-up was 39 ± 16 months. Clinical outcome was assessed by validated questionnaire on postoperative symptoms and satisfaction. Primary endpoints were pain and wound healing. Secondary endpoints were operative time, early and late complications (including recurrences), and patient satisfaction. Data was analyzed using chi-squared test and Fisher's exact test. RESULTS: Despite postoperative pain was less after RF, this difference was significant only for severe pain (expressed as VAS score >7). Significant differences were observed in terms of wound healing. The two techniques were similar in terms of early and late complications. CONCLUSIONS: RF hemorrhoidectomy is followed by reduced severe pain and better wound healing. However, in our experience, this is not followed by earlier return to daily activities.

Porcine dermal collagen matrix injection may enhance flap repair surgery for complex anal fistula.

INTRODUCTION: The use of biomaterials to treat anal fistula has drawn great interest. More recently, a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulas. METHODS: We propose a novel approach consisting in non-cutting seton positioning followed by flap repair associated with dermal matrix injection into the fistula tracts after several weeks. RESULTS: We report our experience with this two-staged procedure on 11 consecutive patients with recurrent high trans-sphincteric fistulas with a minimum follow-up of 6 months. CONCLUSIONS: In our experience, this two-stage approach seems to be safe and effective.

Conservative and surgical treatment of chronic anal fissure: prospective longer term results.

INTRODUCTION: The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). PATIENTS AND METHODS: From January 2004 to March 2009, 311 patients with typical CAF completed the study. All patients were initially treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, the patients were assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (29 +/- 16 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. RESULTS: Overall healing rates were 64.6% and 94% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL after 12 weeks course were 54.5% and 61.5%, respectively. Fifty-four patients (17.4%) responded to further medical therapy. One hundred two patients (32.8%) underwent BTX or LIS. Healing rate after BTX was 83.3% and overall healing after LIS group was 98.7% with no definitive incontinence. CONCLUSION: In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.

Modified stapled transanal rectal resection (Starr) for full thickness excision of rectal tumour.

INTRODUCTION: Traditionally, adenomatous rectal lesions and unexpected malignant polyps that could not be removed endoscopically are referred to surgery. Local excision is the treatment of choice, and several techniques have been proposed. The choice of the approach requires that the tumour is excised intact, with a low recurrence rate and limited morbidity. Local excision can be a straight forward or conversely a demanding procedure due to the restricted space in which the surgeon must work and the difficulty of achieving a satisfactory exposure. METHODS: We describe a modified stapled transanal rectal resection for the excision of flat lesions with a diameter up to 2 cm and located between 5 and 12 cm from the anal verge. DISCUSSION AND CONCLUSION: In our experience, it is quick, simple, and easy to teach but it has not previously been reported. It provides full thickness resection with adequate lateral margins. It overcomes some of the limits of the incomplete surgical field exposure and difficult manipulation, since after the confectioning of double half purse-string suture, the suture and sectioning is made by the stapler device.

Intragastric balloon followed by biliopancreatic diversion in a liver transplant recipient: a case report.

Liver transplantation is a life-saving procedure for end-stage liver disease. In liver transplant recipients, morbid obesity influences post-operative survival and graft function. In 1996, our patient underwent a successful liver transplantation because of a HCV-related liver failure (body mass index (BMI) 31). Follow-up showed a functional graft and the development of severe obesity up to a BMI of 61 in January 2006. In January 2007, he was submitted to intragastric balloon therapy for 6 months, reaching a BMI of 54. In September 2007, he underwent a biliopancreatic diversion. During follow-up to March 2008, he reached a BMI of 42 with ameliorations of comorbidities. In May 2008, during a hospital admission, he suddenly died of a heart attack. Post mortem study revealed a myocardial infarction. This is the first world case report for this approach. According to our opinion, patient's death was not related to bariatric surgery.

Metachronous splenic metastasis from colonic carcinoma five years after surgery: a case report and literature review.

Metastatic lesions of the spleen are a rare finding and are generally associated with widespread disease. Moreover, solitary metastases of the spleen are exceptional. In this paper, we describe the case of a patient who developed an isolated splenic metastasis from colon carcinoma five years after surgery, and was successfully treated by splenectomy. We also review the scant literature experience discussing clinical diagnosis and approaches to this uncommon event.

Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study.

The aim of the study was to evaluate the efficacy of parathyroid hormone 1-hour assay for the early prediction of hypoparathyroidism after thyroidectomy. Candidates for total, subtotal, completion thyroidectomy or lobectomy were entered into the study. Pre- and postoperative calcium and parathyroid hormone (1 hour and postoperative day 1 after thyroidectomy) levels and clinical hypocalcaemia were recorded. Patients were divided into 3 groups and 2 subgroups: 1. patients who underwent lobectomy (control group); 2. patients who underwent total thyroidectomy with postoperative hypocalcaemia (2A: asymptomatic patients, 2B: symptomatic patients); 3. asymptomatic patients with normal calcium levels after total thyroidectomy. Of 119 patients, 109 underwent total thyroidectomy and 10 lobectomy. Of the 109 patients submitted to total thyroidectomy, 35 (32.11%) developed postoperative transient hypocalcaemia. Twenty-one patients (19.27%) were asymptomatic and 14 (12.84%) were symptomatic. Parathyroid hormone levels decreased after 1 hour in group 3 (32.98 pg/dl), 2A (9.84 pg/dl) and 2B (7.46 pg/dl). There was no significant difference in parathyroid hormone levels at 1 hour between group 2A and 2B (p = 0.06), but were significantly lower compared to groups 3 and 1 (p < 0.05). Parathyroid hormone levels at 1 hour after total thyroidectomy is a good predictor of early hypocalcaemia. It might be more useful than serum calcium monitoring for the early identification of patients requiring postoperative calcium supplementation.

Surgical treatment of gastric outlet obstruction due to gastroduodenal tuberculosis.

Gastroduodenal tuberculosis is a very rare location of abdominal tuberculosis; it is usually secondary to pulmonary tuberculosis and is often associated with HIV infection. We report a case of a 45-year-old woman with no HIV infection and no evidence of pulmonary tuberculosis, with a history of duodenal ulcer treated for several months, who presented at the emergency department with severe gastric outlet obstruction of recent onset caused by ulcerohypertrophic antroduodenal tuberculosis. The lesion was misdiagnosed at endoscopy as a malignancy, although histological examination of biopsies showed only chronic inflammation. The diagnosis was established at surgery, when a frozen section of an enlarged lymph node showed the presence of giant cells and caseating granuloma. The treatment was gastric resection with Roux-en-Y gastrojejunal anastomosis. In this patient the rare gastroduodenal location of tuberculosis occurred as primary disease in the absence of other organ involvement.

Medical and surgical treatment of chronic anal fissure: a prospective study.

The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). From 1/04 to 09/06, 156 patients with typical CAF completed the study. All patients were treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (19 +/- 8 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. Overall healing rates were 65.3 and 96.3% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL were 39.8 and 46%, respectively. Thirty-six patients (23.1%) responded to further medical therapy. Fifty-four patients (34.6%) underwent BTX or LIS. Healing rate after BTX was 81.8%. LIS group showed a 100% healing rate with no morbidity and postoperative incontinence. In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.