Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study.

PURPOSE: The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives. PATIENTS AND METHODS: Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study. RESULTS: The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups. CONCLUSION: Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

An enhanced outpatient modality for the treatment of hemorrhoidal disease: preliminary results.

Surgical treatment of haemorrhoids is, primarily, performed on an outpatient basis, and as so, the reduction of the operative time and the hospitalization duration is necessary. In order to achieve these results, both the surgical procedure and the anaesthesia modality should be optimized. Therefore, in this randomized controlled trial, we proposed the hemorrhoidal arteries ligation under pudendal nerve block, as an enhanced outpatient modality, versus the standard of doppler guided hemorrhoidal arteries ligation under spinal anaesthesia. Preliminary results showed that the experimental group was characterized by a similar to the control arm, symptoms remission rate, a lower operation duration and an improved postoperative recovery.

Lymph node ratio as a prognostic factor in gastric cancer patients following D1 resection. Comparison with the current TNM staging system.

INTRODUCTION: Nodal ratio (NR) has been demonstrated to be an independent prognostic factor in patients with gastric cancer. We evaluated the prognostic role of NR comparing it with the current TNM (2010) classification in gastric cancer patients treated with curative (R0) D1 resection. MATERIALS AND METHODS: We retrospectively reviewed 110 patients who underwent R0 resection for gastric cancer at University Hospital of Larissa between 2002 and 2011. All patients had a D1 lymphadenectomy plus the nodes along the left gastric artery. Factors affecting survival as well as correlations between the N status, NR status and resected nodes were investigated. RESULTS: In univariate analysis the N and NR status but not the numbers of retrieved nodes were significant prognostic factors. Inside N1 and N2 categories, patients with different NR groups were present and survival of some of these subpopulations was statistically different at long-rank test. There was a correlation between the nodes retrieved and N status but not with the NR category. In multivariate analysis both N status (HR=1.45; 95% C.I. = 1.19-1.89) and NR (HR=4.53; 95% C.I. = 1.86-11.03) found to be independent prognostic factors of survival. CONCLUSION: Prognostic significance of N status and NR status was comparable. Unlike N status, NR is independent by the number of resected nodes, and therefore it is particularly useful in case of conventional lymphadenectomy.

Colorectal cancer surgery in the elderly: limitations and drawbacks.

PURPOSE: The purpose of this study was to evaluate the outcomes of colorectal cancer surgery among the elderly. METHODS: From March 2002 until February 2010, 434 patients who presented to our institution with the initial diagnosis of colorectal cancer and were submitted to open curative colorectal cancer resections or some kind of palliative procedure either elective or emergencies were retrospectively reviewed. A total of 286 of these patients (65.8%) were below 75 years (group A) and 148 (34.2%) above 75 years (group B). RESULTS: A procedure with curative intent was undertaken in 386 patients (88.9%), while forty-eight patients (11.1%) were submitted to a palliative procedure. Regarding the incidence of emergency operations, forty-five patients (15.7%) from group A and forty-four patients (29.7%) from group B were operated due to an emergency (obstructing, perforating or bleeding tumors; P < 0.001). Mean ASA score was 1.74 ± 0.84 and 2.32 ± 0.94 for groups A and B, respectively (P < 0.001). Mean TNM stage was 2.28 ± 1.00 and 2.74 ± 0.98 for groups A and B, respectively (P = 0.0001). Elderly patients exhibited increased incidence of post-operative complications and increased post-operative mortality compared with their younger counterparts (P = 0.002 and 0.001, respectively). CONCLUSION: Colorectal cancer surgery in the elderly is a challenging clinical scenario. Treatment decision adjusted to each individual case is the ideal practice in order to maintain an acceptable balance between curative cancer resections and palliative procedures.

Side-to-side anastomosis fashioned as stoma after sigmoid resection for sigmoid volvulus: a case report.

PURPOSE: Colonic volvulus is one of the causes of large bowel obstruction with sigmoid colon being the most usually affected part. Surgery is the gold standard when signs of peritonitis are present or endoscopic decompression fails. MATERIALS AND METHODS: We report the case of 65-year-old man with acute large bowel obstruction due to sigmoid volvulus who underwent a laparoscopic-assisted sigmoid resection on an emergency basis. The condition of the bowel wall precluded a primary anastomosis. But instead, a side-to-side anastomosis that its common blind stump was brought out as an end stoma was performed. RESULTS: The postoperative period was eventless. The patient was discharged on the 6th postoperative day. Eight weeks after the initial operation, the patient was readmitted for the secondary closure of the anastomotic stoma. Local anesthesia and minor sedation were enough in order to perform the stoma take down. CONCLUSION: Laparoscopic-assisted sigmoid resection is a useful adjunct to the surgical armamentarium when facing the problem of sigmoid volvulus. When a safe restoration of the alimentary tract continuity cannot be achieved safely with a primary anastomosis, the proposed anastomotic stoma technique is a useful and practical alternative.

Outcomes of Doppler-guided hemorrhoid artery ligation: analysis of 90 consecutive patients.

BACKGROUND: Doppler-guided hemorrhoid artery ligation is a minimal-invasive surgical treatment option for hemorrhoidal disease. The aim of our study was to evaluate the early and long-term results of the procedure 1 year after the operation. PATIENTS AND METHODS: In a period of 4 years, 90 patients were included in this study. The Doppler-guided hemorrhoid artery ligation was performed under either spinal anesthesia or local perianal block. We recorded the length of postoperative inpatient care, on-demand analgesics administered apart from the standard analgesic protocol, short- and long-term complications, and, finally, recurrences. RESULTS: The mean age of patients was 46 ± 12.6 years. The operation was performed under spinal anesthesia in 82 patients and under local perianal block in 8 patients. The mean operative time was 26 ± 4.1 min. On-demand analgesics administration was reported in sixteen patients (17.7%) the first postoperative day and in four patients (4.4%) the second postoperative day. A total of 58 patients (64.4%) were discharged from the hospital the day of the operation, 29 (32.2%) patients stayed overnight, and in three (3.3%) patients, a hospitalization period of 2 days was needed. Four patients (4.4%), two with grade III and two with grade IV hemorrhoids, developed early postoperative complications. Late complications were observed in three patients (3.3%). Recurrences, manifested either as bleeding or as prolapsing piles, were observed in six patients (6.6%), two patients with initial grade III and four with grade IV hemorrhoids. CONCLUSION: Doppler-guided hemorrhoid artery ligation seems to be a safe and effective treatment option for all grades of hemorrhoidal disease. Further prospective randomized comparative studies are needed in order to fully evaluate the true role of DG-HAL in the surgical armamentarium.

Open inguinal hernia repair with the use of a polyglycolic acid-trimethylene carbonate absorbable mesh: a pilot study.

PURPOSE: Tension-free repair with mesh placement has become the gold standard for open inguinal hernia surgery. Traditionally, non absorbable materials have been used for mesh manufacture. The purpose of this pilot study was to evaluate the efficacy of using a totally absorbable prosthetic mesh for open inguinal hernia repair. METHODS: Ten patients with elective inguinal hernias were set to undergo open tension-free inguinal hernia repair with the use of polyglycolic acid-trimethylene carbonate absorbable mesh. In this pilot study, we looked primarily at recurrence and chronic pain assessed 1 year after the operation, while immediate postoperative complications were also recorded. RESULTS: All patients were discharged from the hospital the day after surgery. In three patients (30%), a Foley catheter was inserted to relieve symptoms of urinary retention. None of the patients had any immediate postoperative complication. At the 1st year follow up, none of the patients had clinical signs of recurrence. However, one patient experienced intermittent pain in the operated inguinal area. CONCLUSIONS: Open inguinal hernia repair with the use of polyglycolic acid-trimethylene absorbable mesh proved efficient in the given patient sample. Further studies with a larger number of patients and longer follow up are needed in order to confirm the possible favourable effects of this mesh type.

Effect of histamine on the electrophysiology of the human parietal pleura.

INTRODUCTION: Histamine is involved in the pathogenesis of numerous diseases and regulates the permeability of different tissues. The aim of this study is to investigate the effects of histamine on the electrophysiology of human parietal pleura and the underlying mechanisms involved. MATERIALS AND METHODS: Pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Histamine solutions (1µM to 1mM) were applied in native and pretreated specimens with dimetindene maleate, cetirizine, ranitidine, amiloride and ouabain. Trans-mesothelial resistance was determined (R(TM)). RESULTS: Histamine induced a rapid R(TM) increase on the mesothelial (p = 0.008) and a decrease on the interstitial surface (p = 0.029). This effect was dose-dependent and was totally abolished by dimetindene maleate, cetirizine and amiloride and partially by ranitidine and ouabain. CONCLUSIONS: Histamine induces acute electrochemical changes in human pleura mainly via interaction with the H(1) and partially with the H(2) histamine receptors. It also interferes with trans-cellular permeability and therefore may participate in pleural fluid recycling.

Permeability alterations after surgical trauma in normal rabbit peritoneum.

BACKGROUND: To investigate whether surgical trauma in a rabbit adhesion formation model and the administration of normal saline (N/S), icodextrin (ID) and/or dimetindene maleate (DM) changes the permeability of the normal rabbit parietal peritoneum. MATERIALS AND METHODS: A total of 45 female rabbits were operated on for adhesion formation and were euthanized 10 days later. In some rabbits, ID or N/S was instilled intraabdominally during operation, whereas in others DM was infused intravenously. In others, ID plus DM or no agent was used. Specimens were obtained postoperatively and were mounted between Ussing chambers. Amiloride was used to investigate Na(+) channels. Transmesothelial resistance (R(TM)) was determined as a permeability indicator. RESULTS: Amiloride increased the R(TM) of both surfaces. Surgical trauma increased R(TM) and partially inhibited the effect of amiloride. ID and N/S increased R(TM) and inhibited the effect of amiloride. Use of DM did not change R(TM) and did not inhibit the effect of amiloride. Use of ID plus DM slightly increased R(TM), but the effect of amiloride was blocked. CONCLUSIONS: Surgical trauma impairs the permeability of the normal rabbit parietal peritoneum. ID or N/S surmounted this effect, but DM did not, suggesting that surgical trauma is a diffuse process. Antiadhesion measures influence peritoneal physiology.

Loop stomas with a subcutaneously placed bridge device.

AIM: To describe and evaluate a new technique for supporting a loop stoma with a simple removable subcutaneous bridge device. METHODS: Fifty-five patients underwent a procedure resulting in a loop stoma. Thirty patients had a loop colostomy and twenty-five a loop ileostomy. In all cases, the stoma was supported with a removable subcutaneous redivac drain fixed to the skin. RESULTS: There was no incidence of mechanical obstruction, stenosis, retraction, mucosal erosion or subcutaneous infection. Daily cleaning and care of the stoma was very simple, and the removal of the bridge device was carried out without opening the collecting bag. CONCLUSION: Our proposed technique is safe and feasible without considerable complications.

Pudendal nerve block versus local anesthesia for harmonic scalpel hemorrhoidectomy: a prospective randomized study.

BACKGROUND: This prospective randomized trial was used to compare two different local anesthetic techniques, local perianal anesthesia and pudendal nerve block, used for harmonic scalpel hemorrhoidectomy (HSH). METHODS: A total of 120 patients with grade III or IV hemorrhoids were randomly chosen to perform HSH (60 patients under local anesthesia--Group A and 60 patients under pudendal nerve block--Group B). RESULTS: Additional perioperative analgesia during the procedure was needed in 37 patients of group A and 18 patients of group B (P < 0.001). A total of 27 patients from group A and 8 patients from group B (P < 0.001) required additional postoperative analgesia apart from the standard administered analgesics. A statistical significant difference in favor of the second group (B)--(P < 0.003) was found regarding the discharge point from the hospital when the number of patients that were able to be discharged from the hospital on the day of the operation and the first postoperative day was the comparison parameter. Group B (P < 0.001) was superior to local group regarding VAS pain score at discharge for the patient group that were discharge on the day of surgery (5.1 vs. 2.2). CONCLUSION: These data suggest that HSH performed under pudendal nerve block is a safe and efficient technique.

Clinicopathological differences between right- and left-sided colonic tumors and impact upon survival.

AIM: This study is to analyze the clinicopathological differences between right- and left-sided colonic tumors and to evaluate the impact upon the patient's survival. METHODS: In a period of 5 years (2004-2009), 453 patients were diagnosed with colorectal cancer. RESULTS: From a total of 453 patients diagnosed with colon cancer, 56.5% of them were men, while 43.5% of them were women. Right-sided colonic tumors were diagnosed in 54.53% of the patients compared to the 45.47% of patients with left-sided colonic tumors. The size of colonic tumors is statistically significant greater in right-sided colonic tumors compared to left ones (P < 0.001). Left-sided colon cancer patients identified to have a statistically significant better overall 5-year survival rate compared to right-sided ones (P < 0.001). CONCLUSION: Based upon our results, there is a different biological profile between right- and left-sided colonic tumors.

Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate.

BACKGROUND: To date, no single method has been successful in eliminating peritoneal adhesion formation after major abdominal surgery. This study evaluated the individual and possible synergistic effect of a local intraperitoneal barrier, 4 per cent icodextrin, and an intravenously administered antihistamine drug, dimetindene maleate, in the prevention of adhesion development following surgical trauma. METHODS: De novo experimental adhesions were induced by standardized trauma of the peritoneum and large bowel in 120 New Zealand White rabbits. The animals were randomized into four groups receiving intraperitoneal saline, intraperitoneal 4 per cent icodextrin (60 ml), intravenous dimetindene maleate (0.1 mg/kg) and 4 per cent icodextrin-dimetindene in combination (n = 30 per group). Ten days later, adhesion scores and incidence were assessed by two independent surgeons. and surface area by computer-aided planimetry. RESULTS: Treatment with either icodextrin or dimetindene maleate significantly reduced adhesion scores and increased the incidence of adhesion-free animals in an equipotent manner. The effect of combined treatment on severity, incidence and surface area of adhesions was more pronounced than that of each drug administered separately. CONCLUSION: Combined administration of 4 per cent icodextrin and dimetindene maleate may be used safely and efficaciously to prevent surgically induced adhesions.

The role of antibiotic prophylaxis in elective tension-free mesh inguinal hernia repair: results of a single-centre prospective randomised trial.

Hernia repair is one of the so-called clean operations. Many surgeons, however, use antibiotics, especially in the mesh repair era, without strong evidence to support this policy. We conducted a single-centre prospective randomised trial with a view to clarify this issue on a scientific basis. From January 2000 all patients undergoing elective inguinal hernia repair using a tension-free polypropylene mesh technique, provided they fulfilled predetermined criteria, were randomised to have a single dose of amoxicillin and clavoulanic acid or placebo in a double-blind manner. The main end point was to detect any difference in infectious complication rates - with specific interest to wound infection rates - between the two groups. Between January 2000 and June 2004, 386 patients entered the study (364 men and 22 women, median age 63 years, range 15-90 years) and were randomised to have antibiotic prophylaxis (group A, n = 193) or placebo (group B, n = 193). The two groups were comparable regarding demographic data. In total, 19 (5%) cases with infectious complications were detected. Fourteen of these were wound infections (3.7%). There were five cases of wound infection in group A and nine in group B (p = 0.4, Fisher's exact test). All wound infections were treated with antibiotics. The wound was opened in some cases. Mesh removal was not required in any of the cases. From the results of this study it does not appear that antibiotic prophylaxis offers any benefits in the elective mesh inguinal hernia repair.

Local treatment of a loop colostomy prolapse with a linear stapler.

Stomal prolapse is considered to be a common complication especially following loop colostomies. A variety of methods has been reported for the management of this condition, with many of them requiring extensive reconstruction of the stoma under anesthesia. We report a simple and fast technique for the local correction of the prolapse under minor sedation. A linear stapler device was applied for the amputation and reconstruction of the prolapse stoma at the desired level.