RESUMO
BACKGROUND: The incidence of carcinoma found within an internal hemorrhoid specimen is exceptionally rare. Further, the presence of primary anal canal adenocarcinoma within internal hemorrhoids is even more infrequent. We describe a case in which anal canal adenocarcinoma was found within an internal hemorrhoidectomy specimen and perform a review of the current literature. CASE SUMMARY: The patient was a 79-year-old male who presented with rectal bleeding and was found to have large thrombosed internal hemorrhoids during screening colonoscopy. The patient subsequently underwent a three-column hemorrhoi-dectomy. Pathologic analysis revealed one of three specimens containing a 1.5 cm moderate-to-poorly differentiated adenocarcinoma of anal origin with superficial submucosal invasion. At three-month follow up, he was taken to the operating theatre for biopsy and re-excision of his non-healing wound, which showed no recurrence. His wound has since healed and he was cancer free at ten-month follow up. CONCLUSION: When faced with primary anal canal adenocarcinoma an interdisciplinary approach to treatment should be considered. Routine pathological analysis of hemorrhoidectomy specimens may be beneficial due to the severity of anal canal carcinomas if left undiagnosed and untreated in a timely manner.
RESUMO
BACKGROUND: Practicing general surgeons adopt minimally invasive techniques using training opportunities such as weekend courses, videos, hands-on conferences, and traveling proctors with varying success. By integrating a fellowship-trained surgeon into an established practice, we show that minimally invasive techniques can be readily adopted. METHODS: A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by five practicing surgeons. Three time intervals were formed: 18 months before arrival of the MIS-trained surgeon, a 12-month transition period, and the 18 months following. Only cases performed by the five surgeons, and not by the MIS-trained surgeon, were included. A survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers and effectiveness of different methods for learning MIS techniques. RESULTS: A total of 4,016 cases were reviewed. The percentage of total cases performed laparoscopically increased from 12.1 to 48.3 %. Laparoscopic appendectomies significantly increased across time periods from 19 to 80 % (p < 0.0001). Adoption of laparoscopic ventral/incisional hernia repairs increased from 4.8 to 20.1 % (p = 0.0322). Laparoscopic inguinal hernias increased from 0.6 to 31.1 % (p < 0.0001). Finally, laparoscopic colectomies significantly increased from 25 to 52 % (p < 0.0001). Survey responses indicated that "mentoring by a colleague with MIS training" was superior to other methods for learning MIS procedures (p = 0.0327-0.0516). CONCLUSIONS: The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300 % increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.
